According to CSB Chaiman Carolyn Merritt:
This accident followed a classic syndrome we call 'normalization of deviation,' in which organizations come to accept as ?normal? fires, leaks or so-called small explosions. The company failed to investigate the smaller fires as abnormal situations needing correction or as warnings of potentially larger more destructive events. The CSB almost always finds that this behavior precedes a tragedy."Aside from grain dust, there is no OSHA standard that addresses combustible dust hazards.
The report refers to the National Fire Protection Association's NFPA 484 code as an important prevention document for companies to use to reduce the risk of such an explosion. "In this circumstance, NFPA 484 provisions were not being followed and the risk of such an explosion at this facility was extremely high," Chairman Merritt said.
The Hays Lemmerz explosion was the third combustible dust explosion investigated by the Board. The Board has also issued investigation reports of a 2003 dust explosion in North Carolina that killed six employees, and another dust expolsion in Kentucky less than a month later that killed seven. The Board is currently working on a comprehensive study on the prevention of combustible dust explosions in the United States.
But Boone's sister, Tammy Miser, has found some good coming out of the tragedy:
"I had a mini-breakdown today,” she said in a telephone interview from her Lexington, Ky., home. “I don’t think anything in the report is surprising to me.”(Disclosure: Tammy also compiles the "Weekly Toll" for Confined Space)
Miser has been busy since Boone’s death, founding an organization, United Support and Memorial for Workplace Fatalities, to raise awareness about workplace fatalities and support people who have lost loved ones.
The group is joining forces with organizations, including the National Council for Occupational Safety and Health, to begin a “Stop Corporate Killing Campaign.”
Miser said the report makes their understandings and perceptions of the explosion more "permanent," and gives them a leg to stand on as they try to push for stiffer regulations with the federal Occupational Safety and Health Administration.
"Now we’re finally starting to get different people together on these issues,” she said. "I was beginning to wonder if it was doing any good … something good is coming out of it."
The Board issued formal recommendations to Hays Lemmerz,
urging among other things that it develop and implement a means of handling and processing aluminum chips that minimizes the risk of dust explosions, and implement regular training on such hazards. The CSB recommended the Indiana Occupational Safety and Health Administration develop and distribute an educational bulletin on metal dust explosion prevention, and urged the Indiana Department of Fire and Building Services provide training for fire inspectors on recognition and prevention of combustible metal dust hazards.