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In summary, all the factors involved in grain elevator explosions must be understood before the hazard can be re- duced as far as possible. The examination of explosion sites to obtain data for this understanding requires specialized investigation methods and personnel. On the basis of its regulatory function, OSHA's present investigative procedures even if faultlessly applied and reported, will not satisfy this need. INVESTIGATION OF GRAIN ELEVATOR EXPLOSIONS - CURRENT STATUS At present, OSHA has the primary responsibility for the investigation of grain elevator explosions. On rare occa- sions the Department of Justice conducts an investigation if there is a suspicion or evidence of a criminal act. On equally rare occasions investigations may be conducted by the Department of Agriculture, particularly if there is an injury or fatality to an employee of the Federal Grain Inspection Service. The situation with respect to current investigations has two serious faults. First, every explosion is not investi- gated; some are not even reported beyond the local news media, Elevator operators are required to report explosions only to OSHA and then only if a fatality occurs or there are at least five injuries requiring hospitalization. Second, explosions are usually investigated by OSHA only to determine a basis for legal action. Their purpose in investigating explosions is primarily to seek violations of safety regula- tions,* Investigations to determine the chain of events leading to and following the initial ignition of grain dust are rare occurrences and do not appear to be the responsibil- ity of any organization. . At the request of OSHA a task group of the panel exam- ined investigation records and raw data in OSHA's files of five grain elevator explosions to determine the adequacy of current techniques used by the federal government. Without identifying the individual investigations the task group found the following: 1. All five investigations were conducted without guide- lines or a methodology for conducting an investiga- tion. Each investigation was unique--varying in *See Sections 8, 9, and 10 of 84 Statute 1593 (28 U.S.C, 655); Secretary of Labor's Order 8-76 (41 Federal Register 205029),
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expertise utilized, amount of facts obtained, and subsequent interpretation of facts. 2. None of the five investigation files contained commendations for preventive action. 3. The files of the five investigations are not open to the public because of pending litigation. 4. Only two of the investigations were quite thorough and complete, one particularly so, In the latter, the investigators drew a complete plan of the site, even though no drawings were available, and wrote a report. Thorough interviews of the witnesses by the investigators and a detailed examination of the entire site yielded a well-documented and quite believable sequence for the initiation and subse- quent spread of the explosion. The only fault the task group could find with this report was that the explosion process was not described using current explosion investigation terminology. Nevertheless, the data were sufficiently clear so that an expert, reading the report, would have a clear understanding of what happened. The other well-documented report, which was not an OSHA investigation, contained suf- ficient information concerning the events leading to the explosion, In this case, the investigators repeatedly returned to the scene as portions of the elevator were uncovered by clean-up crews over a period of approximately three weeks. This persis- tence paid off because they discovered a likely source of ignition. 5. In the third incident, even though statements of the witnesses led to fairly obvious conclusions about the ignition source, the documentation was not sufficiently complete. A, report was not prepared, 6. In the fourth incident legal action was required to obtain entry and the investigators were unable to obtain photographs or other evidence before critical portions of the site were disturbed. Thus, they were unable to document the damage patterns and could not ascertain the cause, 7. A fifth investigation file contained only witnesses' statements and field notes without a write-up or follow-up. The cause of this explosion will prob- ably never be understood. The task group that examined the above-mentioned files conducted its own independent on-site investigations of eight grain elevator explosions that occurred since the formation