COMBUSTIBLE DUST EXPLOSION — POLYETHYLENE POWDER ABOVE SUSPENDED CEILING
West Pharmaceutical Services Dust Explosion and Fire
West Pharmaceutical Services, Inc.
📍 Kinston, NC
Incident: January 29, 2003  •  CSB Report: September 23, 2004
6
Fatalities
Polyethylene Antitack Powder (Combustible Dust)
Chemical Involved
9
CSB Recommendations
📋 Incident Summary

On January 29, 2003, an explosion and fire destroyed the West Pharmaceutical Services plant in Kinston, North Carolina, killing six workers and injuring 38 others. West Pharmaceutical produced rubber stoppers and related components for pharmaceutical packaging. The fuel for the explosion was a fine polyethylene antitack powder used in production, which had accumulated above a suspended ceiling in a manufacturing area over time and ignited.

The CSB investigation found that West Pharmaceutical began using the polyethylene antitack powder after a supplier change without conducting a full hazard review of the new material. The material safety data sheet for the powder did not clearly identify its combustible dust explosion hazard. Fine polyethylene particles that escaped the production area accumulated above the ceiling tiles, forming a hidden explosive dust cloud that detonated when ignited -- destroying the entire facility.

The CSB issued 9 recommendations addressing material safety review procedures, engineering project hazard reviews, combustible dust safety programs, and hazard communication. The investigation also contributed to the CSB's landmark Combustible Dust Hazard Study, which identified over 280 combustible dust incidents in the United States between 1980 and 2005 and led to industry-wide attention to dust explosion hazards.

