U. S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD

 INVESTIGATION REPORT 

STEEL MANUFACTURING INCIDENT

 (2 Killed, 4 Injured) 

KEY ISSUES: 

MAINTENANCE JOB PLANNING

FACILITY WINTERIZATION AND 

DEADLEGS

LINE AND EQUIPMENT OPENING

DECOMMISSIONING AND DEMOLITION

BETHLEHEM STEEL 

CORPORATION

BURNS HARBOR DIVISION

CHESTERTON, INDIANA

FEBRUARY 2, 2001

REPORT NO. 2001-02-I-IN

ISSUE DATE: JANUARY 2002
2

CONTENTS 

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 

1.0 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

1.1 Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

1.2 Investigative Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

1.3 Burns Harbor Mill. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

1.4 160-Inch Plate Mill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 

1.5 Coke Oven Gas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 

2.0 DESCRIPTION OF INCIDENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

2.1 Pre-Incident Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 

2.1.1 Furnace Decommissioning and Demolition. . . . . . . . . . . . . . . . .18 

2.1.2 Discovery of Leak, January 1, 2001. . . . . . . . . . . . . . . . . . . . . . .19 

2.1.3 Installation of Slip Blind, January 5, 2001. . . . . . . . . . . . . . . . . .20 

2.2 The Incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 

3.0 ANALYSIS OF INCIDENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

3.1 Condensate Incidents in 160-Inch Plate Mill . . . . . . . . . . . . . . . . . . . . . .25 

3.1.1 Fuel Switchover Problems at #5 Furnace, January 5, 2001 . . . . .25 

3.1.2 Fire at #2 Furnace, January 30, 2001 . . . . . . . . . . . . . . . . . . . . . .26 

3.1.3 Condensate Leakage at #1 Furnace, January 31, 2001. . . . . . . . .26 

3.2 Job Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 

3.2.1 Deadleg Hazard Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 

3.2.2 Written Purge Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 

3.2.3 Installation of Slip Blind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 

3.2.4 Ignition Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 

3.2.5 Hazards Created by Demolition Activity. . . . . . . . . . . . . . . . . . .30 

3.2.6 Communication of Safety and Maintenance Procedures. . . . . . .31 

3.3 Condensate Composition and Removal. . . . . . . . . . . . . . . . . . . . . . . . . .32 

3.3.1 Deadleg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 

3.3.2 Presence of Flammable Liquids in COG Piping . . . . . . . . . . . . .33 

3.3.3 Change in Condensate Removal Rate . . . . . . . . . . . . . . . . . . . . .36 

3.4 Hazard Communication and Training . . . . . . . . . . . . . . . . . . . . . . . . . . .36 

4.0 ROOT AND CONTRIBUTING CAUSES. . . . . . . . . . . . . . . . . . . . . . . . . . . .38

5.0 RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

6.0 REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

APPENDIX A: Incident Timeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 
3

FIGURES 

 1 Two Continuous and Four Batch Furnaces at 160-Inch Plate Mill . . . . . . .14 

2 Active Batch Furnace Showing Crane Removing Steel Slab. . . . . . . . . . . .14 

 

3 COG System in 160-Inch Plate Mill. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 

4 Condensate Removal, Normal Operation. . . . . . . . . . . . . . . . . . . . . . . . . . .17 

5 #4 Batch Furnace COG Piping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 

6 #4 Batch Furnace Debris Pile Present Before Incident . . . . . . . . . . . . . . . .19 

7 Location of Personnel at Time of Release, February 2, 2001 . . . . . . . . . . .22 

8 #4 Batch Furnace COG Piping, Release of Flammable Liquid, 

February 2, 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 

9 Elevated Walkway Looking South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 

10 Probable Flammable Liquid Buildup Scenario . . . . . . . . . . . . . . . . . . . . . 34 

11 Probable Flammable Liquid Carryover Scenario . . . . . . . . . . . . . . . . . . . .35 

 

 

 

