HOT WORK EXPLOSION — NCG SYSTEM FLAMMABLE ATMOSPHERE
Packaging Corporation of America Hot Work Explosion
Packaging Corporation of America (PCA)
📍 DeRidder, LA
Incident: February 8, 2017  •  CSB Report: April 24, 2018
3
Fatalities
Non-Condensible Gases (NCG) — Flammable Pulp Mill Vapors
Chemical Involved
1
CSB Recommendations
📋 Incident Summary

On February 8, 2017, three contractors were fatally injured and seven others were injured in an explosion at the Packaging Corporation of America (PCA) pulp and paper mill in DeRidder, Louisiana. The contractors were conducting hot work -- welding -- in close proximity to a foul condensate tank that contained a flammable atmosphere of non-condensible gases (NCG).

NCG systems at pulp and paper mills collect concentrated non-condensible gases including hydrogen sulfide, methanol, and other volatile organic compounds that are flammable, toxic, and odorous. The CSB found that the NCG system had not been included in PCA's PSM program, leaving workers and supervisors unaware that the area around the foul condensate tank was a hazardous location requiring strict hot work controls.

The April 2018 final report issued a single comprehensive recommendation to PCA requiring it to apply process safety management elements to all NCG systems and foul condensate tanks at its pulp and paper mills, including NFPA explosion prevention standards and periodic training ensuring workers understand all process safety hazards applicable to their areas. The recommendation was closed.

