oversight

Motor Vehicle Safety: Information on Accidental Fires in Manufacturing Air Bag Propellant

Published by the Government Accountability Office on 1990-09-28.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

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                                                                 MOTOR VEHICLE
                                                                 SAFETY
                                                             Information on
                                                             Accidental Fires in
                                                             Manufacturing Air Bag
                                                             Propellant



                                                                                                   142599




                                                                               RF/,FbFFD
                                                 RJBTRICTED --Not      to be relea&d outaide the
                                                 General Accounting Office unless specificauy
                                                 approved by the Office of Congressional
                                                 Relations.
,
                   United States
GAO                General Accounting Office
                   Washington, D.C. 20648

                   Resources, Community,   and
                   Economic Development    Division

                   B-240858

                   September 28,199O

                   The Honorable John D. Dingell
                   Chairman, Committee on Energy
                     and Commerce
                   House of Representatives

                   Dear Mr. Chairman:

                   In response to your September 22,1989, request, this report discusses
                   recent accidental fires at the U.S. and Canadian facilities that make gas
                   generant (propellant) for automobile air bags and at the Canadian
                   facility that makes sodium azide, which is a main propellant ingredient.
                   As agreed with your office, we identified the (1) general hazards associ-
                   ated with manufacturing propellant; (2) causes of the fires and resulting
                   injuries; (3) safety and health investigations conducted at the U.S. facili-
                   ties; and (4) the impact of the fires on suppliers’ ability to meet the auto-
                   motive industry’s air bag needs. As explained in detail later in the scope
                   and methodology section, some information on the causes of the fires,
                   results of investigations, and manufacturers’ corrective actions is based
                   on unconfirmed oral evidence. The manufacturers would not provide us
                   with some documentary evidence because they considered the informa-
                   tion to be proprietary.


                   Air bag propellant manufacturing is not risk-free because sodium azide,
Results in Brief   while not an explosive, can form explosives. When sodium azide comes
                   in contact with an acidic solution such as water, it becomes hydrazoic
                   acid, an explosive, which can detonate from shock or heat. Also, if
                   sodium azide comes into contact with heavy metals such as copper or
                   lead it may form new compounds that are extremely sensitive and easily
                   detonated. Manufacturers told us that they control and monitor to pre-
                   vent conditions that may create hydrazoic acid or expose sodium azide
                   to heavy metals in the manufacturing process.

                   The three principal manufacturers (2 U.S. and 1 Canadian) of air bag
                   propellant for the U.S. automotive industry and the principal manufac-
                   turer (Canadian) of sodium azide have had a total of 11 sodium azide-
                   related fires since February 1988. The two U.S. manufacturers have had
                   two accidental fires each but no fatalities or serious injuries. The Cana-
                   dian sodium azide manufacturer has had two fires but no fatalities or




                   Page 1                                    GAO/RCED-PO-230 Air Rag Propellant Fires
                                                                              L
B-24os58




serious injuries. The Canadian propellant manufacturer had five acci-
dental fires and no fatalities; four employees were seriously injured in
two of the five fires.

Two U.S. fires occurred in Arizona and were investigated by the respon-
sible state agency. The agency’s investigations showed that human error
was the most probable cause of both fires. The other two U.S. fires
occurred in Utah and were investigated by the manufacturer. The manu-
facturer’s investigations showed that one accident resulted from equip-
ment failure and the other, most likely, from hydrazoic acid or metal
azide. Both manufacturers told us that corrective actions, such as
requiring employees to take safety training, revising a safety manual,
and redesigning equipment and facilities, have been taken or initiated.

Six of the seven Canadian accidents were investigated by the manufac-
turer and the seventh was investigated jointly by the responsible Cana-
dian agencies and the manufacturer. The manufacturers told us that
four accidents were caused by human error, one by improper equipment
design, one by improper manufacturing procedure, and one by improper
equipment design and human error combined. After the last fire at the
propellant manufacturer’s facility in March 1990, Canadian agencies
closed the facility until the investigation is completed and corrective
action taken to ensure a safe workplace. The manufacturer expects to
reopen for production in October 1990. Both manufacturers told us that
they have corrected or are correcting the problems identified.

To ensure that employees are provided with a safe and healthy work
environment at the two U.S. manufacturers’ facilities, Arizona and Utah
agencies have conducted five investigations. These are in addition to the
two accident investigations that Arizona conducted. The Arizona agency
conducted four investigations in 1989-three before and one after the
two fires. It found that the manufacturer had failed to adequately
inform and/or train employees on the potential hazards of chemicals
being used. The Utah agency found in a September 1986 investigation
that the manufacturer was complying with applicable safety and health
requirements.

The 11 fires disrupted both sodium azide and propellant production.
Despite these disruptions, U.S. manufacturers have been able to keep
the automotive industry supplied with the propellant needed for driver-
side air bags-the great majority of the demand. However, the Ford
Motor Company has had to market about 75,000,1990 luxury cars



Page 2                                  GAO/RCEJMO-230 Air Rag F’ropellant Firee
-c-
                                                       .I
                     B-240888




                     without passenger-side air bags because the Canadian plant was closed
                     after the March 1990 fire.


