Investigation Report
Sierra Chemical Co. High Explosives Accident — Sierra Chemical Co. Final Report
Sierra Chemical Co. High Explosives Accident — Sierra Chemical Co. Final Report
- CSB
- Investigation Report
- Unknown
- ExplosionHuman factorsIncident investigationProcess safetyStatic electricity
- Hand toolsRotating machinery
- Competence and trainingManagement of changeOperating and work proceduresRisk assessment
- Downstream and process industries
- Onshore facility
Summary
Investigates two explosions at Sierra Chemical’s Nevada explosives plant that killed four workers and injured six. The report favours mixer startup against solidified explosives but retains alternative initiating scenarios. Physical, seismic and metallurgical analyses support the reconstruction, while findings address deficient hazard analysis, procedures, training, change management and building separation.
Classifications: Explosion; explosive atmospheres.
Classifications: Human factors; human performance; ergonomics.
Classifications: Incident investigation; accident investigation.
Classifications: Process safety; major accident hazards.
Classifications: Static electricity; electrostatic discharge.
Classifications: Hand tools; hand-held tools; handheld tools.
Classifications: Rotating machinery; rotating equipment.
Classifications: Competence and training; competency assurance; safety training.
Classifications: Management of change; MOC; change management.
Classifications: Operating and work procedures.
Classifications: Risk assessment; hazard assessment.
Classifications: Downstream and process industries; refining; petrochemicals.
Classifications: Onshore facility; onshore plant.