(WHAS11) -- An explosion that killed two Carbide Industries workers in Rubbertown in March 2011 resulted from the company's failure to investigate and maintain equipment involved in previous incidents, according to a U.S. Chemical Safety Board (CSB) draft final report on the accident released Thursday.
The CSB approved the findings in the report and also had a moment of silence before the meeting began to remember the two men who died.
"Carbide displayed a chronic lack of commitment to figuring out what was going wrong, ignoring all the warning signs, even as its workers were exposed to a potential massive explosion just a few feet away from their control room,” said CSB Chairperson Rafael Moure-Eraso.
“This accident is literally a case study into the tragic, predictable consequences of running equipment to failure even when repeated safety incidents over many years warn of impending failure," Moure-Eraso said.
"When control room windows blew out during previous furnace incidents, the company merely reinforced them," Moure-Eraso said in the CSB news release, "rather than taking the safe course and moving the control room farther from the furnace and investigating why the smaller furnace overpressure events were happening in the first place. It is what we call a ‘normalization of deviance,’ in which abnormal events become acceptable in everyday operations.”
Two workers were killed and two were injured when an electric arc furnace over-pressured and emitted powdered debris, hot gases, and molten calcium carbide. The facility supplies calcium carbide primarily to the iron and steel industry and to acetylene producers. It employs about 160 workers.
“Carbide Industries has been supportive of the CSB’s investigation since the incident occurred," said plant manager John Gant in a statement to WHAS11, "and has addressed all of the recommendations made by the CSB as a result of that investigation. Additional safeguards and policies have been implemented that will further strengthen the safety and environmental performance at Carbide Industries. We appreciate the help and support that the CSB has provided over the past two years.”
Though the Chemical Safety Board does not issue citations or fines, the federal agency does make safety recommendations.
The CSB lead investigator alleges repeated instances of the plant making temporary fixes to malfunctioning equipment.
"One of our key findings was that Carbide Industries issued 26 work orders to repair water leaks on the furnace cover in the five months prior to the March 2011 incident," said Johnnie Banks. "It was distressing to find that the company nonetheless continued operating the furnace despite the hazard from ongoing water leaks. We also found that the company could have prevented this incident had it voluntarily applied elements of a process safety management program, such as hazard analysis, incident investigation, and mechanical integrity.”
“My personal opinion is that’s criminal and it's a shame in this country today that it's not treated as criminal,” said one member of the audience.
Banks noted, however, that Carbide industries was not required to follow the OSHA Process Safety Management standard, since the company did not use threshold amounts of covered hazardous chemicals.