 
4

ACRONYMS AND ABBREVIATIONS 

AFL-CIO American Federation of Labor and Congress of Industrial 

Organizations 

CFR Code of Federal Regulations 

 COG Coke oven gas 

 CSB U.S. Chemical Safety and Hazard Investigation Board 

 oF Degrees Fahrenheit 

 ft3

/day Cubic feet per day 

 IOSHA Indiana Occupational Safety and Health Administration 

 MSDS Material Safety Data Sheet 

 OSHA Occupational Safety and Health Administration 

 
5

EXECUTIVE SUMMARY

ES. 1 Introduction

On February 2, 2001, a fire occurred at Bethlehem Steel Corporation’s Burns Harbor mill 

in Chesterton, Indiana. One Bethlehem Steel millwright and one contractor supervisor 

died. Four Bethlehem Steel millwrights were injured, one seriously. Workers were 

attempting to remove a slip blind1 and a cracked valve from a coke oven gas (COG) line 

leading to a decommissioned furnace. During removal of the valve, flammable liquid 

was released and ignited. 

Because of the serious nature of the incident, the U.S. Chemical Safety and Hazard 

Investigation Board (CSB) launched an investigation to determine the root and 

contributing causes and to issue recommendations to help prevent similar occurrences. 

ES. 2 Incident 

In 1992, the #4 batch furnace in the 160-inch plate mill was decommissioned, which 

created a deadleg2 in the COG piping. The furnace had been undergoing demolition 

since summer 2000. 

On January 1, 2001, coke oven gas was found to be leaking from a crack in a 10-inch 

valve used to close off the COG line that fed the out-of-service #4 furnace. The crack 

was likely caused by the freezing and expansion of water in COG condensate that had 

accumulated above the valve. 

Coke oven gas is a byproduct of the cokemaking process in an integrated steel mill. It is 

used throughout the mill as a gaseous fuel. At the point of distribution, coke oven gas 

typically contains up to 10 percent water vapor. As it passes through cold distribution 

 

1

 A slip blind (referred to as a pancake blind at Burns Harbor) is a round metal plate that is slipped between 

the loosened flanges of a piping connection to prevent flow. 

2

 A deadleg is a section of piping, typically vertical, without flow. In this case, it was connected to the 

main COG piping. 
6

lines, a portion of the water and heavier hydrocarbons3 condense out of the gas. These 

liquids drain into tanks at various locations along the COG distribution system. 

On January 5, millwrights installed a slip blind in the piping at the upper flange of the 

cracked valve to stop the leak. This allowed liquid to again collect in the deadleg, which 

lacked a low point drain. 

Upstream of the #4 furnace, pipe insulation was missing from condensate drain lines on 

the roof of the plate mill. The missing insulation–combined with freezing temperatures in 

December 2000 and January 2001–caused the drain lines to plug with ice, which 

prevented the removal of condensate from the COG piping. It is most likely that 

flammable liquid concentrated and accumulated in the deadleg as the water trapped in the 

piping froze. The inability to remove condensate also resulted in three incidents prior to 

February 2–including one on January 30, in which a large surge of fire and burning liquid 

were emitted from another furnace.

On Friday, February 2, millwrights were assigned to replace the blind and cracked valve 

with a blind flange and drain assembly. A vacuum truck crew from Onyx Industrial 

Services was assigned to remove the condensate, which was expected to be nonflammable. 

There was no way to safely drain the deadleg prior to opening the flange. As the 

millwrights loosened and removed the bolts from around the blind, a small stream of 

liquid began to seep from the flange. The valve and the slip blind suddenly dropped 

down several inches against the loosened bolts. Flammable condensate sprayed out and 

soaked two of the millwrights and the Onyx supervisor. The condensate ignited. CSB 

identified an infrared heat lamp and a natural gas-fired space heater–both used for freeze 

protection–as two potential ignition sources. As the flame reached the valve and the now 

open pipe, there was a blast and flammable liquid sprayed in all directions. 

 

3

 The heavier hydrocarbons include benzene, toluene, and xylenes. 
7

The two millwrights were engulfed in flames and fell behind the furnace structure. One 

of these millwrights died; the other suffered burns and contusions. The Onyx supervisor 

fell onto the demolition debris and was fatally burned. In escaping through the flames, a 

third millwright received serious burns and another suffered smoke inhalation. 

