Chemical incident investigation: new approaches by the chemical safety and hazard investigation board

摘要

The new federal Chemical Safety and Hazard Investigation Board (CSB) has independent and broad federal responsibility to investigate chemical releases,research safety issues and recommend improvements in the safety management of chemicals.On January 7,1998 two explosions in rapid succession destroyed the Sierra Chemical COmpany's Kean Canyon facility new Mustang.NV,killing four workers and injuring three others.Data and analyses from the investigation identified the most probable initiating event and the equipment,management systems,manufacturing process and human-performanc efailures that led to the accident in the explosives,melt-pour manufacturing faility.Using this example and several other investigations,the paper delineatesthe following: organization of CSB,notificatin about chemical incidents,coordination with public and private parties at on site investigations,investigation protocols,report preparation and dissemination,staff and board member responsibilities,recommendations and lessons learned.