Burned Alive at Work: American Workers Dying in Totally Preventable Accidents
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GALLATIN, Tenn. — Small fires were a part of the job at the Hoeganaes Corp. metal powder plant 30 miles northeast of Nashville. By early 2011, some workers later told investigators, they had become practiced in beating down the flames with gloved hands or a fire extinguisher.
The company’s own product fueled the fires. Scrap metal rolls into therust-colored plant on the town’s industrial periphery and is melted, atomized and dried into a fine iron powder sold to makers of car parts. Sometimes, powder leaked from equipment and coated ledges and rafters. Under the right conditions, it smoldered.
Wiley Sherburne, a 42-year-old plant electrician, sometimes told his wife how this dust piled up everywhere, she recalled. On quieter weekend shifts, he said he could hear the telltale popping sound of dust sparking when it touched live electricity.
In the early morning of January 31, 2011, Sherburne was called to check out a malfunctioning bucket elevator that totes dust through the plant. Near his feet, electrical wires lay exposed. When the machine restarted, the jolt knocked dust into the air. A spark — likely from the exposed wires, investigators later concluded — turned the dust cloud into a ball of flame that engulfed Sherburne and a co-worker.
“He’s burned over 95 percent of his body,” doctors told Sherburne’s wife, Chris, when she arrived at the Vanderbilt University Medical Center’s burn unit. “He’s not going to live.” Her husband died two days later.
The fires at the Hoeganaes plant were not over. Another struck in March, then a third in May. In all, five workers died in accidents that shook this small community. Each man left behind a wife and children. One had four children under 11. Another became a grandfather the day before an explosion caused fatal burns.
Each blaze here involved combustible dust, a little-noticed danger that has killed or injured at least 900 workers across the country during the past three decades. The fuel has varied, but the effects have been similarly devastating. In Gallatin, it was iron. In Port Wentworth, Ga., sugar. In Kinston, N.C.,plastic. Elsewhere, dust from substances as varied as wood, nylon fiber, coal and flour sparked fires and explosions.
Since 1980, more than 450 accidents involving dust have killed nearly 130 workers and injured another 800-plus, according to a Center for Public Integrity analysis of data compiled by the federal Occupational Safety and Health Administration and the U.S. Chemical Safety Board. Both agencies, citing spotty reporting requirements, say these numbers are likely significant understatements.
Yet a push to issue a rule protecting workers from the danger has stalled in the face of bureaucratic hurdles, industry pushback and political calculations, the Center for Public Integrity found.
OSHA, in a statement, said it must “make difficult decisions as to how to best allocate the agency’s limited rulemaking resources.” While addressing dangers like combustible dust and dangerous substances breathed by workers are important, OSHA said, it “has placed a great deal of emphasis on broad rulemaking efforts that have the potential to result in fundamental changes [for] safety and health in the workplace.”
Representatives for Hoeganaes refused interview requests from the Center for Public Integrity. In a legal filing, the company has denied violating safety standards at the Tennessee plant where Wiley Sherburne died.
‘All of a sudden one day, boom’
A dust fire is, in a sense, the result of a perfect storm. The powder has to form a cloud in a confined area and touch an ignition source, such as a spark, flame or overheated pipe. “It’s this unlikeliness that leads people to the false sense of security that it can’t occur,” said John Cholin, an engineer who has investigated dust accidents for 30 years and has a consulting firm.
Often, workers don’t know that the dust lurking on flat surfaces could, when dispersed in a cloud, fuel a violent explosion. But experts, worker safety advocates and government officials have been sounding alarms for years.
Steve Sallman, a health and safety official with the United Steelworkers union, still thinks about the dust fire 20 years ago that severely burned two of his co-workers at an Iowa plant making tires for agricultural vehicles. “It bothers me to this day because it was preventable,” he said.
Hindsight in the wake of dust explosions has often revealed missed warning signs. Rarely does a company develop a dust problem overnight.
“It goes along for years with the dust building up, building up, and everything’s fine, nobody’s harmed, nobody thinks anything about it,” said Sandra Bennett, an official at the Tennessee Occupational Safety and Health Administration, which investigated the Hoeganaes accidents. “All of a sudden, one day, boom.”
Standards to address the danger have existed for more than 85 years, but following them is voluntary for many plants. Where they do apply, enforcement is so haphazard that the association that sets the standards believes this policing duty should be placed in OSHA’s hands.
The agency seems to agree. In 2009, OSHA announced it was starting the process of issuing a rule to address combustible dust.
Three years later, the process is still stuck in its early stages, and OSHA has given up on making significant progress this year, moving the topic to its list of “long-term actions.” Some experts point to key impediments OSHA faces: the potential cost of the sweeping rule, an anti-regulatory political climate and an increasingly drawn-out rulemaking process.
