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THE INVESTIGATION OF GRAIN ELEVATOR EXPLOSIONS SUMMARY AND RECOMMENDATIONS The Panel on Causes and Prevention of Grain Elevator Explo- sions of the Committee on Evaluation of Industrial Hazards was constituted in November 1978 at the request of the Occupational Safety and Health Administration (OSHA). As part of its charge, the panel was asked to review the adequacy of OSHA's current procedures used to investigate grain ele- vator explosions and make recommendations for improvement. The panel examined raw data and available reports of five investigations, one conducted by the Department of Agriculture and four by OSHA. The panel also conducted its own on-site investigations of eight recent grain elevator explosions. It found that, in general, OSHA's investigation of grain elevator explosions is performed mainly for deter- mination of any and all code violations, with determination of cause of an explosion a secondary objective. The reports indicated that none of the investigating teams had been specifically trained to conduct explosion investigations for determination of cause. Each of the government investiga- tions was unique—varying in expertise utilized, methodology, amounts of facts obtained, and their interpretation. In cases where subsequent litigation is a possibility, govern- ment files on the investigations are treated as privileged information, and even those files not involving litigation are not readily available to the public. The reports are, therefore, of little value as a basis for remedial action by industry other than for rectifying code violations that may have no relation whatsoever to the cause of the explosion. The panel feels that the primary purpose of investiga- tions should be to provide information that will lead to a reduction of the explosion hazard in grain elevators. The methods and expertise required for this type of investiga- tion are outlined in this report. The panel recommends the establishment of a program for investigating and reporting grain elevator explosions in a manner similar to that used by the National Transportation Safety Board, in which emphasis is placed on determining all factors bearing upon an accident. This is in contrast to investigations conducted by federal regulatory agencies in

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which emphasis is placed on determining violations of codes and regulations for possible subsequent punitive action, even if the violation has no relationship to the explosion. The requirements for such a program are as follows: 1, A federal agency or department should have the sole authority for investigation of grain elevator explosions. To maintain its objectivity, this organization should be an independent agency, i.e., not a rule-making or regulatory agency or one that has a special interest in the grain handling in" dustry. 2, Investigations should be conducted in such a way as to elicit all facts relating to the explosion. The goals of the investigation should be to determine the circumstances and conditions leading to an explosion, the source of ignition, and the way the explosion propagated through the elevator. In recognition that an explosion can be a complex event with many contributing factors, identification of proximate or probable cause should not be absolutely required from an investigation. In the interest of obtaining unbiased information, the investigating team should use considerable care to avoid estab- lishing an adversary relationship with witnesses, employees, and elevator operators and owners, 3, Investigations should be performed by a team con- sisting of experts in dust-explosion phenomena, mechanics of blast damage, electrical engineering, grain elevator operations, interviewing of witnesses, safety regulations and codes, and system analysis. Team members should be able to document their evidence by photographs. They should have at their disposal the services of qualified laboratories for those cases requiring laboratory analyses. Members should be able to proceed to an explosion site with- in two or three hours notice. In order to obtain the most benefit from investigations all reports of this body should be available to the public. As an interim measure and until the foregoing require- ments can be met, an existing government agency that has an interest in reducing the incidence and severity of grain elevator explosions could be granted a coordinating role for the investigation of grain elevator explosions along the lines mentioned above. . .