Abstract

The Hoeganaes Corporation facility in Gallatin Tennessee is a primary provider of iron

parts fashioned from the pressing and sintering of metal powder. Fine particles of iron
metal dust, when dispersed in the air in the presence of an ignition source, can combust
and cause flash fires. Flash fires were somewhat normality at the Hoeganaes facility,
though not usually resulting in serious injury. Until the January 31, 2011 incident, none
had resulted in severe injury or loss of life due to flash fire injuries. [3]
The first incident was the result of a dispersion of fine iron dust into the air that found an
ignition source engulfing both nearby employees, causing both to be seriously injured one
who would evenly succumb to injuries. The ignition source came from the start-up and
vibrations of the motor. The second incident was the result of a worker performing repair
work on a gas line for a furnace. The worker decided to use a hammer to get the gas line in
place when the force of the hammer had dispersed iron dust into the air, and it ignited
burning the engineer resulting in 1st and 2nd-degree burns. The third incident was the
consequence of a gas leak in a pipeline trench. Highly flammable hydrogen leaking from
piping caused a powerful explosion from metal sparks. The force of the blast shook the
building rafters that shed iron dust that would fall and ignite when coming into contact with
the fire. [3]
An operation involving the handling of metal dust is required by the National Fire
Protection Association (NFPA) to perform at least one of two screen tests to evaluate the
combustibility of the metal dust. [2] Through a prior insurance inspection, Hoeganaes was
made aware of the combustible properties of the iron metal dust two years before the first
incident occurred. Rather then putting more rigorous safety procedures in place the
company seemed to ignore the warnings. Instead of instilling proper engineering controls,
and housekeeping, the only change within the facility was an operation training program.
Representatives from Hoeganaes initiated the training program in response to the dust
analysis, which did not ultimately help mitigate the hazard. Still, this training was not
enough to teach employees on how to avoid flammable gas fires and explosions. The CSB,
Chemical Safety Board, used combustible dust testing to analyze dust particles for
explosivity and flammable properties. The CSB performed a combustibility demonstration,
Twenty-Liter Test, and One-Meter Cubed Test. Each test had shown conclusive results for
combustibility. [1] Despite the definite hazard of iron dust particles in the facility, OSHA
did not include the industrial classification code in its Combustible Dust Emphasis
Programs in either of the publications release up to 2008. Even with the City of Gallatin
adopting the International Fire Code for Combustible Dust, Hoeganaes was not forced into
more comprehensive and rigorous NFPA standards to prevent dust fires and explosions.
The three severe incidents at the Gallatin Hoeganaes facility were the result of poor
engineering and administrative controls, housekeeping, and a lack of overall knowledge on
what should be held standard to prevent fatal flash fires and explosions due to combustible
dust. [3]
Introduction

The Hoeganaes Corporation is a global engineering and manufacturing company that

produces metal powder and product solutions for automotive and industrial markets.
Hoeganaes has facilities throughout the United States, Germany, China, and Romania that
provide a large amount of powdered metal to many consumers, that press and sinter the
powdered metal into small metal parts. The Hoeganaes Gallatin facility first became
operational in 1980 and had employed nearly two-hundred men and women. Since the
establishment of the Gallatin facility, Hoeganaes has increased production by over five-
hundred fifty percent, with the main product being a powder that was ninety-nine percent
iron. Despite many previous incidents that did not result in the loss of life, the Hoeganaes
company would fail to instill more safe practice into their process. [3]
In 2011 the Gallatin facility endured three accidents throughout a short four-month period
that resulted in three employees severely injured and five fatalities. These accidents were
due to the dispersion of dust particles throughout the plant that would find an ignition
source resulting in dust explosions and flash fires. The combustibility of metal is not a
newly established hazard in the industry in general. The NFPA, National Fire Protection
Association, and publications from as early as the 1940s describing metal dust, including
iron, give detailed information on the hazards and explosion protection methods for all
types of dust that are available to help prevent incidents. Building construction and fire
codes provide designing specifications, maintenance recommendations, and proper
equipment to specify proper methods for use to minimalize or prevent incidents involving
dust. [1] This case study is an effort to evaluate the three incidents that took place on
January 31 March 29, and May 27 2011, in hopes to deliver a clear description of the
process, a concise timeline of events, results analysis for each event, a determination of the
root of causes and an evaluation of the lessons learned from each incident. [3]

Process Description

Figure 1: Bucket Lift Feeding Crushed Metal Figure 2: Molten Iron Poured into a Thin Stream.[6]
into a Furnace. [6]