                     Chrysler, Ford, and General Motors are installing driver-side air bags in
Background           an increasing number of passenger cars to comply with a National
                     Highway Traffic Safety Administration (NHTSA) safety requirement. Air
                     bag demand increased from about 500,000 in model year 1989 to about 2
                     million in model year 1990, and is expected to increase to 5 or 6 million
                     in 1993. Ford is the only U.S. manufacturer to offer passenger-side air
                     bags as standard equipment in some of its model year 1990 cars.

                     The propellant for air bags is made primarily from sodium azide blended
                     with an oxidizer, such as cupric oxide or ferric oxide, and is hermeti-
                     cally sealed in an inflator. According to NHTSA, sodium azide based pro-
                     pellant is (1) safe and stable when hermetically sealed in the inflator
                     and (2) ideally suited for air bags because, as part of the propellant, it
                     does not explode when ignited, but begins a burning process that gener-
                     ates nontoxic nitrogen gas to inflate the air bag. Research is being con-
                     ducted to develop other types of propellants, but to date, there is no
                     approved alternative to sodium azide.


                     Because of the inherent nature of sodium azide, manufacturing air bag
Hazards and Safety   propellant is not risk-free. Sodium azide, while not an explosive by
ProceduresInvolved   itself, forms an explosive (hydrazoic acid) when it comes into contact
With Manufacturing   with an acidic solution such as acid water and can detonate from shock
                     or heat. Also, when sodium azide comes into contact with heavy metals
Air Bag Propellant   such as copper or lead it may form new compounds that are extremely
                     sensitive and can also be detonated by impact or heat. Manufacturers
                     told us they control and monitor to prevent conditions that may create
                     hydrazoic acid or expose sodium azide to heavy metals in the manufac-
                     turing process.

                     NHTSA  and knowledgeable chemists believe that manufacturing
                     processes and procedures are available to produce air bag propellant
                     safely. In addition to controlling and monitoring for the formation of
                     explosives, the processes and procedures include such measures as
                     (1) installing blow-out walls in the event of a fire or explosion to channel
                     and control the forces generated, (2) using remote control to allow
                     employees to conduct operations from a safe area, (3) performing dif-
                     ferent manufacturing steps in separate buildings to minimize employee
                     exposure to potential dangers, (4) monitoring the air within the plant,


                     Page 3                                   GAO/RCEtNO-230 Air Bag Propellant Firea
                       IS240868




                       (6) requiring employees to wear protective clothing and safety goggles,
                       and (6) inspecting process equipment and facilities to ensure that
                       sodium azide is not exposed to heavy metals. (See app. I.)


                       Between February 1988 and May 1990, TRW Vehicle Safety Systems,
Accidental Fires,      Inc., in Mesa, Arizona, and Morton International, in Ogden, Utah, (U.S.
Causes,and Resulting   propellant manufacturers) had two accidental fires each, and Sabag,
Injuries               Inc., McMasterville, Quebec, (Canadian propellant manufacturer) had
                       five fires. Additionally, CIL Inc., in McMasterville, Quebec, (Canadian
                       manufacturer of sodium azide) had two fires.’ Sodium azide was
                       involved in all 11 fires, and each fire was investigated by either the
                       manufacturer involved or by an external organization. No employees
                       were killed in the 11 fires. Also, no one was seriously injured in the four
                       U.S. fires. In two of the seven Canadian fires, four employees were seri-
                       ously injured. NHTSA believes the safety measures manufacturers have
                       built into their facilities and operations before the accidents occurred
                       contributed largely to the fact that there were no fatalities.

                       The two TRW fires, which occurred on June 16 and July 28, 1989, were
                       investigated by the Arizona Division of Occupational Safety and Health
                       (ADOSH). ADOSH found that human error was the most probable cause of
                       both fires. According to their investigation of the June 16 fire, equip-
                       ment was not maintained as required; consequently sodium azide and
                       other chemicals were exposed to heat. AJXISH cited TRW for failing to
                       eliminate a recognized hazard from the workplace that could result in
                       death or serious injury. Concerning the July 28 fire, ADOSH concluded
                       that the most probable cause was a spark from a metal scoop acciden-
                       tally dropped into equipment used to blend sodium azide and other
                       chemicals. As a result of these accidents, TRW took several actions to
                       improve workplace safety. For example, TRW (1) established a require-
                       ment that all employees take 40 hours of safety training, (2) revised its
                       safety manual to require a written test for job certification, and
                       (3) started to construct separate buildings for performing its major man-
                       ufacturing steps, which reduces the number of employees exposed to
                       potential harm in the event of an accident.

                       The two Morton fires, which occurred on July 24 and August 14,1989,
                       were investigated by Morton officials. According to the investigation,
                       the July fire started when a spark from a broken press part ignited the

                       ICIL was renamed ICI ExplosivesCanada on May 1,199O. CIL haa been producing sodium azide for
                       over 40 years and is the only commercial producer in North America.



                       Psge 4                                             GAO/FEED-B&280 Air Bag Propellant Firea
    propellant. The August fire started when the propellent mixture was
    ignited by a unknown source. Morton officials told us that several cor-
    rective actions have been taken to prevent recurrence of similar
    problems and to improve overall workplace safety. Corrective actions
    include (1) running inert material through the press to ensure that it is
    working properly and (2) installing fireproof cabinets to store finished
    propellant after it is manufactured.

