2006年11月发生的CAI/Arnel墨水和油漆产品制造工厂发生了巨大的爆炸和火灾，因为CAI缺乏保障措施，例如警报和自动关闭，这将阻止10,000磅重的易燃溶剂混合物在无人看管的建筑中过热，所以美国化学安全委员会（CSB）在2008年5月13日公开的最终报告中说。
Steam heat to the mixing tank was most likely inadvertently left on by an operator before he left for the day. As the temperature increased, vapor escaped from the mixing tank, built up in the unventilated building, ignited, and exploded.
CSB的调查人员说，墨水制造商CAI没有遵守法规或适当的良好做法来处理易燃溶剂，CSB报告提议更改国家消防法规，并对国家许可和检查程序进行更改，以改善设施处理危险材料的安全性和监督。
Investigators said that on the night of the accident, ink base materials–including a volatile mixture of heptane and propyl alcohol–continued to heat and then boil after all the employees left work late in the afternoon. The heating was controlled by a single, manual valve that needed to be closed by an operator to prevent the 3,000-gallon tank from overheating.
The building ventilation system was turned off at the end of the workday–a routine procedure–and vapor coming out of the unsealed tank spread throughout the production area and then ignited from an undetermined source, possibly a spark from an electrical device. The explosion occurred at approximately 2:46 a.m. on November 22, 2006.
爆炸邻Danversportneighborhood, waking sleeping residents as windows were blown into bedrooms and shattered, ceilings fell, and belongings and appliances flew about. The blast wave damaged scores of homes. At least 16 homes and three businesses were damaged beyond repair, and approximately ten residents required hospital treatment for cuts and bruises. The fire department ordered the evacuation of more than 300 residents within a half-mile radius of the facility.
‘The community damage was the worst we have seen in the ten-year history of the Chemical Safety Board,’ said CSB Board Member William Wright, who accompanied the investigative team to the accident site. ‘As others have noted, this explosion had a serious potential for life-threatening injuries and fatalities.’
该设施由墨水制造商CAI和油漆制造商Arnel共享，被爆炸和随后的火灾完全摧毁，尚未重建。Arnel停止了操作，而CAI继续在马萨诸塞州乔治敦的一家设施中生产水基油墨。
Mr. Wright said, ‘The immediate cause of the accident was the overheating of a highly flammable mixture for many hours. We found an underlying cause was CAI’s failure to conduct a hazard analysis or other systematic review to ensure flammable liquids were safely handled during the manufacturing process.’
‘The company did not have automated process controls, alarms, or other safeguards in place. The standard practice at the company was to shut off ventilation at night – to retain heat in the building and to allay residential complaints about fan noise,’ Mr. Wright said. ‘When the mixture continued to overheat – absent automatic shutoffs and proper ventilation–the vapor accumulated and filled much of the building over a period of hours. Without safeguards, it is likely that a small but foreseeable human error led to disaster.’
CSB首席研究员John Vorderbrueggen，P.E。表示，应改进马萨诸塞州的消防法规和当地执法，以更好地保护社区和雇员。他说：“现有的马萨诸塞州消防法规（以及联邦OSHA标准）对通风易燃蒸气的要求，以防止结构内部的危险积累。但是马萨诸塞州并未采用最新的易燃液体消防法规。我们的调查还发现，尽管该州要求当地消防部门定期检查处理易燃材料的设施，但法律并未指定进行这些检查的任何检查频率或标准。
The CAI/Arnel facility was last inspected by the fire department in 2002, but the inspection focused on a newly installed fire suppression system and did not identify fire code or permitting violations. In addition to the inadequate ventilation that contributed to the accident, non-causal fire code violations included improper venting of flammable storage containers, use of improper hoses for flammable service, and lack of fire walls.
根据马萨诸塞州的一般法律，CAI/Arnel财产必须获得易燃材料的土地使用许可。The only license, first issued to a predecessor company in 1944 and re-registered annually thereafter, initially authorized the presence of 250 gallons of ‘lacquer.’ In 1955, the property owners were granted an amended license by the Danvers Board of Selectmen to store and use 6,000 gallons of ‘miscellaneous’ flammable materials.
