BPS3453 ACCIDENT INCIDENT INVESTIGATION & ANALYSIS

NURSUHAIDA BINTI KAMARULZAMAN (PA12063)

INCIDENT INVESTIGATION REPORT

Background of Company
Name of Company:
Code:
Carbide Industries
No. 2011-05-1-KY
Address:
Type of Operation:
LLC, Louisville, KY
Production of Calcium Carbide
Information of The Event/Incident
Day/Date :
Monday, 21st March 2011 Time :

5.40
pm

Location :
Carbide Industries plant
Event/Incident :
Electric Arc Furnace (EAF) Explosion
Total of fatality:
Total of Injured:
2 workers
2 workers
Executive Summary
On March 21, 2011, during calcium carbide production at the
Carbide Industries plant in Louisville, KY, an electric arc furnace
exploded, ejecting solid and powdered debris, flammable gases,
and molten calcium carbide at temperatures near 3800F
(2100C). Two workers died and two others were injured.
Initial Assessment
Type of Events
Accident
Ill HeathBasic Near
Misses
Dangerous
Causes
Personal Factors
Y/N
Job Factors Occurrence
Y/N
Inadequate
Inadequate
capability
Detail
of The
Accident/Incident/Event
Actual/Potential
For Harm
leadership/supervision
Serious
Minor work standards
Damage Only
LackFatal/
of knowledge
Inadequate
LackMajor
of skill
Inadequate engineering
Y
Immediate Causes
Improper
Inadequate maintenance
Y
motivation
Y/N
Substandard Condition
Stress
YInvestigation
Wear and Level
tearSubstandard Action
Y
Others
Y
High
MediumY Others
Low Level
Minimal
Operating equipment
without
Inadequate ventilation
Level
Level
authority

Failure to warn
Y High or low temperature
exposure
Failure to secure
Y Poor housekeeping/disorder
Horseplay
Fire and explosion hazards
Making safety devices
Inadequate warning system
inoperable
Removing safety devices
Congestion or restricted action
Failing to use personal
Y Inadequate or improper
protective equipment properly
protective equipment
Improper placement
Others
Location of
victims

Root Causes Analysis

Y/N

Y
Y

Operating equipment without

authority
Others
Y Incident
Description of The
At about 5:40 pm on Monday, March 21, 2011, the EAF at the
Carbide Rubber town facility violently over pressured, ejecting solid
and powdered debris, hot gases, and molten calcium carbide at
temperatures near 3800F (2100C). Witnesses reported an initial
overpressure event from the furnace, a large explosion, and and two
to three more overpressure events. The cloud of debris and smoke
traveled high enough to obscure the five-story furnace building.
The hot gases and debris blown from the furnace broke through the
double-pane reinforced glass window of the control room, severely
burning the two workers inside; they died within 24 hours from their
injuries.
Hot material also was ejected from the active tap hole on the
mezzanine level. One worker was in an operating shack about 30
feet from the tap hole. The door to the shack was a jar, and he
crouched to the floor, seeking shelter from the hot gases and dust
that engulfed him. He received a minor burn to the back of his neck,
but did not seek medical treatment. Another worker was walking
away from the furnace when the explosion knocked him to the
ground and the hot gases and debris engulfed him. He was taken to
a maintenance area, where he was given oxygen and his vital signs
monitored. He was later taken to the hospital for observation and
subsequently released.

Corrective Action/ Measure

The control room should be relocated and cameras installed to better protect workers while they remotely monitored the furnace.

Built a new furnace cover or alert the leakage with immediately maintenance.

The company should have a process safety management in place that required the elimination of overpressure incidents in the furnace.

NFPA 86 should specify requirements for electric arc furnaces operating as Class A furnaces.
Preventive Action

Establish a committee to evaluate and develop a standard that defines the safety requirements for electric arc furnaces operated with

flammable materials and low oxygen atmospheres.

Modify the design and procedures for the electric arc furnace and related structures including the control room to comply with the NFPA

standard developed per R1 of this case study.

Implement a mechanical integrity program for the electric arc furnace and cover, including preventive maintenance based on periodic
inspections, and timely replacement of the furnace cover. At a minimum, the program should include factors such as leak detection and
repair and refractory lining wear.
-

Lack of awareness
Not suitable attire working
in high temperature
Lack of knowledge in
maintenance/repair the
furnace

Not fully maintain

Failed to follow the
operating procedure in
a right ways

Metho

Peopl

Air
pollution
Exposed
to
hazardous

Electric Arc
Furnace
Explosion

Environment

Materia
Machine

Leakage
- Eruption of hot liquid from the
furnace
- Thinning of the refractory
lining, fouling and the

1.
2.
3.
4.
5.

Management

Carbide-forming
reaction generated
sufficient energy to
emit hot materials
from inside the
furnace
Overpressure to
flammable gases

Reported by:

Position:

Nursuhaida bt
Kamarulzaman

Safety & Health

Officer

Signature:

Reviewed by:

Position:

Dato Zainal b. Rizal

General Manager

Investigation Team Members

Name
Job Position
Jalal b. Hasan
Safety, Health &
Environmental Manager
Sharifah bt Hashim
Process Engineer
Saleha bt Saman
Safety Supervisor
Saleh b. Yakuub
Technician
Hamzah b. Salleh
Senior Operator

Not provide previous report of incident to

determine the root cause
Inadequate process safety management
Failed to provide better protection to the
workers

Date:
15 Nov 2014

Signature:

Date:
16 Nov 2014