    Of the five Sabag fires, which occurred between February 1988 and
    March 1990, four were investigated by the manufacturer and the fifth
    was investigated jointly by two Canadian agencies-Department of
    Energy, Mines, and Resources, Office of the Chief Inspector of Explo-
    sives; and the Commission of Health and Work Security-and the manu-
    facturer. According to the manufacturer, hydrazoic acid was the most
    probable cause of one fire. The manufacturer was using dry ice to cool
    equipment, and moisture from the ice came into contact with sodium
    azide. The most probable cause of another fire was copper azide and
    human error combined. Brass screws used to secure a conveyor lid first
    caused copper azide to form and then was ignited from the shock of a
    mallet being used by employees to dislodge a blocked conveyor. The
    manufacturer said human error was the most probable cause of the
    other fires. Specifically,

l an employee was making adjustments to a machine before it had been
  decontaminated (cleaned), and a spark from a screwdriver ignited the
  propellant mix;
. employees failed to secure a dust filter properly, and a spark ignited the
  propellant mix; and
. maintenance employees, without proper clearance, were drilling above a
  piece of equipment, and the cuttings from the drill ignited the propellant
  mix.

    The Department of Energy, Mines, and Resources and the Commission of
    Health and Work Security closed the Sabag plant until the investigation
    of the fifth fire was completed and the problems are corrected. The
    manufacturer expects to reopen the plant for production in October
    1990. Moreover, the manufacturer told us that action had been or is
    being taken to correct the problems identified in this investigation, as
    well as the other investigations. For example, liquid nitrogen is now
    being used to cool equipment in place of dry ice.




    Page 6                                  GAO/RCED-90-230 Air Bag Propellant Fires
                         B240858                                                                 ,




                         CIL investigated its two fires, which occurred on October 8 and
                         November 1, 1989. CIL officials said that a pressure-reducing valve reg-
                         ulating steam heat going to equipment used to dry the sodium azide
                         (dryer) was the most probable cause of the first fire. The valve was
                         located too close to the dryer and caused the sodium azide to overheat.
                         The officials also said the most probable cause of the second fire was
                         sodium azide contacting raw sodium. They were temporarily storing wet
                         sodium azide in drums that had previously contained raw sodium. The
                         drums were to have been cleaned before storing wet sodium azide, but
                         one was not. CIL officials said that they have (1) relocated the valve,
                         (2) stopped storing wet sodium azide in drums that previously contained
                         raw sodium, and (3) established rigid procedures to verify that the
                         drums are clean. (See app. II.)


                         The Occupational Safety and Health Administration (OSHA), Department
Safety and Health        of Labor, has primary responsibility for ensuring that employees are
Investigations at U.S.   provided with a safe and healthy work environment. OSHA can delegate
Facilities               this responsibility to any state that develops an approved plan that
                         adopts standards and enforcement requirements which are at least as
                         effective as federal requirements. Currently, 25 states have approved
                         plans, including Arizona and Utah-the states where propellant is
                         made.


Investigations at TRW    TRW purchased the Mesa, Arizona, propellant facilities from Talley
                         Defense Systems in April 1989. Since that time, ADO~H has conducted
                         four investigations in addition to the investigations it conducted of
                         TRW’s two fires. Three investigations were made prior to the first fire in
                         June 1989. In its first investigation, AIXXH cited TRW for (1) not main-
                         taining in the workplace copies of safety data sheets for each hazardous
                         chemical being used and (2) not providing required information and
                         training to employees on hazardous chemicals used in the workplace.
                         ADOSH classified each violation as serious and initially assessed TRW a
                         $700 penalty-$350      for each violation. AWSH reduced the penalty to
                         $400 because TRW had inherited some of the problems from the pre-
                         vious owner and because of TRW’s positive attitude and corrective
                         efforts. The next two investigations did not identify any serious safety
                         or health violations.

                         The last investigation, conducted after the July 1989 fire, showed that
                         some employees were still working with sodium azide without receiving
                         proper training about its hazards. ADOSH again classified this violation as


                         Page6
                           serious and assessed TRW a $1,000 penalty. ADOSH reduced the penalty
                           to $640 because TRW was in the process of implementing a hazard com-
                           munication program at the time of the investigation. TRW told us that
                           the program was administered to all employees by the end of October
                            1989.

                           We did not evaluate the reasonableness of the penalties assessed by
                           ADOSH because it was not within the scope of this review. (See app. III.)


Investigations at Morton   On September 25,1986, Utah Occupational Safety and Health @JOSH)
International              conducted a safety investigation of Morton’s facilities for manufacturing
                           air bags.2 UOSH found that Morton was in compliance with applicable
                           safety requirements and reported that Morton had an excellent attitude
                           toward safety. According to the director, UOSH did not investigate either
                           of the two Morton fires because neither fire met the criteria for trig-
                           gering an investigation. (See app. III.)


                           Although the accidents have disrupted production and reduced the
Impact of Fires on         supply of both propellant and sodium azide, U.S. propellant manufac-
SUPPlY                     turers have been able to meet the automotive industry’s demand for
                           driver-side air bags-the great majority of the demand for air bags, The
                           Ford Motor Company, on the other hand, has had to market about
                           75,000 of its 1990 luxury cars without passenger-side air bags, which
                           were to be standard equipment, because it could not get propellant after
                           the Sabag plant was closed in March 1990. (See app. IV.)


