Investigation Report
Sterigenics Ethylene Oxide Explosion — Final Investigation Report
Sterigenics Ethylene Oxide Explosion — Final Investigation Report
- CSB
- Investigation Report
- ExplosionHazardous substancesHuman factorsProcess safetyRegulation and legislation
- Inspection and maintenance
- Process pipework and pipelines
- Competence and trainingAtmospheric gas testingIndependent audit and verificationRisk assessment
- Onshore facility
Summary
Investigation of an ethylene oxide sterilisation explosion at Sterigenics’ Ontario facility. Bypassed gas washing allowed an explosive mixture to reach the oxidiser, with flame propagation back to the chamber. The report examines safeguards, concentration monitoring, maintenance training, hazard analysis and control-room glazing, and recommends improvements across sterilisation facilities.
Classifications: Explosion; explosive atmospheres.
Classifications: Hazardous substances; hazardous chemicals; chemical exposure.
Classifications: Human factors; human performance; ergonomics.
Classifications: Process safety; major accident hazards.
Classifications: Regulation and legislation; safety legislation; regulatory requirements.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Process pipework and pipelines; process piping.
Classifications: Competence and training; competency assurance; safety training.
Classifications: Atmospheric gas testing; gas testing; atmosphere testing.
Classifications: Independent audit and verification.
Classifications: Risk assessment; hazard assessment.
Classifications: Onshore facility; onshore plant.