ES. 3 Key Findings 

1. The #4 batch furnace was decommissioned in 1992, which created a deadleg of 25 

feet of vertical 10-inch-diameter piping where COG condensate collected. The 

foreseeable sequence of events `that could lead to the accumulation and freezing 

of water in the deadleg was not taken into account in planning the 

decommissioning work. 

2. Missing pipe insulation caused water in the COG condensate to freeze and plug 

the system drains at the 160-inch plate mill in December 2000. It is most likely 

that the condensate trapped in the COG piping separated into water and 

hydrocarbon layers. As the water layer continued to freeze, liquid hydrocarbons 

accumulated in the COG piping and were carried into the furnace piping. 

3. Three incidents in the 160-inch plate mill in January 2001, including one that 

produced a surge of fire and a flow of flaming liquid from a furnace, 

demonstrated that the amount of condensate in the COG system was unusually 

high and could be flammable. The Burns Harbor facility did not have a system 

for monitoring and controlling hazards that could be caused by changes in COG 

condensate accumulation rates or flammability. Burns Harbor staff was 

investigating these incidents and conducting followup activities at the time of the 

February 2 incident. Knowledge of the previous incidents was not shared with the 

workforce performing the maintenance job on February 2. 

4. The majority of the Burns Harbor and contractor personnel interviewed by CSB 

considered COG condensate to be mostly water; they did not think that it posed a 

fire risk. The potential presence of flammables was not considered in job 
8

planning. The Material Safety Data Sheet (MSDS) for COG condensate does not 

list the potential for flammability. A sample of COG condensate taken by CSB 

from another furnace in the plate mill after February 2 was highly flammable, 

with a flash point of 29 degrees Fahrenheit (o

F).4

 

5. The installation of the slip blind above the cracked valve on January 5 and the 

attempted removal of the leaking valve on February 2 were both done without 

written procedures, as required by the Burns Harbor Lockout, Blue Flag, and Tag 

policy and the Burns Harbor Gas Hazard Control Program. These procedures 

required detailed written instructions for isolation, drainage, and purging of 

piping. 

6. The initial leak repair plan was to install a blind flange and drain valve to replace 

the cracked valve. However, a slip blind was installed to save time. The slip 

blind created a hazardous situation; it allowed COG condensate to again 

accumulate in the deadleg and prevented safe draining of the line because there 

was no low point drain. 

7. The demolition work at the #4 furnace was being conducted without sufficient 

planning, oversight, or control. Demolition activities resulted in elevated 

walkways without railings and obstructed egress pathways, which prevented 

workers from quickly escaping when the ignition occurred. 

ES. 4 Root Causes 

1. Management systems for the supervision, planning, and execution of 

maintenance work were inadequate.

Burns Harbor mill personnel often bypassed the Lockout, Blue Flag, and Tag and 

Gas Hazard Control Program procedures when performing COG line maintenance 

in the steel handling areas of the facility. Company requirements for written 

 

4

 Flash point is the minimum temperature at which a liquid gives off sufficient vapor to form an ignitable 

mixture with air near the surface. Liquids with flash points of less than 100o

F are classified as flammable. 
9

planning, job setup, and line isolation and purging were not followed on January 5 

or February 2. 

The work on January 5 and February 2 should not have been scheduled without a 

plan to control the hazards created by the potential for flammables and by the lack 

of a low point drain in the deadleg. 

Personnel performing the work were not made aware of the possible presence of 

flammables, nor were they informed of the condensate incidents that occurred 

prior to February 2. 

Obstructed exit routes due to demolition work on the #4 furnace were not 

considered during job planning. 

Insulation was not reinstalled after the completion of maintenance work on an 

outdoor section of system piping. This allowed water in the COG condensate to 

freeze. The freezing blocked drains and led to the accumulation of a flammable 

phase in the furnace system. 

2. The Burns Harbor facility did not have a system for monitoring and controlling 

hazards that could be caused by changes in COG condensate flammability or 

accumulation rates. 

Changes in the amount of condensate being collected were not taken into account 

by management. By not examining or responding to these changes, the facility 

missed opportunities to take corrective action, which could have prevented the 

February 2 incident. 