                           To obtain information on the hazards of making air bag propellant, the
Scopeand                   accidental fires, and the impact of the fires on the automotive industry,
Methodology                we interviewed NHTSA headquarters officials in Washington, D.C.; TRW
                           officials in Washington, Michigan; and Mesa, Arizona; Morton Interna-
                           tional officials in Ogden, Utah; CIL Inc. and Sabag officials in McMas-
                           terville, Quebec; ADOSH officials in Phoenix, Arizona; and UOSH officials
                           in Salt Lake City, Utah. We toured TRW’s air bag plant in Mesa, Arizona,
                           and GIL’s sodium azide plant in McMasterville, Quebec.

                           We requested all internal and external reports prepared on the acci-
                           dental fires. We received external reports on the two TRW fires and

                           2Morton International was created in July 1989 by Morton Thiokol, Inc., to handle all its commercial
                           operations, including the manufacture of air bags and propellant.



                           Page 7                                                 GAO/RCED-90-286 Air Bag Propellant Fires
B-240818                                                                       ,




internal reports on the two Morton fires, one of which had large sections
deleted for proprietary reasons. Also, we received some written infor-
mation on the second CIL fire. However, both CIL and Sabag declined
our requests for copies of the investigative reports on their seven fires
for proprietary reasons. Accordingly, unconfirmed oral evidence sup-
ports much of the information related to the fires, particularly those
that occurred in Canada.

In addition, we interviewed OSHA headquarters officials and Environ-
mental Protection Agency (EPA) headquarters and regional officials to
identify the safety and environmental regulations applicable to the man-
ufacturing of air bag propellant and to ascertain who investigated the
accidental fires. Further, we interviewed Chrysler, Ford, and General
Motors officials to determine whether the fires adversely affected their
production of automobiles. We performed our work between December
 1989 and May 1990. We discussed the information in this report with
the sodium azide and propellant manufacturers, state agencies, and
OSHA, EPA, and NHTSA officials who agree with the facts. However, as
requested, we did not obtain official agency comments on a draft of this
report.


As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days from
the date of this letter. At that time, we will provide copies to other inter-
ested congressional committees, the Secretary of Transportation, the
Secretary of Labor, the NHTSA Administrator, the OSHAAdministrator,
the EPA Administrator, and other interested parties. If you have any
questions about this report, please contact me on (202) 275-1000.

Majors contributors to this report are listed in appendix V.

Sincerely yours,




Kenneth M. Mead
Director, Transportation Issues




Page 8                                    GAO/RCED-90-280 Ah Bag Propellant Fires
Page 9   GAO/RCED-90-220 Air Bag Propellant Fires
Contents


Letter
Appendix I
Hazards of
Manufacturing Air
Bag Propellant and
Safety Measures to
Protect Employees
Appendix II                                                                                              13
Accidental Fires,
Causes,and Resulting
Injuries
Appendix III                                                                                             18
Safety and Health
Investigations at U.S.
Facilities
Appendix IV                                                                                              21
Impact of Fires on
SUPPlY
Appendix V                                                                                               23
Major Contributors to
This Report
Table                    Table II. 1: Accidental Fires at Air Bag Propellant and                         13
                             Sodium Azide Manufacturing Facilities-February
                              1988 to March 1990




                         Page 10                                 0Ao/BcEDQo-280    Air Itag Propellant Fires
.


    Contenta




    Abbreviations

    ADOSH      Arizona Division of Occupational Safety and Health
    EPA        Environmental Protection Agency
    GAO        General Accounting Office
    NHTSA      National Highway Traffic Safety Administration
    OSHA       Occupational Safety and Health Administration
    PEL        permissible exposure limit
    UOSH       Utah Occupational Safety and Health


    Page 11                                 GAO/RCED-90-220 Air Bag Propellant Firea
Appendix I

Hazards of Manufacturing Air Bag Propellant                                                      ’
and Safety Measuresto Protect Employees

               In its natural state, sodium azide is a colorless crystal that, by itself, is
               insensitive to impact and friction and will not detonate. Sodium azide
               based propellant is a low-energy propellant, possessing about one-third
               the energy of rifle powder and one-thirtieth that of gasoline. However,
               sodium azide, in acidic solution such as water with a high acid content,
               forms hydrazoic acid- a highly toxic and volatile chemical which can
               explode when shocked or heated. Moreover, sodium azide in contact
               with heavy metals, such as lead, mercury, cadmium, silver, and copper
               and its alloys can form extremely sensitive explosives that can also be
               detonated by impact or heat. Manufacturers told us that they control
               and monitor to prevent conditions that may create hydrazoic acid or
               expose sodium azide to heavy metals.

               Furthermore, sodium azide is a poison and, while it is not mutagenic to
               humans or carcinogenic, it can cause health problems if it (1) is inhaled,
               (2) comes into contact with skin or eyes, and (3) is ingested. For
               example, it can cause severe lowering of blood pressure, severe irrita-
               tion of the respiratory tract, skin irritations, and blurred vision.

               A NHTSA report, Sodium Azide in Automotive Air Bags, originally issued
               in March 1978 and updated in February 1981, stated that adequate safe-
               guards exist or can be put into place to ensure occupational safety and
               health. Also, the report stated that sodium azide and inflator manufac-
               turers are experienced in handling chemicals whose danger is at least as
               great as is the danger of sodium azide.