Top agency officials refused to explain the rule’s status. In a statement, OSHA said, “Prevention of worker injuries and fatalities from combustible dust remains a priority for the agency.” But, the statement said, developing the rule is “very complex,” and “could affect a wide variety of industries and workplace conditions. As a result it has been moved to long-term action to give the agency time to develop the analyses needed to support a cost-effective rule.”
News of OSHA’s decision reached Chris Sherburne at the end of January, around the first anniversary of her husband’s death. “I just couldn’t believe it,” she said. “You put it on the back burner, and that’s where it’s going to stay.”
Her frustration is shared by victims’ families who have seen other health and safety rules similarly stalled, shelved or eviscerated. Whether it’s combustible wood dust at a sawmill, disease-inducing beryllium at an aluminum smelter or lung-wrecking silica at an iron foundry, OSHA allows workers to face conditions that many experts and even the government’s own scientists consider unsafe.
OSHA’s statement said it is “committed to protecting workers,” but that “numerous steps in the regulatory process mean OSHA cannot issue standards as quickly as it would like.”
Not the first time
Documented dust explosions have been killing workers since the late 1800s or earlier, and technical publications discussing the hazard date to the early 20th century.
The Chemical Safety Board, an independent federal agency, has examined a handful of major dust accidents and identified disturbing trends. The board, however, can’t issue or enforce rules. Among the catastrophic accidents the board investigated, each plant also had a history of small dust fires that did little or no damage and prompted little concern.
“You have to consider all those fires as close calls for something that could kill somebody,” the board’s chairman, Rafael Moure-Eraso, said in an interview. “Hoeganaes is precisely the case in point.”
At the Gallatin plant, periodic small dust fires ignited in certain areas, investigators found. Some employees told state inspectors they put out blazes once or twice a month; others said the fires came about once a week.
Because the fires had done little damage, workers had come to accept them as part of the job, investigators found. That changed the January day a dust cloud ignited and fatally burned Wiley Sherburne and Wayne Corley.
Two months later, investigators found, a worker accidentally knocked loose dust that had collected on a furnace and was engulfed in flames. He leaped off a ladder to safety and survived.
Then, on May 27, sparks triggered an explosion of hydrogen gas leaking from a pipe, investigators determined. The blast knocked dust loose from the rafters, and some of it ignited as it rained down on workers. “There was so much dust in the air that you could only see the areas where it was burning,” one employeetold investigators. Three workers died, and two more were injured.
Last year was not the first time Hoeganaes had experienced the deadly potential of its iron dust. The May accident in particular bore “striking similarities” to one that occurred in 1992 at the company’s plant in Riverton, N.J., said the CSB’s lead investigator, Johnnie Banks.
Twenty years later, Jeffrey Richardson remembers that accident well. It left him with third-degree burns covering 97 percent of his body. He has one ear and one hand, though it has no fingers. His body is covered with skin grown in a lab; it heals slowly and tears easily.
“They said my foot and my eyelids were the only place where I wasn’t burned,” he recalled recently. “I still to this day have a nurse come every day to dress wounds that I still have ongoing.”
As in the May 2011 accident, a hydrogen explosion shook the building, and burning dust fell from the rafters. Richardson recalls it covering him as he struggled to find an escape route. “I could hear it sizzling and cracking,” he said.
The company contested the 10 serious violations OSHA issued for the fire that burned Richardson, and the agency cut the fine from $22,500 to $15,300. Hoeganaes is now contesting the 25 serious violations and $122,900 in fines assessed by the Tennessee regulators after the 2011 accidents in Gallatin.
Optional standards, lax enforcement
Many plants already are required to follow rules addressing combustible dust — at least in theory.
The National Fire Protection Association, a nonprofit group that sets an array of standards and conducts research and training, first issued guidance in the 1920s. Since then, committees of industry officials and experts have updated the association’s combustible dust standards regularly. Many experts praise the standards, and OSHA often points to them as widely recognized practices when citing violations.
But two problems limit the standards’ reach: They are optional in many areas, and, where they apply, enforcement is often lax or nonexistent, experts have found.
Some state and local governments have adopted the NFPA standards as part of their fire codes, while others have chosen the International Fire Code, which has general guidance on combustible dust and references the NFPA codes without explicitly requiring companies to follow them.
Even where the rules apply, those charged with enforcing them are typically state or local fire inspectors. Inspections of industrial plants are rare, the CSB has found, and inspectors are often ill-equipped to recognize even glaring dust hazards. “The rank-and-file first line of code enforcement is totally ignorant of the problem,” Cholin said.
