West explosion investigation finds lack of protection

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The Chemical Safety Board released preliminary findings into the April 17, 2013, West Fertilizer explosion and fire in West, Texas, which resulted in at least 14 fatalities, 226 injuries and widespread community damage. Large quantities of ammonium nitrate (AN) fertilizer exploded after being heated by a fire at the storage and distribution facility. The CSB’s investigation focuses on shortcomings in existing regulations, standards, and guidance at the federal, state and county level. 

The investigative team’s presentation will occur this evening at a public meeting in West, Texas, at 5:30 pm CDT.  

CSB Chairperson Rafael Moure-Eraso said, “The fire and explosion at West Fertilizer was preventable. It should never have occurred. It resulted from the failure of a company to take the necessary steps to avert a preventable fire and explosion and from the inability of federal, state and local regulatory agencies to identify a serious hazard and correct it.”

The CSB’s investigation found that at the state level, there is no fire code and in fact counties under a certain population are prohibited from having them. “Local authorities and specifically—local fire departments—need fire codes so they can hold industrial operators accountable for safe storage and handling of chemicals,” said Dr. Moure-Eraso.

CSB Supervisory Investigator Johnnie Banks said “The CSB found at all levels of government a failure to adopt codes to keep populated areas away from hazardous facilities, not just in West, Texas. We found 1,351 facilities across the country that store ammonium nitrate.  Farm communities are just starting to collect data on how close homes or schools are to AN storage, but there can be little doubt that West is not alone and that other communities should act to determine what hazards might exist in proximity.”

The CSB’s preliminary findings follow a yearlong investigation which has focused on learning how to prevent a similar accident from occurring in another community. “It is imperative that people learn from the tragedy at West,” Dr. Moure-Eraso said.

The investigation notes other AN explosions have occurred, causing widespread devastation. A 2001 explosion in France caused 31 fatalities, 2500 injuries and widespread community damage. In the United States, a 1994 incident caused 4 fatalities and eighteen injuries. More recently a July 2009 AN fire in Bryan, Texas, led to an evacuation of tens of thousands of residents. Fortunately no explosion occurred in the Bryan, Texas, incident which highlights the unpredictable nature of AN.

The CSB’s investigation determined that lessons learned during emergency responses to AN incidents – in which firefighters perished --  have not been effectively disseminated to firefighters and emergency responders in other communities where AN is stored and utilized.

The CSB has found that on April 17, 2013, West volunteer firefighters were not aware of the explosion hazard from the AN stored at West Fertilizer and were caught in harm’s way when the blast occurred.

Investigators note that the National Fire Protection Association (NFPA) recommends that firefighters evacuate from AN fires of “massive and uncontrollable proportions.” Federal DOT guidance contained in the Emergency Response Guidebook, which is widely used by firefighters, suggests fighting even large ammonium nitrate fertilizer fires by “flood[ing] the area with water from a distance.”  However, the investigation has found,  the response guidance appears to be vague since terms such as “massive,” “uncontrollable,” “large,” and “distance” are not clearly defined.

Investigator Banks said, “All of these provisions should be reviewed and harmonized in light of the West disaster to ensure that firefighters are adequately protected and are not put into danger protecting property alone.”

The CSB has previously noted that while U.S. standards for ammonium nitrate have apparently remained static for decades, other countries have more rigorous standards covering both storage and siting of nearby buildings. For example, the U.K.’s Health and Safety Executive states in

guidance dating to 1996 that “ammonium nitrate should normally be stored in single story, dedicated, well-ventilated buildings that are constructed from materials that will not burn, such as concrete, bricks or steel.”  The U.K. guidance calls for storage bays “constructed of a material that does not burn, preferably concrete.”

At the county level, McLennan County’s local emergency planning committee did not have an emergency response plan for West Fertilizer as it might have done under the federal Emergency Planning and Community Right to Know Act.  The community clearly was not aware of the potential hazard at West Fertilizer.

Chairperson Moure-Eraso commended recent action by the Fertilizer Institute in establishing an auditing and outreach program for fertilizer retailers called ResponsibleAg, and for disseminating with the Agricultural Retailers Association a document called “Safety and Security Guidelines for the Storage and Transportation of Fertilizer Grade Ammonium Nitrate at Fertilizer Retail Facilities.” It also contains recommendations for first responders in the event of a fire. 

“We welcome this very positive step,” Dr. Moure-Eraso said, “We hope that the whole industry embraces these voluntary guidelines rather than being accepted only by the companies that choose to volunteer.”

The Chairperson called on states and counties across the country to take action in identifying hazards and requiring the safe storage and handling of ammonium nitrate. “Regulations need to be updated and new ones put in place. The state of Texas, McLennan County, OSHA and the EPA have work to do, because this hazard exists in hundreds of locations across the U.S.  However, it is important to note that there is no substitute for an efficient regulatory system that ensures that all companies are operating to the same high standards. We cannot depend on voluntary compliance.”

The CSB is an independent federal agency charged with investigating serious chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.


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