               NHTSA   and knowledgeable chemists believe that manufacturing
               processes and procedures exist to allow safe production of air bag pro-
               pellant. In addition to controlling and monitoring for hydrazoic acid, the
               processes and procedures include such measures as (1) installing blow-
               out walls to channel and control the pressure wave generated in the
               event of a fire or explosion, (2) using remote control to allow employees
               to conduct operations from a safe area, (3) performing different manu-
               facturing steps in separate buildings to minimize employee exposure to
               potential dangers, (4) monitoring the air within the plant, (5) requiring
               employees to wear protective clothing and safety goggles, and
               (6) inspecting process equipment and facilities to ensure that sodium
               azide is not exposed to heavy metals.




               Page 12                                    GAO/RCED-90.220 Air Bag Propellant Firea
Appendix II

Accidental Fires, Causes,and Resulting @juries


                                                            From February 1988 to May 1990, air bag propellant and sodium azide
                                                            manufacturers have had a total of 11 accidental fires. Internal and
                                                            external investigations showed that 6 of the 11 fires were caused by
                                                            human error, and the remaining fires were caused either by improper
                                                            procedures, improper equipment design, faulty equipment, improper
                                                            equipment and human error combined, or formation of hydrazoic acid.
                                                            No one has been killed in any of these fires, and no employee has been
                                                            seriously injured in the fires at U.S. plants or at the CIL plant. Four
                                                            employees were seriously injured, however, in two of Sabag’s fires. (See
                                                            table II. 1.)

                                                            In a January 11, 1990, letter to the Chairman, House Committee on
                                                            Energy and Commerce, NHTSA stated:

                                                            These events [fires], both in Canada and the U.S., have fortunately not caused loss
                                                            of life, mostly as a consequence of the design and layout of the facilities which
                                                            employ state-of-the-art safety construction and remote control systems for operator
                                                            safety. Each of the events has led to improved safety in subsequent production, and
                                                            the long history of commercial production of sodium azide provides confidence that
                                                            production of this material can be safely accomplished to satisfy air bag application
                                                            needs.


Table 11.1:Accidental Fires at Air Bag Propellant and Sodium Azide Manufacturing Facilities-February                                  1988 to March 1990
                                      Date of         Injuries
Manufacturer                        Accident     Serious       Minor Probable Cause
United States                                                    -.-_.-
TRW                                             6/16/09                   0             0      Human error
                                                7/20/09                   0             5      Human error
Morton                      ___.---             7/24/09                   0             0      Equipment failure
                                                0/r 4109                  0             0      Hydrazoic acid or metal azide
Canada                             .----   -_______-__
Sabag                                            2/l 7100                 1             3      Human error                                                           -
                                                 3/l l/09                 0             0      Human error                                                      --
                                                 7/l 3109                 0             0      Improper procedure caused hydrazoic acid to form
                                               12/00/09                   0             2---   Human error                               -___
.I.“_“I _.^.._
            .-...--_..._.-_--..-----.-           3/14/90                  3             0      Human error and improper equipment design
GIL                                            I o/00/09                  0             0      lmorober eauioment desian
                                               1l/01/09                   0             0      Human error
                                                            Note: No fatalities resulted from the fires.

                                                            Source: Internal and external investigation reports and oral testimony from manufacturers’ officials.




                                                            Page 18                                                  GAO/RCED-SW30 Air Bag Propellnnt Fires
                                                                                                  .
                       Appendix II
                       Accidental Fires, Causes, and
                       Resulting Injules




TRW                    TRW had two accidental fires in 1989-June 16 and July.28-while
                       blending sodium azide and the oxidizer. No fatalities or serious injuries
                       resulted, but in one fire five employees received minor injuries-three
                       were bruised, one developed ringing in the ears, and one received glass
                       in one eye. Both fires were investigated by the Arizona Division of Occu-
                       pational Safety and Health (ADOSH) along with the fire department of
                       Mesa, Arizona. Representatives of the Arizona Department of Environ-
                       mental Quality were present during these investigations but did not par-
                       ticipate in them. ADosH found that the first fire was caused by improper
                       maintenance of the blender. It concluded that the most probable cause of
                       the second fire was a spark from a metal scoop that was accidentally
                       dropped into the blender. (See appendix III for more details on the
                       investigations conducted by ADOSH.)

                       After TRW acquired the propellant manufacturing facilities from Talley
                       Defense Systems in April 1989, it initiated the following safety actions:

                       Hired several additional employees with expertise in safety/environ-
                       mental areas.
                       Established a requirement that all employees take 40 hours of safety
                       training.
                       Revised its safety manual, which was reviewed and approved by ADOSH.
                       TRW now requires all its operators to take a written test for job certifi-
                       cation and to be recertified periodically.
                       Established tool-control procedures.
                       Started to construct separate facilities for its three major manufacturing
                       steps-grinding, blending, and pressing.
                       Decided to install a smaller blender in the new facilities to mix propel-
                       lant in reduced-lot sizes.
                       Contracted with an architect and engineering firm to design a system for
                       automatic loading of the blender.

                       ADOSH officials told us that TRW has been very cooperative in assisting
                       ADOSH since the accidents and is concerned about safety. This position
                       was substantiated by a Mesa fire department report that stated TRW’s
                       cooperation in its investigation and cleanup and in providing informa-
                       tion was exemplary.


Morton International   Morton also had two fires in 1989. No one was killed or injured in either
                       of these fires. Also, according to the Director, Utah Occupational Safety




                       Page 14                                 GAO/RCED-90-230 Air Rag Propellant Fire.8
        .