The Hoeganaes facility in Gallatin, TN, and the Hoeganaes Corporation is a leading
provider of steel and iron parts fashioned from metal powder. Powder metallurgy is a green
process of using scrapped metal to engineer new metal parts. [6] Hoeganaes receives and
melts scrap metal into molten metal where they can add in various metals if specified by
 the customer. The scrap is crushed and compact before grappled and lift into a furnace.
They use high-pressure water jets to atomize the steel into fine metal powders as it exits
the furnace as a thin stream of molten metal. The iron particles are dried and ground into
the desired size distribution. The dried iron granules are then reduced in a decarburizing
furnace in order to reach fixed chemical composition and metallurgical properties. At this
point additives can be introduced, for example, pure iron is too soft so different metals may
be added into the molt in order to strengthen the steel and make it harder. [3] This initial
reduction takes 60 hours in a gas fired tunnel kiln at around 1200oC. Direct reduction of
iron is a solid-state process that reduces the amount of iron oxides present into metallic
iron at temperatures below the melting point of iron. As the powder goes through the
furnace it forms into a thick sheet referred to as a cake. Once the molten metal hardens into
a thick cake it is milled into a grainy powder that is then fed into an annealing furnace,
band furnace, to improve the iron ductility. Hydrogen gas is transported to the furnaces
through pipelines located in a trench below
the floor and covered by metal plates. The
long conveyor, or band, feeds the powdered
iron into the hydrogen atmosphere of the
furnace in order to reduce the iron further.
The final product is screened to achieve a
particle with a diameter between 45-150
micro-meters before being packaged and sent
to the customer. [5] As the iron powder
Figure 3: Iron Cake Leaving Gas Fired Tunnel Kiln.
travels through the facility it is transported by
a system of conveyors and bucket elevators. The belts on the bucket elevators were attached
to motors that had to be kept within alignment to work properly. A dust collection baghouse
is used to filter any dust left behind from moving the iron powder throughout the facility.
[6]

Ultimate Results

The first fatal incident at the Hoeganaes facility in Gallatin TN resulted in two employees
being severely burned over a large percentage of their body. Both were transported to the
Vanderbilt Burn Center in Nashville TN, and later succumbing to their injuries one passing
two days later and the other surviving four short months after the incident. This incident
spurred an investigation by the CSB, who observed, and test dust accumulated on
machinery, rafters, and the floor. Even after the findings of the combustibility tests showing
all samples taken were combustible there was no complete overhaul of the dust
containment and housekeeping procedures at the Gallatin facility. [3]
During the second incident on March 29, 2011 involved two workers, one had escaped the
area without injury and the other had been injured. The injured technician was able to leave
without server burns due to personal protective equipment and a FRC rated jacket that
protected his upper torso from the flash fire. After this incident the Gallatin facility was
visited by the local fire department, but the documented observation did not note any
combustible dust hazards only emergency egress and fire suppression.[3]
An incident occurring on May 27, 2011 seen the loss of life to two more employees, another
hospitalized for several years due to the severity of injuries, and two employees injured but
released same day from the hospital. After this incident the Gallatin Hoeganaes facility
would shut down for nearly a month to address a full plant safety review and was forced to
cooperate with Tennessee OSHA and the U.S. Chemical Safety Board to evaluate the direct
cause of the accident. After the first incident the CSB investigation noted holes in the
Hydrogen gas piping, but a full repair of the pipeline was never conducted. In total the
Hydrogen gas explosion and subsequent dust fires resulted in nearly thirty-seven million
USD in damages and cost of loss of workdays. In November 2011 Tennessee OSHA issued
Hoeganaes Gallatin Facility citations for the third incident. Fifteen OSHA PSM standard
violations related to the hydrogen gas system. [3]
References

1. “Basic Principles of Flash Fires.” Guidelines for Evaluating the Characteristics of Vapor Cloud
Explosions, Flash Fires, and BLEVEs, 2010, pp. 147–156., doi:10.1002/9780470938157.ch5.
2. Ben Peetz. “Combustible Dust Fires and Explosions.” Fire Engineering, 3 Sept. 2019,
www.fireengineering.com/2012/03/01/302300/combustible-dust-fires-and-explosions/.
3. Case Study, CSB. “Hoeganaes Corporation Fatal Flash Fires.” CSB, Dec. 2011,
www.csb.gov/hoeganaes-corporation-fatal-flash-fires/.
4. L.Cashdollar, Kenneth. “Overview of Dust Explosibility Characteristics.” Journal of Loss
Prevention in the Process Industries, Elsevier, 21 Apr. 2000,
www.sciencedirect.com/science/article/pii/S095042309900039X.
5. Iron-consortium.org. (2019). iron manufacturing process description. [online] Available at:
https://www.iron-
consortium.org/assets/files/sief/Iron_ManufacturingProcessDescription_Dec2013_clean.pdf
[Accessed 6 Nov. 2019].
6. Youtube.com. (2019). YouTube. [online] Available at:
https://www.youtube.com/watch?time_continue=47&v=piAINJSp9Fs [Accessed 6 Nov. 2019].