Employees were not generally aware of the potential flammability of COG 

condensate under certain operating conditions. 

ES. 5 Contributing Cause 

The Burns Harbor facility did not have a program to identify and address hazards 

that might be created by decommissioning and demolition operations. 

 
10

The hazards created by the deadleg were not considered when the #4 furnace was 

decommissioned in 1992. The deadleg was not removed or protected from 

freezing at that time or when demolition activities began in 2000. 

The demolition work resulted in the creation of hazards, such as lack of railings 

on the elevated platform and obstructed egress. 

ES.6 Recommendations 

Bethlehem Steel Corporation, Burns Harbor Mill 

1. Implement a work authorization program that requires higher levels of 

management review, approval, and oversight for jobs that present higher levels of 

risk, such as opening lines potentially containing flammable liquids where there is 

no low point drain. 

2. Monitor the accumulation and flammability of COG condensate throughout the 

mill. Address potentially hazardous changes in condensate accumulation rates 

and flammability. 

3. Survey the mill for deadlegs and implement a program for resolving the hazards. 

Develop guidance for plant personnel on the risks of deadlegs and their 

prevention. Include deadlegs in plant winterization planning. 

4. Provide drains at low points in piping to allow for the safe draining of potentially 

flammable material. 

5. Ensure that Burns Harbor and contractor employees are trained with regard to the 

potential presence of flammable liquids when working with or opening COG or 

condensate piping and equipment. 
11

6. Establish procedures to ensure that insulation is replaced when removed for 

maintenance. 

Bethlehem Steel Corporation 

1. Conduct periodic audits of work authorization, line and equipment opening, 

deadleg management programs, and decommissioning and demolition activities at 

your steelmaking facilities. Share findings with the workforce. 

2. Revise the Material Safety Data Sheet (MSDS) for COG condensate to highlight 

the potential flammability hazard. Ensure that management at your steelmaking 

facilities trains employees and informs contractors with regard to the potential 

presence of flammable liquids when working with or opening COG condensate 

piping and equipment. 

3. Communicate findings of this report to the workforce and contractors at 

Bethlehem Steel’s steelmaking facilities. 

American Iron and Steel Institute, Association of Iron and Steel Engineers, United 

Steelworkers of America, AFL-CIO Building Trades Council 

Communicate findings of this report to your membership. 
12

1.0 INTRODUCTION 

1.1 Background 

On February 2, 2001, a fire in the furnace area of the 160-inch plate mill at Bethlehem 

Steel Corporation’s Burns Harbor mill in Chesterton, Indiana, killed a Bethlehem Steel 

millwright and a supervisor with Onyx Industrial Services, a vacuum truck contractor. 

Another millwright was seriously injured, and three millwrights received lesser injuries. 

Workers were attempting to remove a slip blind5 and a cracked valve from a coke oven 

gas (COG) line when flammable liquid was released and ignited. 

1.2 Investigative Process 

The U.S. Chemical Safety and Hazard Investigation Board (CSB) examined physical 

evidence at the site, conducted interviews, and reviewed relevant documents. The CSB 

incident investigation team coordinated activities with the Indiana Occupational Safety 

and Health Administration (IOSHA), which also investigated the incident. 

CSB contracted with Phoenix Chemical Laboratory Inc. for analysis of condensate 

samples and with Engineering Systems Inc. for inspection of an infrared heat lamp found 

at the incident scene. 

1.3 Burns Harbor Mill 

The Burns Harbor mill of Bethlehem Steel is located on the shore of Lake Michigan. 

Burns Harbor opened in 1962. The mill, which covers approximately 3 square miles, 

employs about 5,000 members of the United Steelworkers of America union and 1,100 

salaried personnel. There is a daily contractor population of 200 to 300. 

 

5

 A slip blind (referred to as a pancake blind at Burns Harbor) is a round metal plate that is slipped between 

the loosened flanges of a piping connection to prevent flow. 
13

As an integrated mill, Burns Harbor uses iron ore and coke to produce iron, which is 

converted to steel in three basic oxygen furnaces. Coke is produced onsite from coal in 

two coke oven production units. 