    .
                bpendlx II
                Accidental Fires, Caurrecr,and
                ReeulthgLnjurlee




                and Health, neither of the fires met the federal or state criteria for trig-
                gering an investigation-one    or more fatalities, five or more people hos-
                pitalized, or an imminent danger situation.’

                Morton conducted its own investigations to determine the probable
                cause(s), and made recommendations to prevent the recurrence of sim-
                ilar accidents. The investigation report on the July 24, 1989, fire con-
                cluded that the most probable cause of the fire was a fractured press
                part that fell into the press die, and when pressure was applied the pro-
                pellant ignited. The report made several recommendations that were
                adopted to help prevent a recurrence of this type of accident, including
                (1) running inert material in the press to assure that dies and steel
                punches are compatible and (2) installing fireproof storage cabinets to
                store propellant after it has been made into tablets.

                The investigation report on the August 14, 1989, fire did not identify the
                precise cause and initiation point but stated that the accident was most
                likely caused by the presence of hydrazoic acid or sensitive metal azide
                materials. The report contained three recommendations to prevent this
                type of fire from happening again, but, for proprietary reasons, Morton
                deleted two of the recommendations completely and one partially from
                the copy of the report provided to us. According to Morton officials, the
                three recommendations were adopted.


Sabag, Inc.     Sabag, a joint venture between CIL and TRW, began making propellant
                in December 1987.’ It has had five accidental fires since then. A total of
                nine employees sustained injuries-four     serious and five minor-in
                three of the fires. Because of proprietary reasons, our written request
                for copies of the investigation reports was denied. However, we dis-
                cussed the Sabag accidents with the Director of Technical Support for
                CIL, and he provided the following details on the Sabag fires:

              . The first fire occurred on February 17, 1988; one employee received
                serious injuries, and three other employees received minor injuries.
                After the shift had ended for the day and the employees had removed
                their protective clothing, an employee went back to make adjustments to
                the coating machine. The machine had not been decontaminated
                (cleaned), and a spark from a screwdriver ignited the leftover material.


                ‘According to TRW, CIL is responsible for the design and operation of the facility and TRW is respon-
                sible for marketing the propellant.



                Page 16                                               GAO/RCED-W-230 Air Rag Propellant F’irea
               Appendix II
               Accidental Fires, Causes, and
               Resulting Injuries




               The machine has since been completely redesigned to prevent a similar
               accident from occurring.
           9   The second fire occurred on March 11,1989; no employees were injured.
               An internal investigation determined that the most probable cause was a
               filter in the dust collector had not been secured properly and permitted
               static electricity to build up and discharge, igniting leftover material in
               the dust collector and other equipment. Another probable cause identi-
               fied by the investigation was that dry ice used to cool the grinder caused
               moisture to form and generated hydrazoic acid.
           .   Another fire occurred in the grinder on July 13, 1989, and no injuries
               resulted. Most probably the dry ice used to cool the machine caused
               moisture to form and generated hydrazoic acid. Liquid nitrogen is now
               used in lieu of dry ice to cool the grinder.
           .   A fourth fire occurred on December 8, 1989. Two maintenance
               employees, without proper clearance, were drilling above the equipment
               used to grind sodium azide, and the cuttings ignited leftover material.
               The machine had not been cleaned of propellant mix. Each employee
               received minor injuries.
           .   The fifth and most recent fire occurred on March 14, 1990; three
               employees were seriously injured. The most probable cause was twofold.
               Brass screws used to secure a conveyor lid caused copper azide to form
               which was then ignited from the shock of a mallet being used to dislodge
               the blocked conveyor. The facility was shut down by the Department of
               Energy, Mines, and Resources, Office of the Chief Inspector of Explo-
               sives; and the Commission of Health and Work Security until the
               ongoing joint company-government investigation is completed and the
               problems are corrected. The conveyor has been redesigned and brass
               screws will not be used in the new system. The plant will be reopened
               for production in October 1990.


CIL Inc.       In late 1989, CIL experienced two accidental fires that prevented it from
               drying sodium azide for 4 months. CIL officials told us that no injuries
               resulted from either fire. CIL officials also said that the company is
               investigating ways to do the entire drying operation by remote control.

               According to CIL officials, the first fire occurred on October 8, 1989. An
               internal investigation found that a pressure-reducing valve for regu-
               lating steam heat was located too close to the dryer and caused the
               sodium azide to overheat. They said the valve has been relocated.

               The second fire occurred on November 1, 1989. Since the cause of the
               fire was not readily apparent, CIL formed an investigating committee.


               Page 16                                 GAO/RCED-90-230 Air Bag Propellant Fires
CIL officials told us the investigation found that the most probable
cause of the fire was the storing of wet sodium azide in a drum previ-
ously used to store raw sodium without decontaminating the drum. CIL
officials said that they have stopped storing wet sodium azide in drums
that previously contained raw sodium and have established rigid proce-
dures to verify that the drums are clean.