In Gallatin, the fire department’s senior inspector visited the Hoeganaes plant in May 2011 — after the first two fires but before the third. He noted a list of concerns, including inadequate emergency lighting and the need to keep exit routes clear. He didn’t mention combustible dust.
The department eventually noted dust levels during inspections this January and March. Asked if inspectors ever brought up combustible dust with Hoeganaes before last year’s accidents, Fire Chief William Crook said, “If they have, I’m not aware of it.”
The CSB found a similar pattern after other accident investigations in Indiana and North Carolina: Fire officials had missed dust problems in inspections before deadly accidents.
Recognizing dangers that could lead to dust fires and explosions also can be a problem for companies and their insurers. In investigations of four dust explosions that killed 28 workers, the CSB found insurers had missed serious dust hazards during audits in each case.
In Gallatin, the insurer Allianz did note the potential risks from iron dust in a 2008 audit. Hoeganaes commissioned testing in 2009 and 2010 that showed its dust was combustible. In August 2010, Hoeganaes hired a company to clean up the dust, according to a report by the state inspector examining the January 2011 accident. But, the report notes, “it was apparent that the employer was not ensuring clean up [sic] was maintained through good housekeeping practices between these cleanings.” Piles of dust up to four inches thick sat on equipment throughout the plant, the inspector found.
Such breakdowns point to the need for an OSHA standard, which could lead to “broader recognition and the potential for stronger enforcement,” said Guy Colonna, manager of the NFPA division that oversees the association’s combustible dust standards.
Still, enforcement by OSHA isn’t a perfect solution. The CSB’s 2006 study found that OSHA inspectors weren’t adequately trained to recognize dust hazards.
In a statement, OSHA said it developed a three-and-a-half-day session to train its inspectors to recognize combustible dust hazards in December 2007. But the agency can get to only a fraction of the plants that may have dust problems.
Since October 2007, OSHA has been targeting plants that may have dust problems through a special enforcement program. During that time, the agency and its state counterparts have conducted more than 2,800 inspections. Asked for an estimate of the number of plants that meet the criteria for inspection under the program, though, OSHA said the total was likely “in tens of thousands.”
Applying the program without a combustible dust standard in place means inspectors must resort to issuing citations for rules not written to address dust. If dust is piling up around the plant, for example, housekeeping standards might apply. If wires are exposed, electrical safety rules might form the basis for a citation.
OSHA can use the “general duty clause” to cite companies for exposing workers to well-known dangers not addressed by specific standards. This approach, however, often leaves the agency vulnerable to industry challenge.
Consider Hoeganaes: The last time the plant was inspected by the Tennessee Occupational Safety and Health Administration before the 2011 fires was in 2008. The inspector, Dave McMurray, visited the plant after the agency received information that a few workers had suffered hearing loss — problems for which he ended up citing the company.
While he was there, however, he saw enough iron dust collecting around the plant to cause concern. “If you put your hand on the railings, it would come away black,” McMurray, who is now retired, recalled in an interview.
Without a combustible dust standard, he felt his only option was to see whether workers were breathing levels of dust that might pose a health risk — a hazard for which there was a standard. The samples, however, weren’t above the limit. The monitors measured only what was in the air near the workers at the time, not what had collected on ledges and rafters.
McMurray felt there was little he could do. “It’s a whole world of difference when we have a standard,” he said. “When we have a specific standard, we go for it.” At Hoeganaes, he said, “I went as far as I thought I could.”
After the fires in 2011, state regulators drew on a variety of standards to cite Hoeganaes. They alleged electrical safety violations, shoddy maintenance of the hydrogen pipe that leaked in May and an inadequate emergency response plan, for example. They accused the company of allowing dust to build up throughout the plant and failing to train workers on its dangers.
‘Past time to issue a standard’
Four years ago, Jamie Butler sat on a curb outside the burning wreckage of the packing building at the Imperial Sugar refinery in Port Wentworth, Ga., an industrial hub near Savannah. His brother sat beside him. They’d escaped one of the worst dust explosions in U.S. history.
There had been a ball of flame, Butler recalled, and then fire everywhere — on the walls, on machines, in the air. Sugar dust had exploded in a conveyor belt, then triggered blasts throughout the plant. Dust that had built up over the years fueled the explosions and rained down on Butler and his co-workers.
Butler had found a hole that had been blown in the wall and made it, with his brother, to the curb outside. They talked for a minute or two, before emergency responders loaded Butler into one ambulance and his brother into another. “That was the last time I ever saw my brother,” Butler said.