🔎 Key Findings
Finding 01
New Material Introduced Without Full Hazard Review
West Pharmaceutical began using polyethylene antitack powder after a supplier change but did not conduct a complete hazard review of the new material, failing to identify its combustible dust explosion properties before introducing it into the manufacturing environment.
Finding 02
Polyethylene Dust Accumulated Above Suspended Ceiling
Fine polyethylene particles escaped the production process and accumulated above a suspended ceiling in the manufacturing area, forming a hidden explosive dust layer that was inaccessible to housekeeping and invisible to facility personnel.
Finding 03
MSDS Did Not Identify Combustible Dust Explosion Hazard
The material safety data sheet for the polyethylene antitack powder did not clearly identify the explosive properties of the fine dust generated from the product in manufacturing use -- a critical hazard communication failure that left both management and workers unaware of the risk.
Finding 04
Engineering Design Did Not Prevent Dust Accumulation in Inaccessible Spaces
The facility design allowed fine powder to migrate into the above-ceiling space where it could not be cleaned. The engineering and PSSR processes did not evaluate this accumulation pathway or require sealing of ceiling penetrations.
Finding 05
Explosion Destroyed Entire Facility -- 6 Killed, 38 Injured
The accumulated polyethylene dust above the ceiling ignited and the resulting explosion destroyed the entire West Pharmaceutical plant, killing six workers and injuring 38 others -- one of the most destructive industrial dust explosions in U.S. history at that time.
🔍 Root Causes
1
New Material Hazard Review Did Not Identify Combustible Dust Properties
West Pharmaceutical's process for reviewing new materials failed to identify the combustible dust explosion hazard of the polyethylene antitack powder -- the hazard review used outdated MSDS information and did not include engineering evaluation of the material's behavior in the manufacturing environment.
2
Engineering Projects Were Not Subject to Formal Process Hazard Review
The facility lacked a formal process hazard review requirement for engineering projects -- including changes to the production process and introduction of new materials -- that would have evaluated the accumulation of fine powder in concealed spaces as a potential explosion hazard.
3
Combustible Dust Hazards Were Not Communicated to the Workforce
Neither management nor workers at the West Pharmaceutical plant understood that polyethylene powder could form an explosive dust in a manufacturing environment -- hazard communication gaps meant the hazard was not recognized until after it destroyed the facility.
☑ CSB Recommendations
→ West Pharmaceutical Services, Inc.
Revise policies and procedures for new material safety reviews to use current MSDSs, fully identify hazardous characteristics including physical properties, and include an engineering element evaluating safety implications of new materials on manufacturing processes.
→ West Pharmaceutical Services, Inc.
Develop and implement policies for safety reviews of engineering projects including hazards of materials and equipment, conceptual and construction phases, projects by outside firms, and applicable codes and standards.
→ West Pharmaceutical Services, Inc.
Identify manufacturing facilities using combustible dusts and ensure applicable NFPA 654 precautions are implemented, including sealing dust-tight penetrations of partitions, floors, walls, and ceilings, and sealing spaces inaccessible to housekeeping.
→ West Pharmaceutical Services, Inc.
Improve hazard communication programs so combustible dust hazards are clearly communicated to the workforce with current MSDSs and training on revised information.
→ West Pharmaceutical Services, Inc.
Communicate the findings and recommendations of the CSB report to the West Pharmaceutical workforce.
→ North Carolina Department of Labor (NCOSHA)
Identify manufacturing industries at risk for combustible dust explosions and develop an outreach program on combustible dust hazards.
→ North Carolina Building Code Council
Amend the International Fire Code as adopted by North Carolina to make compliance with NFPA 654 mandatory for facilities handling combustible particulate solids.
→ North Carolina Code Officials Qualification Board
Incorporate NFPA 654 provisions into training programs for state and local building and fire code officials.
→ Crystal, Inc. - PMC (powder supplier)
Modify the material safety data sheet for polyethylene antitack agents to include hazards posed by the end-use of the product in manufacturing, including the combustible dust explosion hazard.
💡 Lessons Learned
A change in supplier or raw material can introduce new hazards that the facility has never encountered. A rigorous new material safety review -- using current MSDSs and including engineering evaluation of how the material behaves in the actual production environment -- is not optional. The West Pharmaceutical explosion began with a supplier change and an inadequate hazard review.
Fine dusts can accumulate in locations that are inaccessible to normal housekeeping. Suspended ceilings, ductwork, overhead structures, and any space above or around production equipment can trap fine particles. Engineering design must eliminate these concealed accumulation pathways, and PHAs must specifically evaluate dust migration to inaccessible areas.
If the MSDS for a material does not identify whether the dust is combustible and explosive, that absence of information is not evidence of safety -- it may mean the hazard simply was not evaluated. Materials used in fine powder form in manufacturing require specific combustible dust testing and hazard characterization, regardless of what the MSDS says.
The West Pharmaceutical explosion destroyed an entire manufacturing facility. Secondary dust explosions triggered by an initial disturbance are the most destructive mechanism. Preventing secondary explosions requires eliminating accumulated dust from all surfaces, not just the floor -- including overhead ledges, equipment tops, and concealed spaces.
Combustible dust hazards are not limited to facilities that obviously process bulk powders. Any manufacturing process that generates fine particles as a byproduct -- including rubber, pharmaceutical, food, metal, and plastic processing -- can accumulate explosive dust in unexpected locations.
PSI: Process Safety InformationPHA: Process Hazard AnalysisTRN: Training
🔨 Safety Meeting Toolbox Talk
►Can you name three locations in your facility where fine dust could accumulate and be inaccessible to normal cleaning? Have those locations been evaluated in your PHA and housekeeping program?
►When your facility introduces a new raw material or changes suppliers, what is the formal process for hazard review? Does it include engineering evaluation of how the material behaves in your specific process?
►Has the combustible dust explosion hazard of each powder or fine solid used in your facility been specifically characterized? Or are you relying on general-purpose MSDSs that may not reflect the material's behavior in manufacturing?
►Are all penetrations of ceilings, walls, and floors in your facility sealed dust-tight where fine particles are present? Has anyone actually inspected above suspended ceilings for accumulated dust?
►Do your workers understand which materials in their area are combustible dusts and what actions would create a dangerous dust cloud? Has combustible dust been covered in training recently?
Immediate Action Items
✓Walk your facility and identify every location where fine powder or dust could accumulate in areas inaccessible to normal housekeeping -- including above suspended ceilings, on top of ductwork, and in enclosed overhead spaces. Document and schedule remediation.
✓Pull the MSDSs/SDSs for every powder or fine solid material used at your facility and verify that each one includes specific combustible dust characterization, including minimum ignition energy, Kst, and minimum explosive concentration where applicable.
✓Review your new material introduction procedure and confirm it requires an engineering-level hazard evaluation before any new powder or dust-generating material enters the production environment.
✓Verify that all ceiling and wall penetrations in areas handling combustible dusts are sealed dust-tight per NFPA 654 to prevent migration of fine particles into concealed spaces.
✓Schedule a combustible dust hazard awareness briefing for all workers who handle, generate, or work near fine powders -- including the specific consequence of secondary dust explosions triggered by an initial disturbance.
🔗 PSM Failures Behind This Incident

This incident traced to breakdowns across 3 PSM elements (PSI · PHA · TRN). Each represents a documented gap that process safety documentation and consulting can close before a similar event occurs at your facility.

Process Safety Information (PSI)
Accurate, complete Process Safety Information is the foundation every other PSM element depends on. When PSI is missing or wrong — chemistry data, equipment specs, P&IDs — the entire hazard analysis is built on a flawed base.
Supporting documents in our library →
Process Hazard Analysis (PHA)
A structured PHA or HAZOP study exists to identify exactly these scenarios before they occur. When PHA is absent, superficial, or overdue for revalidation, hazards operate unseen until they kill someone.
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.
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