CSB Releases Another Combustible Dust Safety Video

Yesterday the Chemical Safety Board (CSB) released a safety video outlining the causes and results of the May 2017 combustible dust explosions and fires at Di Didion Milling facility in Cambria, Wisconsin. As we have come to expect from CSB videos, the new video provides a compelling summary of the results of the CSB’s accident investigation and report.

There have been two earlier dust explosion videos from  the CSB. The first was the video about the explosions at Imperial Sugar. The second was a follow up video about the lack of action at OSHA about combustible dust hazards.

Review - CSB Publishes Didion Milling Investigation Report

Yesterday, the Chemical Safety Board (CSB) published their final report on the Didion Milling explosion and fire that occurred on May 31^st, 2023. This combustible dust incident resulted in five employee deaths and an additional 14 employees injured (100% of 19 employees working at the facility at the time of the incident). The incident resulted in $15 million in damages, with no off-site damage or injuries reported.

Safety Concerns

The CSB report identified safety concerns that contributed to the incident. These include:

• Process Hazard Recognition,

• Dust Hazard Analysis,

• Engineering Controls for Combustible Dust Hazards,

• Structural Design for Combustible Dust Hazards,

• Fugitive Dust Management,

• Management of Change,

• Incident Investigations,

• Process Safety Information,

• Management of Audits and Inspections,

• Emergency Preparedness,

• Personal Protective Equipment,

• Process Safety Leadership, and

• Regulatory Coverage of Combustible Dust.

While these safety issues are discussed in detail throughout the report. CSB provides a summary of these issues on pages 173 - 183.

Safety Recommendations

This report concludes (pgs 183 – 186) with thirteen recommendations that could prevent the reoccurrence of an incident such as this. These include nine recommendations for Didion Milling, three for OSHA, and one for the NFPA.

Commentary

This is another of a long line of comprehensive reports from the CSB. It provides a detailed review of the processes involved and an in-depth discussion of the process safety management shortcoming that inevitably led to the incident. Interestingly, it does not, however, mention the criminal investigations and convictions of four Didion management employees for falsification of records related to the facility’s cleaning logs that I reported on in October. Safety oversights and misunderstandings are a large enough problem to overcome to prevent serious chemical incidents, but adding criminal malfeasance to situation is sure to exacerbate safety problems.

 

For more information about the details of this report, including a brief look at other combustible dust reports by the CSB, see my article at CFSN Detailed Analysis - https://patrickcoyle.substack.com/p/csb-publishes-didion-milling-investigation - subscription required.

CSB Addresses Combustible Dust Hazards

 

Yesterday the Chemical Safety and Hazard Investigation Board published a new document in its ongoing campaign to prevent combustible dust incidents. Not only was the document ‘new’ in a timeliness sense, but it is a new format for the CSB; a ‘Learning Review’ document.

Methodology

On October 24^th, 2018 the CSB issued a ‘call to action’ “to gather comments on the management and control of combustible dust from companies, regulators, inspectors, safety training providers, researchers, unions, and the workers affected by dust-related hazards.” As a result, he CSB received comments from 57 different entities about the problems and perceptions associated the combustible dust problem.

The results were provided to Dynamic Inquiry LLC for review. That company used a relatively new investigation technique called a “learning review” to analyze the responses. There is a brief discussion of that technique here and a paper on the topic here. In short, the technique tries to avoid a linear assessment of ‘blame’, but rather tries to determine:

• Why did it make sense for those workers to do what they did at that time?

• Were their choices part of otherwise normal operation?

• How can we change those processes to make the facility safer?

In this case, instead of looking at the facts associated with a single incident, Dynamic Inquiry took the comments from the 57 ‘call to action’ responses as the database upon which they assessed the problem of how to address the combustible dust problem.

Results

The Conclusion of the study determined that (pg 29):

“Replies from this voluntary outreach revealed many industry assumptions and challenges and also offered suggestions for improvement. Important and innovative topics emerged through the sensemaking phase of the Learning Review.”

It went on to explain that what new information that various parts of the study identified, including:

• Barriers to improvement explored how individuals and organizations approach risk.

• Controls examined the efficacy of traditional approaches to risk and hazard management. Reporting identified the importance of creating psychological safety in the workforce to facilitate the open sharing of information.

• Language and Communication revealed that even the words used to describe combustible dust can introduce vulnerabilities to the system and that effective communication within and between facilities is essential for safe practices.

• Learning was shown to be a function of the willingness to share information and change assumptions and was not guaranteed through traditional training methods.

• Sharing information was found to be the most desired and valued topic from respondents.

Commentary

Anyone looking to find concrete solutions to the combustible dust problem at a given facility is not going to find a great deal of help in this document. There is some information included in Appendix B that may be helpful. Here the report takes quotes from the various responses and groups them in categories like ‘awareness’ and ‘judgement & experience’. Anyone that has perused industry responses to requests for information will realize that this categorization of comments is very helpful for analysis, but finding useable brilliant nuggets of information in those comments is very unlikely.

This is my first exposure to a ‘learning review’ type assessment and I am not sure that it is really the most appropriate way of reviewing this type of data. The ‘facts’ being used here are not necessarily factual and are certainly clouded by the agendas of the individual commentators. It would be interesting to see a parallel chemical incident investigation done using the standard CSB investigative techniques and this learning review and to compare the recommendations that came out of each. I think that this would be very informative.

One question here; how much is the issuance of this ‘new’ type report being governed by the lack of governance at the CSB? The question is not meant to be malicious or casting aspersions at anyone at the CSB, but the CSB board only has one member. As such the agency is not legally able to reach conclusions about incidents or make recommendations to improve industry safety. How much of the issuance of this report is about the CSB remaining influential while legally impotent? There is nothing the CSB can do about their lack of a quorum; that is the President’s fault.