在200年的事故6, the registration record on file with the Town of Danvers referenced a ‘license’ to store and handle up to 11,500 gallons of ‘miscellaneous’ flammable materials. However, the CSB found no record of such a license in the Danvers town files. Therefore, the CSB concluded, the current licensed amount was 6,000 gallons, well below the more than 20,000 gallons of flammable liquid and more than 50,000 pounds of flammable solid, nitrocellulose, stored on site.
CSB发现，马萨诸塞州法律尚不清楚城镇批准增加要增加易燃物品的要求和程序，包括在工业场所存储的燃料量，包括是否应向相邻的财产所有者通知预期的增加。调查还指出，该州的许可和注册表不需要有关存储的特定类型和数量的信息。
A CSB survey of six Massachusetts municipalities–including Boston, Worcester, Springfield, Danvers, Leominster, and Georgetown–found significant variability in how state licensing and registration laws are applied. Although the six municipalities issued a total of more than 400 flammable materials licenses, only two reported ever having denied a license application.
In addition to a license, Massachusetts regulations require companies to obtain separate permits from the local fire department for the storage of flammable liquids, gases, and solids. However, at the time of the explosion in Danvers, no permits had been obtained by or issued to CAI or Arnel, except an expired permit for underground storage tanks. The lack of permits had not been previously identified by the fire department.
Based on the quantities of flammable materials used, CAI but not Arnel was required to comply with OSHA’s Process Safety Management standard, which would have required the company to conduct a process hazard analysis. Such a review could have identified the need for more sophisticated process control equipment, operator checklists, and continuous building ventilation. The standard also requires the use of written operating procedures, which can reduce the occurrence of human errors.
但是，CAI管理层表示，该公司不知道流程安全管理标准的存在，也没有实施其要求。OSHA在事故发生前没有检查过该设施。
Finally, the report stated that national model fire codes developed by theNational Fire Protection Association (NFPA)和International Code Council (ICC)请勿为建筑物内加热的易燃液体提供足够的保障措施。该标准是自愿的，除非州和地区专门采用，否则该标准包含有关过程船舶的含糊语言，并且不明确要求自动关闭或冷却系统以防止意外过热和不受控制的易燃蒸气释放。
CSB在2006年在一家芝加哥地区混凝土产品公司进行了类似的事故，该公司在那里装满了七烷的船只在一座未通风的建筑物内意外过热，造成爆炸炸死驾驶员并造成财产损失。
调查报告提出了许多安全建议，董事会将考虑。该报告调用NFPA(based in Quincy, Massachusetts) and the ICC to revise the national fire codes to prohibit the heating of flammable liquids inside buildings in unsealed tanks that do not vent outside and to require automatic safeguards to prevent overheating.
该报告调用Massachusetts legislature to require companies to certify compliance with state fire codes and safety regulations, to require public input before allowing companies to increase the quantities of licensed flammable materials, and to require the Office of the State Fire Marshal to audit localities’ compliance with licensing and permitting requirements.
Other proposed recommendations call on the state’s Office of Public Safety to adopt current national fire codes for handling flammable liquids (NFPA 30) and manufacturing of coatings (NFPA 35），为消防部门检查制造设施检查的标准和强制性频率，并需要许可和注册表格，以专门列出每种危险材料的类型和数量。
Pending completion of the recommended changes at the state level, the report calls for the Town of Danvers to undertake similar initiatives for certification, licensing, and inspection. Additional, specific safety recommendations were directed to CAI, in the event the company resumes solvent-based processing at another location. The draft report’s findings, statements of cause, and recommendations are all subject to approval by a vote of the Board and are subject to change.
For more information, contact Director of Public Affairs Dr. Daniel Horowitz at (202) 441-6074 (cell), Public Affairs Specialist Hillary Cohen at (202) 446-8094 (cell), or Sandy Gilmour at (202) 251-5496 (cell).
