Investigation Report
Horsehead Holding Company Fatal Explosion and Fire
Horsehead Holding Company Fatal Explosion and Fire
- CSB
- Investigation Report
- ExplosionHot Work and Fire
- ExplosionFireHuman factorsLoss of containmentRisk management
- Valve
- Alarm managementOperating and work proceduresPermit to work
- Onshore facility
Summary
An independent desk study examines the fatal Monaca zinc-refinery incident using CSB evidence and the author’s records. It proposes sump restriction, liquid-zinc backfilling and explosive decompression as the sequence, while acknowledging disputed analysis. Discussion covers distillation-column design, temperature trends, operating procedures, human factors and predictive warnings.
Classifications: Explosion; explosive atmospheres.
Classifications: Fire; fire safety.
Classifications: Human factors; human performance; ergonomics.
Classifications: Loss of containment; containment loss.
Classifications: Risk management; risk evaluation.
Classifications: Valve; valves.
Classifications: Alarm management.
Classifications: Operating and work procedures.
Classifications: Permit to work; PTW; work permit.
Classifications: Onshore facility; onshore plant.
Themes: explosion, hot work and fire.