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Root Cause Analysis training by Sologic provides the tools, skills, and knowledge necessary to solve complex problems in any sector, within any discipline, and of any scale.  Learn More
 

SOFTWARE

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Dust Hydrogen Fire RCAOn January 31, 2011 at around 5:00AM, the [company] experienced an incident that led to two fatalities. Two employees were severely burned in an iron dust fire. The employees were wearing fire protective clothing, however this was not adequate protection due to the temperature of the fire, the contact time with the fire, and the proximity of the employees to the fire.

The two employees had been sent to repair a belt conveyor motor that had tripped. Upon examination, the employees did not find an obvious problem. One employee radioed the control room to attempt to restart the motor. This triggered an iron dust fire that immediately engulfed the two workers.

When the motor was restarted, it caused vibration in the surrounding equipment. This vibration mobilized into the air a large amount of iron dust that had settled on the equipment and surrounding structures. This dust encountered an ignition source - likely exposed wiring for the motor - and immediately ignited. It is unknown why the wiring had been left exposed. The team also discovered that the motor was not grounded properly, which could have contributed to the ignition.

There are tons of iron dust throughout the entire facility. The facility was not designed according to dust management best practices and therefore has many flat surfaces that can gather dust in areas where cleaning is difficult.

The iron dust comes primarily from muliple places in the dust handling system that are not completely sealed. Also, dust comes from open conveyor systems. The dust collection system is down frequently due to mechanical failures.

There are regulatory gaps and loopholes which prevent oversight of this type of production facility.

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RCA TRAINING

Root Cause Analysis training by Sologic provides the tools, skills, and knowledge necessary to solve complex problems in any sector, within any discipline, and of any scale.  Learn More
 

SOFTWARE

Sologic’s Causelink has the right root cause analysis software product for you and your organization. Single users may choose to install the software locally or utilize the cloud.  Our flagship Enterprise-scale software is delivered On Premise or as SaaS in the cloud.  Learn More