NIOSH Finds Department at Fault for 2009 Death of Firefighter
Herald Times Reporter via YellowBrix
August 10, 2010
ST. ANNA, WI – A federal investigation of the Dec. 29 fire and explosion that killed St. Anna firefighter Steven Koeser found fault with the training and decision-making of the St. Anna Fire Department.
The investigation by the National Institute for Occupational Safety and Health (NIOSH) also faulted the disposal and storage of materials by Bremer Manufacturing Co., the town of New Holstein foundry where the fatality occurred.
The blast that killed Koeser and injured eight other volunteer firefighters happened after firefighters directed streams of water and suppressant foam onto a burning recycling bin that contained aluminum alloy shavings and 55-gallon steel barrels of aluminum oxide dross.
The NIOSH report speculates that a thermite reaction had ignited the aluminum shavings and that the addition of water and foam generated hydrogen gas, which reacted with the aluminum and exploded.
Seventeen firefighters were within 50 feet of the recycling bin when it blew up. Koeser, 33, of Kiel, was operating a pump near the bin. His body was found 50 feet away.
NIOSH investigator Matt Bowyer identified five key contributing factors in the tragedy:
- Wet extinguishing agent applied to a combustible metal fire.
- Lack of hazardous materials awareness training.
- No documented site preplan.
- Insufficient scene size-up and risk assessment.
- Inadequate disposal/storage of materials.
St. Anna Fire Chief Robert Thome, who served as the incident commander at the scene, said Monday that he no longer plans to issue a departmental report on the case. He said the NIOSH report would be the final chapter to the investigation.
“What we did could have been a contributing factor,” Thome said.
The NIOSH report said the foundry placed a barrel of aluminum slag into the bin of shavings while it was too hot to touch — maybe 700 to 800 degrees Fahrenheit. A barrel of slag normally was allowed to cool for 24 hours, but in this case was allowed to cool for only 1½ to three hours.
Tom Dolack, president of Bremer Manufacturing, said Monday that company officials were reviewing the report, but he declined to discuss specifics of the case.
“We are taking the recommendations from the NIOSH folks to heart to make our situation more safe,” he said.
St. Anna firefighters who responded to the scene said they saw 2-foot-high bluish green flames coming from the top of the metal bin and a 10-inch reddish-orange glow at the bottom of the bin’s south wall.
Thome used a ladder to view the contents of the bin: aluminum shavings, foundry floor sweepings and a 55-gallon barrel.
Firefighters put 700 gallons of water on the fire without effect. They then put 100 gallons of foam solution on the fire.
“Just over 12 minutes on scene, the contents of the Dumpster started sparking (and) then exploded, sending shrapnel and barrels into the air,” the NIOSH report says.
Thome, who has basic hazardous materials training, said he thought the fire was burning cutting fluids among the shavings and floor sweepings.
Cutting fluids are used in machining to cool and lubricate.
“We didn’t think it was a metal fire,” he said. “The aluminum stuff is not supposed to be hazardous, flammable stuff.”
The NIOSH report makes nine recommendations designed to prevent a similar tragedy.
It says firefighters should develop and annually update pre-incident plans for high-risk sites like foundries and they should acquire specialized training for high-risk sites with unique hazards, like combustible metals.
“Proper training is a must to properly identify and handle these unique fires,” the report says.
Thome said his department had a pre-incident plan for Bremer Manufacturing’s building, but not for the site around the building.
“There is nothing saying that outside stuff is supposed to be preplanned,” he said.