OSHA News Release - (Archived) Table of Contents|
Five Workers Killed in April 1995 Accident
EPA/OSHA Joint Accident Investigation Report
Napp Technologies, Inc., Lodi, New Jersey (Issued: October 1997)
(Note: The full report, including graphics, is available from National Center for Environmental Publications and Information (NCEPI) 1-800-480-9198.)
The Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA) today identified root causes and contributing factors in the April 1995 fire and explosion at the Napp Technologies, Inc., chemical plant in Lodi, N.J., that killed five employees.
Listed as root causes and contributing factors were inadequate process hazards analysis that resulted in not taking appropriate preventive actions; less than adequate standard operating procedures and training; inadequate information in making an important decision; inappropriate equipment; inadequate communication between Napp and a company for which it was doing a blending operation; and inadequate training of fire brigade members.
The fire and explosion also demolished most of the plant, destroyed or significantly damaged other nearby businesses, forced the evacuation of hundreds of residents and resulted in release of thousands of gallons of chemicals into the environment that were carried via firefighting water runoff into streets and subsequently the Saddle River.
Under a Memorandum of Understanding (MOU), OSHA and EPA have jointly assumed responsibilities to investigate certain significant chemical accidents.
The goal of such an investigation is to determine the root cause of the accident and make recommendations in order to reduce the likelihood of recurrence, minimize consequences associated with accidental chemical releases and make chemical production, processing, handling and storage safer.
"Today's report is the first published as the result of a joint investigation, and the personnel of both agencies are to be congratulated on the quality and thoroughness of the report," said Acting Assistant Secretary of Labor for Occupational Safety and Health Gregory R. Watchman.
The Napp investigation was conducted in conjunction with OSHA's enforcement investigation, which resulted in the company's paying $101,600 in fines and agreeing to institute new safety measures.
At the time of the explosion and fire, Napp was conducting a blending operation involving water-reactive chemicals. OSHA and EPA found that the most likely cause of the accident was inadvertent introduction of water and heat into the highly water-reactive chemicals (aluminum powder and sodium hydrosulfite) during the mixing operation. During an emergency operation to empty the blender of its reacting contents, the material ignited and the explosion and fire occurred that resulted in the deaths of the employees and destruction of the facility.
Because of the Napp Technologies accident, OSHA plans to consider adding additional reactive chemicals to the list of toxic and reactive chemicals covered by the process safety management standard.
EPA has agreed to harmonize its List of Regulated Substances (under the Risk Management Program under Section 112(r) of the Clean Air Act) with OSHA's Highly Hazardous Chemicals List. EPA also intends to consider adding reactive chemicals to this list.
The joint OSHA-EPA chemical accident investigation team (JCAIT) identified the following root causes and contributing factors of the event:
An inadequate process hazard analysis was conducted and appropriate preventive actions were not taken. Napp's process hazard analysis identified the water reactivity of the substances involved, but was inadequate to identify and account for other factors, including sources of water or heat, mitigation measures, recognition of deviations, consequences of failures of controls, and steps necessary to stop a reaction in the blender. Consequently, appropriate prevention actions were not taken.
Standard operating procedures and training were less than adequate. Napp's standard operating procedures (SOPs) and related training did not adequately address emergency shutdowns, including conditions requiring a shutdown and assignment of shutdown responsibility, and operating limits, including the consequences of deviations, abnormal situations, and corrective steps required.
The decision to re-enter the facility and off-load the blender was based on inadequate information. Although Napp was aware of, and concerned for, the strong possibility of a fire, there was a lack of knowledge or understanding whether off-loading (emptying) the blender would have made the situation worse or increase the potential for fire and explosion.
The equipment selected for the blending process was inadequate. The blender used by Napp for the process was inappropriate for the water-reactive materials blended.
Communications between Napp and the customer were inadequate. Napp was carrying out a blending operation for another company. Inadequate communication of hazard information between the companies led to an inadequate process hazard review.
The training of fire brigade members and emergency responders was inadequate. Napp fire brigade members were not trained to respond to the type of emergency that occurred.
The JCAIT developed recommendations to address the root causes and contributing factors to prevent a recurrence or similar event at other facilities. The recommendations included:
Facilities need to fully understand chemical and process hazards, failure modes and safeguards, deviations from normal and their consequences, and ensure that all relevant personnel know the proper actions to take to operate the process safely, recognize and address deviations, return to normal operations, or safely shut down. This is best achieved through process hazards analyses, standard operating procedures, and training;
Guidance is needed to address the unique circumstances surrounding tolling arrangements (where one company does a process for another) and the responsibilities for hazards assessments and communication of process safety information;
Facilities should ensure that equipment manufacturers' recommendations for proper use of equipment are followed;
OSHA and EPA should review the lists of substances subject to the OSHA Process Safety Management of Highly Hazardous Chemicals and EPA Risk Management Program regulations to determine whether additional reactive substances should be added.
OSHA needs to review the role of material safety data sheets (MSDSs) in conjunction with its standards for process safety management, hazard communication and hazardous waste and emergency response to clarify that MSDS should not be used beyond their intended design. Industry should consider additional consensus standards or guidelines to address MSDS consistency and use; and
OSHA and EPA should consider whether additional guidance or outreach is needed for users to understand the limitations of MSDSs and industry awareness that more than the MSDS is needed to conduct full process hazards analyses.
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