MOS 5101
SAFETY AND ACCIDENT PREVENTION
Case Study
MOS 5101-18N-SU21L-S1
Master of Science Occupational Safety & Health
Hoeganaes Corporation: Gallatin,
TN
Hoeganaes Corporation is a producer of atomized steel and iron powders and is a
subsidiary of GKN. The Hoeganaes Corporation facility where the incidents occurred
employs a workforce of about 200 and has a manufacturing capacity of 300,000 tons
of powdered metal that are used by various industries in the world.
Work
Process
The Hoeganaes facility receives and melts scrap steel. Various elements are added to the
molten metal according to customer’s requirements and when cooled, the molten metal
is milled into coarse powder that is then processed in annealing furnaces to make the
metal more ductile. During the process, hydrogen is provided in the furnace to remove
oxides in the metal to prevent oxidation. The hydrogen is supplied by an on-site
contractor through pipes located in a trench under the floor and covered by metal plates.
The coarse powder
is then processed into a thick sheet and sent to a breaker to be crushed into the
finished product, powdered metal.
Incident
s
, There were three notable incidents that occurred within five months of 2011 that
resulted in a total of five fatalities and three injuries to the employee. From the study of
the incidents, a risk assessment of the fire hazard is performed using the Risk Matrix
from Appendix 1 and is as follows:
S/No Hazards Risks Severity Likelihood Risk
Factors
1 Poor housekeeping resulting in Fire, explosion 5 4 20
metal dust accumulation
2 Poor maintenance regime Fire, explosion due 5 4 20
resulting in leaking of hydrogen to introduction of
gas in pipe trench heat source
From the risk assessment performed, the main causes of the three incidents can be
attributed to poor housekeeping and lack of proper maintenance regime/schedule. As
read in the investigation report by CSB, the first two incidents occurred due to an
accumulation of combustible metal dust in the surrounding area of the incidents and
when the employees of Hoeganaes went to conduct repairs and maintenance, the dust
was disturbed and spread through the atmosphere which resulted in a fire when the dust
came in contact with air and heat. The third incident was a result of a lack of
maintenance regime and instructions to mitigate leaks of gases from the pipe trench.
There was no written procedure for the team to mitigate the risk of investigating and
repairing damage of pipe in the trench and this resulted in them doing what they thought
was right and it resulted in a disaster for the team.
Applicable OSHA Standards
From the case study report, the applicable OSHA standards I believe can be applied to
the hazards are firstly, Section 5(a)(1) of the OSH Act (https://www.osha.gov/laws-
SAFETY AND ACCIDENT PREVENTION
Case Study
MOS 5101-18N-SU21L-S1
Master of Science Occupational Safety & Health
Hoeganaes Corporation: Gallatin,
TN
Hoeganaes Corporation is a producer of atomized steel and iron powders and is a
subsidiary of GKN. The Hoeganaes Corporation facility where the incidents occurred
employs a workforce of about 200 and has a manufacturing capacity of 300,000 tons
of powdered metal that are used by various industries in the world.
Work
Process
The Hoeganaes facility receives and melts scrap steel. Various elements are added to the
molten metal according to customer’s requirements and when cooled, the molten metal
is milled into coarse powder that is then processed in annealing furnaces to make the
metal more ductile. During the process, hydrogen is provided in the furnace to remove
oxides in the metal to prevent oxidation. The hydrogen is supplied by an on-site
contractor through pipes located in a trench under the floor and covered by metal plates.
The coarse powder
is then processed into a thick sheet and sent to a breaker to be crushed into the
finished product, powdered metal.
Incident
s
, There were three notable incidents that occurred within five months of 2011 that
resulted in a total of five fatalities and three injuries to the employee. From the study of
the incidents, a risk assessment of the fire hazard is performed using the Risk Matrix
from Appendix 1 and is as follows:
S/No Hazards Risks Severity Likelihood Risk
Factors
1 Poor housekeeping resulting in Fire, explosion 5 4 20
metal dust accumulation
2 Poor maintenance regime Fire, explosion due 5 4 20
resulting in leaking of hydrogen to introduction of
gas in pipe trench heat source
From the risk assessment performed, the main causes of the three incidents can be
attributed to poor housekeeping and lack of proper maintenance regime/schedule. As
read in the investigation report by CSB, the first two incidents occurred due to an
accumulation of combustible metal dust in the surrounding area of the incidents and
when the employees of Hoeganaes went to conduct repairs and maintenance, the dust
was disturbed and spread through the atmosphere which resulted in a fire when the dust
came in contact with air and heat. The third incident was a result of a lack of
maintenance regime and instructions to mitigate leaks of gases from the pipe trench.
There was no written procedure for the team to mitigate the risk of investigating and
repairing damage of pipe in the trench and this resulted in them doing what they thought
was right and it resulted in a disaster for the team.
Applicable OSHA Standards
From the case study report, the applicable OSHA standards I believe can be applied to
the hazards are firstly, Section 5(a)(1) of the OSH Act (https://www.osha.gov/laws-
