CSB Investigation — Fire
Bethlehem Steel Corporation Gas Condensate Fire
Bethlehem Steel Corporation
📍 Burns Harbor (Chesterton), IN
Incident Date: February 2, 2001  |  CSB Report Released: September 2001
2
Fatalities
4
Injuries
5
CSB Recommendations
COG Condensate
Chemical / Hazard
📋 Incident Summary

On February 2, 2001, a fire at Bethlehem Steel Corporation Burns Harbor mill in Chesterton, Indiana, killed one Bethlehem Steel millwright and one contractor supervisor, and seriously injured four others. The victims were performing maintenance work on a coke oven gas (COG) line when flammable liquid was released and ignited.

Workers were attempting to remove a slip blind and a cracked valve from a coke oven gas line leading to a decommissioned blast furnace. The valve had developed a crack one month earlier, likely from water in COG condensate that had frozen and split the valve body. When workers began removing the cracked valve, flammable COG condensate — which had accumulated in the line — was released and ignited.

The CSB found that Bethlehem Steel planning and supervision of the maintenance work was inadequate. The maintenance plan did not account for the presence of flammable COG condensate in the line, nor did it include adequate energy isolation verification. Workers were not provided with information about the condensate hazard.

🔎 Key Findings
Finding 1
COG Condensate Trapped in Piping
Flammable coke oven gas condensate had accumulated inside the piping associated with the cracked valve. The maintenance plan did not account for the presence of this flammable liquid.
Finding 2
Cracked Valve Not Adequately Pre-Assessed
The valve had been known to be cracked for one month before the maintenance work. Pre-job planning did not assess what fluids might be present or released during valve removal.
Finding 3
Inadequate Maintenance Work Planning
The work plan for removing the cracked valve did not include steps to drain, vent, and verify the line was free of flammable liquids before work began.
Finding 4
Deficient Energy Isolation
Pre-job energy isolation did not adequately account for the presence of flammable liquid condensate trapped in the piping section being worked on.
Finding 5
Inadequate Supervision of Hazardous Work
The maintenance work was not supervised by a person with authority and responsibility to ensure safe completion. Workers were not adequately guided through the hazards specific to this job.
Finding 6
COG Condensate Flammability Hazard Underestimated
Workers and supervisors did not adequately recognize the flammability hazard of COG condensate trapped in the low point of the decommissioned blast furnace piping.
🔍 Root Causes
1
Inadequate Pre-Job Hazard Planning
The maintenance plan did not identify or address the flammability hazard of COG condensate in the piping section, leaving workers without knowledge of the primary hazard.
2
Failure to Drain and Verify Line Before Work
No procedure required draining and verifying the piping section was free of flammable liquids before beginning valve removal work.
3
Deficient Supervision of High-Hazard Maintenance
The high-hazard nature of the work required active, qualified supervision — which was not provided in a manner adequate to prevent a fatal mistake.
4
Energy Isolation Plan Did Not Address All Hazards
The LOTO / energy isolation plan focused on pneumatic and electrical hazards but did not adequately address the flammable liquid content of the piping.
☑ CSB Recommendations
→ Bethlehem Steel
Implement a formal work authorization system for all hazardous maintenance activities requiring pre-job hazard analysis, line draining verification, and management sign-off before work begins.
→ Bethlehem Steel
Require all valve and piping maintenance on coke oven gas systems to include specific steps to drain the piping section, verify gas-free and liquid-free conditions, and document verification before work authorization.
→ Bethlehem Steel
Establish a hazardous work supervision requirement specifying who is responsible for safety oversight and what authority they have to stop work if conditions change.
→ OSHA
Issue safety communication on the hazards of coke oven gas condensate in maintenance activities on decommissioned or low-use piping.
→ Steel Industry / AISI
Develop industry guidance on maintenance safety procedures for coke oven gas piping, including condensate drainage, verification, and supervision requirements.
💡 Lessons Learned
⚠ Hazardous maintenance work planning must identify and address all fluid hazards in the piping being worked on — not just electrical and pneumatic energy sources. Flammable liquid in a "decommissioned" line is still a live hazard.
⚠ Draining and verifying a piping section is free of flammable liquids before beginning valve or fitting removal is a fundamental pre-job safety step. This verification must be documented, not assumed.
⚠ A cracked valve known for a month before maintenance requires heightened planning, not routine scheduling. Pre-knowledge of a defect demands a more thorough pre-job hazard assessment.
⚠ Supervision of hazardous maintenance must be active and qualified — present during critical steps, with authority to stop work if conditions change. Remote or administrative supervision is not adequate for high-hazard tasks.
⚠ Coke oven gas and other process gas condensates are flammable liquids that accumulate in piping low points. Lines that appear empty may contain flammable liquid that will be released when valves or fittings are removed.
PSM Elements: MI · SOP · HOW · CON
🔨 Safety Meeting Toolbox Talk
Topic: Hazardous Maintenance Work Planning & Line Clearing
💬Do our work procedures for valve and piping maintenance specifically require draining and verifying the line is free of flammable liquids before removal of any valves or fittings?
💬When maintenance is planned on piping in gas or condensate service, is a pre-job hazard analysis conducted that specifically identifies what fluids may be present?
💬Is there a supervision requirement for high-hazard maintenance specifying who is responsible for safety oversight and authorizes work to proceed or stop?
💬Are workers who perform maintenance on process piping trained to recognize the signs of flammable liquid presence and to stop work if unexpected conditions are encountered?
💬Does our LOTO / energy isolation process for piping maintenance specifically address the hazard of trapped liquid in low points of lines being worked on?
✎ Team Action Items
✓Review work procedures for piping and valve maintenance — confirm specific draining, venting, and flammable liquid verification steps are included before any valve or fitting removal
✓Pull a recent work order for hazardous maintenance on a gas or condensate line and verify a pre-job hazard analysis identified all fluid hazards in the piping section
✓Confirm that your LOTO / energy isolation procedure specifically addresses trapped liquid in low points of piping sections being worked on
✓Identify all personnel with supervisory responsibility for hazardous maintenance and verify their role includes authority to stop work if conditions change
🔗 PSM Failures Behind This Incident

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

Mechanical Integrity (MI)
Equipment must be designed, inspected, and maintained to operate safely in its intended service. Mechanical integrity failures — degraded equipment, missed inspections, deferred repairs — contributed to loss of containment here.
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 →
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 →
Contractor Safety Management
Contractor workers must be held to the same PSM standard as employees. When contractor safety oversight fails, knowledge and compliance gaps follow contract workers onto your site.
Supporting documents in our library →
Process Safety Management Consulting & Document Library
📂
PSM Document Library
32 ready-to-deploy PSM documents covering all 14 OSHA elements — procedures, checklists, and audit templates built for facilities operating under 29 CFR 1910.119.
Browse the Library →
📊
Free PSM Health Score
Find out where your PSM program stands across all 14 OSHA elements. Our free health score surfaces your biggest gaps in under 10 minutes — no account required.
Check Your Score →
📞
Consulting Services
PHA facilitation, PSM program builds, compliance audits, and OSHA inspection support. Transparent flat-fee pricing — no retainer required to get started.
View Pricing →
📋 Explore the full incident library: All 132 CSB Case Studies →