Page 17                                GAO/RCED-90-230 Air Bag Propellant Fires
 Ppe
                                                                                                 .
iG:& and Health Investigations at
U.S. Facilities

                        The Occupational Safety and Health Administration (OSHA),Department
                        of Labor, has primary responsibility for ensuring that employees have a
                        safe and healthy work environment. OSHAis authorized by the Occupa-
                        tional Safety and Health Act of 1970 to inspect the workplace of any
                        business that affects commerce to ensure compliance with standards
                        and regulations, Regulations require that all employers provide their
                        employees with a safe and healthful working environment. Employers
                        are required to report to the nearest OSHA office within 48 hours any
                        accident that results in one or more deaths or in the hospitalization of
                        five or more employees. Regulations also require an investigation of
                        these reported accidents and of any situation where there is imminent
                        danger that could cause death or serious physical harm. The act encour-
                        ages states to assume full responsibility for the administration and
                        enforcement of their job safety and health laws. To assume such respon-
                        sibility, OSHA must approve a state’s plan that includes standards and
                        regulations that are at least as effective as the comparable federal stan-
                        dards. After approval, OSHA monitors the states’ performance. OSHA has
                        approved state plans for both Arizona and Utah-the states where pro-
                        pellant is made.

                        In March 1989,os~~ adopted a permissible exposure limit (PEL) effective
                        September 1, 1989, for sodium azide of 0.3 milligrams per cubic meter of
                        air. Data submitted by the American Conference of Governmental Indus-
                        trial Hygienists and other data formed the basis for OSHA'S PEL. Prior to
                        1989, sodium azide exposure was not regulated by federal or state occu-
                        pational safety and health agencies.

                        The Environmental Protection Agency (EPA) under section 102 (a) of the
                        Comprehensive Environmental Response, Compensation, and Liability
                        Act of 1980 (P.L. 96-610) has designated sodium azide as a hazardous
                        substance. Regulations require a company to notify the EPA of any acci-
                        dent that releases 1,000 pounds or more sodium azide into the environ-
                        ment. According to EPA officials, EPA was not involved in any of the TRW
                        and Morton fires.


Investigations at TRW   Since TRW began producing air bag propellant in April 1989, ADOSH has
                        conducted six investigations- three health investigations prior to the
                        fires, and two safety investigations and one health investigation after
                        the fires. The results of these investigations follow.

                        On May 9, 1989, as a result of an employee complaint, ADOSH initiated a
                        comprehensive health investigation at plant 3 on North Greenfield Road.


                        Page 18                                 GAO/WED-90-230 Air Bag Propellant Fires
.


    Appendix III
    Safety and Health Inve&gationa   at
    U.S. Facilities




    The investigation showed four violations-two     serious and two nonser-
    ious. Regarding the serious violations, TRW was cited for not (1) main-
    taining in the workplace copies of material safety data sheets for
    chemicals being used, such as sodium azide and cupric oxide and (2) pro-
    viding required information and training to employees on hazardous
    chemicals used in the workplace. The two nonserious violations involved
    (1) employees not using available protective equipment and (2)
    employees not being provided with suitable eyewash facilities in the
    work area.

    For the two serious violations, ADOSH initially assessed TRW a $700 pen-
    alty-$360 for each violation. ADOSH later reduced the penalty to $400
    because TRW had inherited some of the problems from the previous
    owner and because of TRW’s positive attitude and corrective efforts.

    Two other health investigations were initiated by ADOSH on May 9, 1989.
    One, resulting from an employee complaint, was conducted at plant 4
    located on North Higley Road. The other one, resulting from a scheduled
    investigation, was conducted at another plant on North Greenfield Road.
    Concerning the complaint investigation, TRW was cited for a nonserious
    violation of not providing suitable eyewash and shower facilities to
    employees working with sodium azide. Concerning the scheduled inves-
    tigation, ADOSHidentified no violations.

    ADOSH conducted safety investigations of the June 16 and July 28, 1989,
    fires. ADOSH found that the June 16 fire was caused by improper mainte-
    nance of the blender. Following its investigation, ADOSH determined that
    TRW had committed a serious violation and issued a citation for vio-
    lating the “General Duty Clause” by failing to eliminate a recognized
    hazard in the workplace, and assessed a $1,000 penalty. TRW contested
    (1) the occurrence of a violation, (2) the proposed penalty, and (3) the
    classification of the violation as serious. Both the citation and penalty
    were withdrawn on December 14, 1989, according to ADO&S Assistant
    Chief Counsel, because (1) the blender was being leased from Talley
    Defense Systems, and it was uncertain who was responsible for its main-
    tenance; (2) TRW no longer leases the Talley blender, and the conditions
    that caused the accident would not be repeated; and (3) a citation issued
    citing the “General Duty Clause” as the authority is difficult to defend
    in the courts.

    ADOSH concluded that the most probable cause of the July 28 fire was a
    spark from a metal scoop that was accidentally dropped into the



    Page 19                                GAO/WED-90-230 Air Bag Propellant Firea
                                                                                                  ,


                           Appendix III
                           Safety and Health Investigations at
                           U.S. Facilities




                           blender. ADOSHnoted no apparent violations of its standards and did not
                           issue a citation or assess a penalty.

                           In conjunction with its safety investigation of the July 28, 1989, fire,
                           ADOSH conducted a health investigation. The investigation showed that
                           employees, who were transferred from other departments within the
                           propellant manufacturing facility, were handling sodium azide and
                           cupric oxide without receiving proper training as to the hazards in their
                           new work area. ADOSHclassified this violation as serious and assessed
                           TRW a $1,000 penalty. ADOSH reduced the penalty to $640 because TRW
                           was in the process of implementing a hazard communication program at
                           the time of the investigation.


