美国CSB西部药厂粉尘爆炸调查报告

U.S.CHEMICALSAFETYANDHAZARDINVESTIGATIONBOARDINVESTIGATIONREPORTDUSTEXPLOSION(6Killed,38Injured)WESTPHARMACEUTICALSERVICES,INC.KINSTON,NORTHCAROLINAJANUARY29,2003REPORTNO.2003-07-I-NCSEPTEMBER2004KEYISSUES:
HAZARDRECOGNITIONANDCOMMUNICATION
GOODENGINEERINGPRACTICE
LOCALAMENDMENTSTOFIRECODES1INVESTIGATIONREPORTREPORTNO.2003-07-I-NCSEPTEMBER2004(6Killed,38Injured)WESTPHARMACEUTICALSERVICES,INC.KINSTON,NORTHCAROLINAJANUARY29,2003KEYISSUESHAZARDRECOGNITIONANDCOMMUNICATIONGOODENGINEERINGPRACTICELOCALAMENDMENTSTOFIRECODESDUSTEXPLOSIONU.S.CHEMICALSAFETYANDHAZARDINVESTIGATIONBOARD23AbstractThisinvestigationreportexaminesadustexplosionatWestPharmaceuticals,Inc.,inKinston,NorthCarolina.Sixworkerswerekilledand38otherswereinjured,includingtwofirefighters.TheKinstonplantmanufacturedrubberdrug-deliverycomponents.Thisreportidentifiestherootandcontributingcausesoftheincidentandmakesrecommendationsonhazardrecognitionandcommunication,goodengineeringpractice,andlocalamendmentstofirecodes.TheU.S.ChemicalSafetyandHazardInvestigationBoard(CSB)isanindependentFederalagencywhosemissionistoensurethesafetyofworkers,thepublic,andtheenvironmentbyinvestigat-ingandpreventingchemicalincidents.CSBisascientificinvesti-gativeorganization;itisnotanenforcementorregulatorybody.EstablishedbytheCleanAirActAmendmentsof1990,CSBisresponsiblefordeterminingtherootandcontributingcausesofaccidents,issuingsafetyrecommendations,studyingchemicalsafetyissues,andevaluatingtheeffectivenessofothergovern-mentagenciesinvolvedinchemicalsafety.Nopartoftheconclusions,findings,orrecommendationsofCSBrelatingtoanychemicalincidentmaybeadmittedasevidenceorusedinanyactionorsuitfordamagesarisingoutofanymattermentionedinaninvestigationreport(see42U.S.C.§7412[r][6][G]).CSBmakespublicitsactionsanddecisionsthroughinvestigationreports,hazardinvestigations,safetyrecommenda-tions,casestudies,safetybulletins,incidentdigests,specialtechnicalpublications,andstatisticalreviews.MoreinformationaboutCSBmaybefoundat:orobtainedbycontacting:orobtainedbycontacting:orobtainedbycontacting:U.S.ChemicalSafetyandHazardInvestigationBoard2175KStreetNW,Suite400Washington,DC20037-1848(202)261-7600CSBinvestigationreportsCSBinvestigationreportsCSBinvestigationreportsCSBinvestigationreportsCSBinvestigationreportsmaybepurchasedfrom:maybepurchasedfrom:maybepurchasedfrom:maybepurchasedfrom:maybepurchasedfrom:NationalTechnicalInformationService5285PortRoyalRoadSpringfield,VA22161-0002(800)553-NTISor(703)487-4600Email:[e-mail]s,see::TheOnlyCredibleFuelforExplosion.........................................322.1.2OtherFuelSourcesConsidered.....................342.2CenterofExplosion......................................................352.3AccelerationofFire......................................................392.4InitiatingEvent.............................................................392.5Engineering..................................................................412.6NewMaterialSafetyReview.........................................432.7PreviousIncidents..................................