Opportunity Lost: Repeat Incidents Involving Combustible Dust in Metal Powder Facility Leads to Five Fatalities

摘要

When the third worker injured in a fiery explosion at a metal powders production facility died in July 2011, his death marked the end of a string of three tragic incidents at the facility that resulted in five worker fatalities and injuries to three more. The failure to effectively address the causes of these incidents from the outset is striking for a number of reasons, but particularly because of multiple failures to effectively reduce or eliminate the threat posed by the material being processed and prevent the initial or recurring events. This paper will examine some of those unheeded warning signs, and the circumstances of each incident that unfolded in light of the failure to address the causes.