Investigations at Morton   On September 27, 1986, UOSHinitiated a comprehensive safety investiga-
International              tion of the-then Morton Thiokol, Inc., air bag manufacturing facilities.
                           Morton International did not come into existence until July 1989 when
                           Morton Thiokol created it to handle all its commercial operations,
                           including the manufacture of air bags and propellant. UOSH found that
                           Morton was in compliance with all safety and health requirements and
                           had an excellent attitude toward safety. According to the director, IJOSH
                           did not investigate either of the two Morton International fires.




                           Page 20                                  GAO/RCED-90-230 Air Bag Propellant Fires
Appendix IV

Impact of Fires on Supply


                      TRW and Morton International officials said that, although the fires
                      have caused disruptions in the production of both sodium azide and pro-
                      pellant, they have been able to meet the increasing demand for propel-
                      lant by the US. automotive industry for driver-side air bags-the great
                      majority of the demand for air bags. Chrysler, Ford, and General Motors
                      officials confirmed that the fires have not caused any shortages in
                      driver-side air bags. Ford has had to market about 75,000 1990 Lincoln
                      Continental and Town Car models without passenger-side air bags
                      because of the March 1990 fire at Sabag and its subsequent closing.


Sodium Azide Supply   According to TRW officials, CIL was TRW’s only source of sodium azide
                      until CIL experienced its two fires in 1989 that shut down its operations
                      for drying sodium azide. To maintain their supply, TRW officials said
                      that they began acquiring some sodium azide from two Japanese firms
                      (Masuda and Toyo Kasei Kogyo) and one German firm (Dynamit-Nobel).
                      Also, they continued to buy wet sodium azide from CIL.

                      According to Morton officials, Morton has not been affected greatly by
                      the shutdown of GIL’s drying operations because it had a 2- to 3-month
                      supply of sodium azide when the accidents occurred and can use wet or
                      dry sodium azide in manufacturing propellant. Morton officials said that
                      one impact of not being able to buy dry azide from CIL was that they
                      had to manually load the wet azide into the blender, whereas the dry
                      azide could be loaded automatically. Morton officials said that they have
                      also identified Toyo Kasei Kogyo, Masuda, and Dynamit-Nobel as
                      sources of sodium azide and have made some purchases from those com-
                      panies in order to initiate steps to qualify them as suppliers.

                      CIL officials told us that they are expanding their production capability
                      to meet the increasing demand for sodium azide. They said that by July/
                      August 1990, their production capacity will have increased from 450
                      metric tons annually to 1,300 metric tons or from 990,000 to 2,860,OOO
                      pounds. CIL officials estimated that 80 percent of the sodium azide pro-
                      duced will be available for manufacturing air bag propellant.

                      According to TRW officials, on the basis of the known expansion plans
                      by the sodium azide producers they are using, there will be excess pro-
                      duction capacity through model year 1994. They estimated that, after
                      July or August 1990, production capacity for sodium azide would
                      exceed demand by 300 percent in model year 1991,400 percent in 1992,
                      268 percent in 1993, and 150 percent in 1994. Similarly, Morton officials
                      estimated that production capacity would exceed demand from 2.0 to


                      Page 21
                    Appendix IV
                    Impact of Fires on Supply




                    4.0 million pounds in model year 1994. Furthermore, TRW and Morton
                    officials said that if increasing demand requires it, additional production
                    capacity could be brought on line in 2 years.


Propellant Supply   TRW officials told us that the second fire destroyed their only blender
                    and that their new blending facilities would not be in operation until the
                    end of 1990. For the interim, they have contracted with Talley Defense
                    Systems to do the blending operations for them. Morton officials said
                    that they had excess capacity to meet the demand for propellant and
                    their fires had no adverse impact on supply. A CIL official told us that
                    Sabag’s operations were shut down after the March 1990 fire and they
                    are not expected to come back into production until October 1990.
                    Because of the fire, Ford has had to market about 75,000 Lincoln Conti-
                    nental and Town Car models without passenger-side air bags. TRW offi-
                    cials said that they are developing the capability for making the
                    passenger-side propellant at their Mesa, Arizona, facility. They esti-
                    mated that the facility would be operational by February 1, 1991.

                    TRW is increasing its production capacity to meet the increasing
                    demand for air bags and propellant. TRW officials said that they have
                    reached agreement with vehicle manufacturers to increase air bag pro-
                    duction to meet the expected demand through model year 1995. By the
                    end of 1990, TRW will have two blenders in operation for making pro-
                    pellant. They estimated that the capacity of 1.2 blenders will be needed
                    to meet the demand for the 1991 model year. Also, a blender owned by
                    Talley Defense Systems will be available to TRW as a back-up if needed.
                    TRW fully expects to meet the industry demand with its expansion
                    plans, if additional air bag production is needed, TRW officials esti-
                    mated that a 2-year lead time would be required to bring a new produc-
                    tion facility on line.

                    Morton officials said that they currently have backup blending facilities,
                    and more than double the capacity now needed to meet their customers’
                    demands in model year 199 1.




                    Page 22                                  GAO/RCED-90-230 Air Bag Propellant Fires
       L




Appendix V

M&or Contributors to This &port


                       John W. Hill Jr., Associate Director, Transportation Issues
Resources,             Ron E. Wood, Assistant Director
Community, and         Paul K. Elmore, Assignment Manager
Economic               GeorgeJ. Warholic, Evaluator-in-Charge
Development Division
Washington, DC.




                       Page 28                                GAO/RCEIM@m    Air Bag Propellant Fires
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