The disaster killed 14 people — including Butler’s brother and uncle, a longtime plant employee — and left dozens burned. Butler, now 29 with three children, remained in a coma for months; he has severe burns on his head, face, legs and arms. “Since I got burned, I’ll be in the hospital on a regular basis, just sick, throwing up, dehydrated,” he said recently, sitting in his lawyer’s riverfront office. “I don’t sweat how I used to sweat.”
The blast was the type of catastrophe that can spur reform. Congress held ahearing, and then-Sen. Barack Obama said in a statement, “It is past time to issue a standard to prevent these kinds of accidents.”
Even before Imperial Sugar, the CSB had investigated a series of deadly dust accidents and recommended in 2006 that OSHA issue a rule to protect workers from dust fires and explosions. After investigating the disaster in Port Wentworth, the board again urged OSHA to act.
This time, OSHA appeared to be listening. It launched a special enforcement program targeting companies with unaddressed dust problems. In April 2009, the agency announced it was starting the rulemaking process.
“We felt that our efforts had paid off,” CSB chairman Moure-Eraso said recently. “And then we wait and we wait. And there are more accidents; there are more fatalities. And this process continues, and it seems to be never-ending.”
Long rulemaking processes have become the norm for OSHA. For the 58 significant standards the agency has issued since 1981, the average time from beginning the process to finalizing the rule was almost eight years, a recentstudy by the Government Accountability Office found.
To issue a significant new rule, federal agencies must navigate a complicated process that includes multiple rounds of review — both internally and at the White House’s budget office — and public comment. New laws and executive orders have added requirements over the past three decades.
OSHA, however, faces particular challenges. The agency must show that a proposed rule is both technically and economically feasible for every industry that would be affected — a research-intensive task. If a rule could affect a significant number of small businesses, OSHA must convene a panel and allow them to raise objections to an unpublished rule draft. It is one of only three federal agencies required to do this.
OSHA is particularly vulnerable to legal challenges after issuing a standard. In general, agencies must prove to a judge that a rule isn’t arbitrary, capricious or an abuse of discretion. OSHA, however, must show its rule is supported by “substantial evidence in the record considered as a whole” — a much higher standard.
All of this means addressing combustible dust is a mammoth task. OSHA has to research the dangers of everything from the coal dust at a power plant to the wood dust at a sawmill, then show that addressing the danger would be realistic in each case. The rule would affect many small businesses, and OSHA said in a statement that it plans to convene the required small-business panel this year.
Industry groups generally haven’t opposed a rule altogether, instead arguing that the rule shouldn’t apply to them. The National Cotton Council, for example,told OSHA many of its members shouldn’t be included and challenged the accuracy of the agency’s list that included past cotton dust fires and explosions. The American Home Furnishings Alliance insisted in written comments that “no federal intervention in our industry is justified or required.”
The American Chemistry Council has taken a harder line, arguing that a new rule is unnecessary. “We believe that the accidents that have occurred might have been prevented if current OSHA regulations and relevant combustible dust consensus standards had been followed and enforced,” the council wrote to the Center.
Some see the political climate — in which the phrase “job-killing regulation” is never far from the discussion — as one explanation for the slow progress. “OSHA has its heart in the right place; we know that they’re struggling with this,” said Robyn Robbins, a safety and health official with the United Food and Commercial Workers union. “It’s just a shame that people make this political.”
Lessons from a previous dust fight
Many arguments echo those made 30 years ago during a tussle that led to a standard now widely considered a success story. In the late 1970s, a series of deadly grain dust explosions at grain elevators and similar facilities attracted national attention. OSHA announced in 1980 that it was considering a rule to regulate the handling of grain dust.
Large industry trade groups and small grain elevator operators objected vociferously. The National Grain and Feed Association called the rule“unwarranted” in comments to OSHA and said it “could have a substantial economic impact on the grain and feed industry without substantially improving the safety or health of workers.”
In 1987, OSHA issued the rule. In 2003, the agency reported evidence that, in the decade after it took effect, deaths in grain dust explosions dropped by 70 percent and injuries by 60 percent.
In 2010, the National Grain and Feed Association — the same group that had sued OSHA to try to block parts of the rule — noted this “unprecedented decline in explosions, injuries and fatalities at grain handling facilities” in comments submitted to OSHA.
Nor did meeting the rule’s requirements ruin the industry. The association cited the “economic benefit of implementing the grain handling standard” and wrote, “We firmly believe that there is overwhelming evidence supporting the grain handling standard’s effectiveness in preventing fires and explosions and resulting injuries during a time when grain handling capacity increased almost sixty percent.”