🔎 Key Findings
Finding 01
Hot Work Conducted Adjacent to Flammable NCG Tank
Three contractors were welding on or near a foul condensate tank that contained a flammable atmosphere of non-condensible gases -- the ignition of this atmosphere caused the fatal explosion.
Finding 02
NCG System Not Included in PSM Program
PCA's PSM program did not include the NCG system or foul condensate tanks -- excluding one of the most hazardous process areas in pulp and paper manufacturing from required hazard analysis, operating procedures, and worker training.
Finding 03
Workers Not Trained on NCG Process Safety Hazards
Contractors and plant workers in the vicinity of the NCG system had not received training on the specific process safety hazards of the NCG system, including the flammability of the gases contained in foul condensate tanks.
Finding 04
Hot Work Permit Did Not Identify Flammable Atmosphere Hazard
The hot work permit system at the facility did not adequately identify or control the hazard of performing ignition-source work adjacent to a tank that could contain a flammable atmosphere.
Finding 05
NFPA Explosion Prevention Standards Not Applied to NCG System
PCA had not applied NFPA 69 (Explosion Prevention Systems) or NFPA 68 (Deflagration Venting) to the NCG system -- standards that could have provided effective explosion prevention for this hazardous process.
🔍 Root Causes
1
NCG System Excluded from PSM Program Boundaries
PCA's decision not to include NCG systems and foul condensate tanks within PSM program boundaries removed the NCG process from required hazard analysis, operating procedures, mechanical integrity, and worker training -- leaving a high-hazard system effectively unmanaged from a process safety perspective.
2
Hot Work Permit Failed to Identify NCG Hazard
The facility's hot work permit process did not require evaluation of process-specific hazards at the work location, including flammable gases that could be present in nearby tanks or process equipment.
3
Workers Lacked Knowledge of NCG System Hazards
Neither PCA employees nor contractors working in the NCG system area had received training on the flammability and toxicity hazards of non-condensible gases -- a fundamental training gap that left workers unable to recognize and avoid the hazard.
☑ CSB Recommendations
→ Packaging Corporation of America
Apply comprehensive process safety management to all NCG systems and foul condensate tanks at PCA pulp and paper mills, including: effective PSM elements per CCPS good practice guidance; expansion of PSM program boundaries to cover NCG hazards beyond minimum legal requirements; application of NFPA 69 explosion prevention and NFPA 68 deflagration venting standards; ISA-84 functional safety lifecycle for safety interlocks; TIP 0416-09 for NCG system design and operation; and periodic training ensuring workers understand all PSM hazards applicable to their areas.
💡 Lessons Learned
Non-condensible gas systems at pulp and paper mills are among the most hazardous process areas in that industry. NCG contains hydrogen sulfide, methanol, and other flammable and toxic compounds. Excluding NCG systems from a PSM program is not a conservative compliance interpretation -- it is a dangerous oversight with fatal consequences.
Hot work permits are only as effective as the hazard identification process behind them. A permit issued without evaluating whether nearby tanks or process equipment could contain a flammable atmosphere is not a safeguard -- it is a false assurance that can cost lives.
Contractors working in process areas have the right to know the specific hazards of the processes they work near -- not just generic fire and life safety information. Process-specific hazard training for contractors is a PSM requirement and a life-safety necessity.
Pulp and paper facilities handling NCG should apply NFPA 69 (Explosion Prevention Systems) and NFPA 68 (Deflagration Venting) to those systems. These standards provide effective methods for preventing and mitigating explosions that PSM alone does not specify.
PSM program scope decisions have life-or-death consequences. When management decides a process does not meet the threshold for PSM coverage, that decision should be formally documented and rigorously justified -- not made informally, leaving a high-hazard system outside all formal safety management.
HOW: Hot Work PermitsSOP: Operating ProceduresTRN: TrainingEP: Employee Participation
🔨 Safety Meeting Toolbox Talk
►Before we issue a hot work permit, do we evaluate not just the immediate work area but nearby tanks, pipes, and process equipment that could contain or release flammable gases?
►Are all high-hazard process systems at our facility covered by our PSM program? Could there be a system handling flammable or toxic materials that is excluded from PSM and its required hazard analyses?
►When contractors come to work in our process areas, do they receive training on the specific process hazards at their work location -- or just a general site safety orientation?
►Do our hot work procedures require flammable gas testing of the atmosphere in adjacent vessels or tanks -- not just at the immediate work point -- before permitting ignition-source work?
►Have you ever questioned whether a task was safe to perform in the area you were working? What happened when you raised that concern?
Immediate Action Items
✓Review your hot work permit procedure to verify it requires evaluation of flammable and toxic hazards in tanks and equipment adjacent to the proposed work location, not just at the immediate work point.
✓Audit your PSM program scope to identify any process systems handling flammable or toxic chemicals that may be excluded; document the basis for exclusion or initiate corrective action to include them.
✓Review contractor pre-job briefing requirements to confirm that process-specific hazards at the work location are communicated before any hot work or ignition-source work begins.
✓Verify that applicable NFPA explosion prevention and protection standards have been applied to all systems at your facility that collect or handle flammable vapor streams.
✓Brief your operations and safety team on the PCA DeRidder explosion and identify any areas where hot work could be conducted near a flammable atmosphere that might not be apparent from the permit process.
🔗 PSM Failures Behind This Incident

This incident traced to breakdowns across 4 PSM elements (HOW · SOP · TRN · EP). Each represents a documented gap that process safety documentation and consulting can close before a similar event occurs at your facility.

Hot Work Permits
Unauthorized or poorly controlled ignition sources near flammable atmospheres are entirely preventable. A rigorous hot work permit system with pre-job atmospheric testing closes this pathway.
Supporting documents in our library →
Operating Procedures (SOPs)
Operators cannot reliably hold safe operating limits without clear, current, enforced procedures. Deviation from acceptable operating conditions — a root cause here — is a direct consequence of SOP failure.
Supporting documents in our library →
Training & Operator Competency
Workers must understand process hazards — not just the steps on the page. Training records, refresher frequency, and verified competency are all OSHA PSM requirements that gaps here violated.
Supporting documents in our library →
Employee Participation
OSHA PSM requires workers to be meaningfully involved in hazard analyses and procedure development — not just trained on the finished product. Active participation catches gaps that management alone misses.
Supporting documents in our library →
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