The investigators' report was released to the public at a public meeting held May 14 in Washington, DC.
The explosion occurred March 21 last year while workers were producing nylon-related plastic. After aborting an attempt to start the process, an unusually large amount of waste plastic entered the catch tank, setting of an unexpected chemical reaction.
The reaction produced high gas pressures inside a hot molten core of liquid plastic that was surrounded by a hard plastic shell. When unsuspecting workers removed half the bolts from the cover of the catch tank, the remaining bolts gave way and the cover blew off. Hot plastic poured out and three workers perished.
In a report to board members at the May 14th meeting, the investigative team cited the following root causes of the incident:
- Amoco did not adequately review the process design to identify chemical reactive hazards;
- The Augusta facility did not have an adequate review process for correcting design deficiencies;
- The plant's system for investigating previous incidents and near-misses failed to identify causes and hazards.
During the presentation, lead investigator Stephen Selk emphasized the importance of unrecognized design deficiencies as an essential cause of the fatal blast. "Don't build things that get plugged up," he declared.
The facility is still producing Amodel, the product that caused the explosion, but the plant is now owned by Solvay Advanced Polymers. The company spent $10 million redesigning the process, according to Arthur Viebrock, maintenance team leader for Solvay.
"We've taken all the energy out of the process," he said. "The waste material is not hot anymore."
A spokesperson for the company agreed with all of CSB's recommendations and pointed out that most of them have already been implemented. "We have put together a chemical reactive matrix, as they suggested and we now track and code all our near-misses by type," said Solvay spokesperson Pamela Barbara.
But Barbara did not accept everything in the CSB report. "We take issue with the point that this was avoidable, that we knew there were problems, and that we could have done something about it," she commented. "Hindsight is wonderful, but we did not know there were problems - for us this was an unforeseen chemical reaction."
CSB investigators argued that the company should have known that a chemical reaction was possible, and should have designed the process more safety with that in mind.
Beginning with the CSB's vote on Aug. 24, 2000 to adopt the investigation report of the 1998 Morton Specialty Chemical explosion in Paterson, N.J., every CSB investigation report concludes the chemical incident that was investigated "could have been prevented."
CSB board members must review and accept the investigators' report on the BP Amoco explosion before the findings of fact and recommendations to prevent similar incidents become official.