OSHA’s current attempts to address combustible dust are more complicated, encompassing many different industries with different types of dust. But some view the grain dust rule as an example of what could be accomplished.
“A general industry standard does have the potential to be at least as successful [as the grain dust standard] in terms of awareness, but how successful depends on the specifics of the regulation,” said Bob Zalosh, a consultant who investigates accidents and advises companies on prevention.
Some in Congress want OSHA to act now. California Rep. George Miller and two other House Democrats have introduced a bill that would require the agency to issue an interim rule within a year.
“The fact that workers are killed and injured in all too frequent, clearly preventable combustible dust explosions shows that Congress must act,” Miller said in a statement to the Center. “Legislation is needed to protect workers because of the years it takes to cut through the red tape just to get a final protection in place.”
‘Fall through the cracks at every level’
In Georgia, the building Jamie Butler and his co-workers knew during their time at Imperial Sugar is long gone, consumed entirely by the inferno of February 2008. In its place is a modern packing facility company officials say stands as evidence of what they learned from the disaster. The project, which included some work on the refinery itself, took about two years and cost roughly $220 million, vice president of manufacturing Raylene Carter said.
“If there is ever an explosion again — and that’s just not going to happen — it would never spread from building to building ever again,” Imperial Sugar health and safety official Kathleen Gonzalez said during a recent tour, pointing to a system designed to blanket the area with water and halt a fire in its tracks.
Sugar no longer enters the packing building on a conveyor belt — the location of the initial explosion in 2008. It is shot through pipes in pellets packed so densely that they shouldn’t be able to ignite. Sensors can detect the first signs of sparks in the pipes, then automatically isolate the area and flood it with a neutralizing solution.
Near work areas, vacuums take spilled dust to a vessel outside the building — a contrast from the company’s previous practice of using compressed air to clean dust, which blew it onto ledges and rafters where it eventually was shaken loose, fueling explosions. A sign reminds workers, “Your job is not complete until your work area is CLEAN.”
The company has told OSHA it “strongly support[s]” issuing a combustible dust rule. “We believe that there is still a low level of knowledge of the extent of hazards of combustible dust in industry,” the company wrote OSHA.
Such about-faces often come after deaths have occurred — and company officials, inspectors or auditors missed warning signs. The NFPA’s Colonna said he is frequently called to conduct training after explosions — in Georgia after the Imperial Sugar catastrophe, and in Kentucky after a 2003 dust explosion killed seven workers. This March, the Gallatin Fire Department’s two inspectors attended a two-day training seminar on combustible dust led by the NFPA, said Crook, the department’s chief.
Meanwhile, dust accidents continue. In February, after a dust explosion, OSHA cited a Wisconsin company that makes whey products. In April, the agency issued violations to a New Hampshire wood pellet mill where a dust-fueled fire spread throughout the building. The same month, the agency alleged violations – some of them willful, which OSHA says are intentional violations or those committed with indifference to the law – at an Illinois pasta manufacturer where two workers were seriously burned in a sugar dust explosion.
“I think the universal theme is that these accidents are a symptom of the fact that there isn’t a comprehensive dust standard,” said Daniel Horowitz, the CSB’s managing director. “Hoeganaes really illustrates how problems like this can fall through the cracks at every level.”
A father’s memory
In Gallatin, dust piled up for years despite inspections, audits and small fires.
“They need a set of guidelines,” Chris Sherburne said. “If there was a standard, I think that would have made a lot of difference because there was so much [dust] there at the time.”
As the gears grind in Washington, she’s raising a teenage son and tending to a 34-acre patch of farmland. She hasn’t given up on some of the plans she and Wiley made. They had always hoped to build a new house on their land to replace their double-wide, and in December 2010 — about a month before his death — they’d decided to start the following spring.
Chris stuck to the plan, functioning as her own general contractor. “I decided to just build it and see what happens,” she said recently.
Last December, Chris and her son moved into their new house. No pictures of Wiley adorn the walls or mantelpieces. “It’s easier for us not to have stuff in plain view,” Chris said. When Wiley’s body was cremated, at first the ashes sat on Chris’ bedroom dresser. “After a few days,” she recalled, “I said, ‘Wiley I can’t look at you every day; I can’t do this.’ He’s in the closet now.”
Some reminders are inescapable. Chris and her son have kept his tools and work clothes, keepsakes of the man who could fix anything. “You could bring him a motor in a box, and he’d put it back together,” Chris recalled.
As their son approached driving age, the plan was for Wiley to help him find a clunker and fix it up. Instead, he now drives his father’s souped-up Dodge Ram 2500. “Every now and then, when I see it coming up the driveway,” Chris said, “for a split second I still think it’s Wiley.”