Molten steel is converted to slabs in continuous casters. The slabs, resembling king-size 

mattresses in shape and weighing up to 20 tons each, are further processed into various 

shapes in the hot strip mill or the 160-inch plate mill, where the February 2 incident 

occurred. 

1.4 160-Inch Plate Mill 

The 160-inch plate mill contains two continuous and four batch furnaces (Figure 1), 

where steel slabs are heated to greater than 2,300 degrees Fahrenheit (oF). The slabs are 

further processed by being passed through heavy rolls, becoming thinner and longer, until 

a final steel plate is produced. Either coke oven gas or natural gas is burned to heat the 

batch furnaces. Figure 2 shows one of the batch furnaces in operation. 

1.5 Coke Oven Gas 

Coal is carbonized to coke by heating it to a high temperature (2,200o

F) in an oxygendeficient atmosphere. 
14

Figure 1. Two continuous and four batch furnaces at 160-inch plate mill. 

Figure 2. Active batch furnace showing crane removing steel slab. 

#8 Batch Furnace #7 Batch Furnace #5 Batch Furnace

#6 Batch Furnace #4 Batch FurnaceDebris Pile

SLAB YARD

Onyx Vac Truck

N

#1 Cont.

Furnace

#2 Cont.

Furnace

Slab

Conveyor

Cont.

Room

Onyx Pickup Truck

Natural Gas-Fired

Cracked Valve Space Heater

Crane

Elevated Walkway
15

Volatile materials and gases formed in the cokemaking process are vaporized and 

removed, leaving the solid coke behind. At Burns Harbor, the coal chemical unit cleans 

the raw coke oven gas to produce fuel for use in the mill. The following steps are 

required to process coke oven gas: 

Cool the gas by direct contact with a liquid condensate stream, which removes the 

majority of the water and hydrocarbon liquids. 

Remove tar particles by electrostatic precipitation. 

Absorb ammonia in a sulfuric acid solution and convert to ammonium sulfate, a 

commercial byproduct. 

Remove naphthalene via direct contact washing. 

Forty percent of the gas is used to heat the coke oven units, leaving 60 percent available 

to the rest of the mill. The COG flow rate is approximately 80 million cubic feet per day 

(ft3

/day). Gas users in the mill include a power generating station and blast furnaces. 

The remaining gas then continues to the hot strip mill and, finally, to the 160-inch plate 

mill. Excess gas not consumed by the plant is burned in a flare tower. The COG 

distribution system runs for several miles within the Burns Harbor facility (Figure 3). 

The coal chemical unit does not remove all of the condensate from the coke oven gas. 

The gas enters the distribution system at a temperature of 85 to 110o F, and vapors 

continue to condense as the gas cools in the piping. The liquid formed is carried 

downstream to a series of drains located at intervals along the COG system (Figure 4), 

where it is collected in tanks for recycle and disposal. 
16

160-Inch Plate Mill

20-Inch COG Header

20- Inch

Isolation

Valve

#1 Continuous Furnace

#2 Continuous Furnace

#4 Batch Furnace

#5 Batch Furnace

#7 Batch Furnace

#8 Batch Furnace

Cracked

10-Inch

Valve

Piping

Deadleg

#6 Batch Furnace

Figure 3. COG system in 160-inch plate mill. 

The Bethlehem Steel Material Safety Data Sheet (MSDS) for coke oven gas provides the 

following composition data:

Composition of Coke Oven Gas at 100oF 

Component Weight Percent 

Water 

Benzene 

Carbon monoxide 

Carbon dioxide 

Ethylene 

Hydrogen 

Methane 

Ethane 

Hydrogen sulfide 

Approx. 10 

1 – 4 

13 – 16 

6 – 8 

5 – 11 

9 – 13 

43 – 53 

2 - 3 

0.9 – 1.5 
17

The MSDS also identifies trace components, including butylenes (< 0.8 percent), toluene 

(< 0.5 percent), and xylenes (< 0.3 percent).6

The Burns Harbor MSDS for COG condensate lists a specific gravity of 1 and a boiling 

point of 212oF, which indicates that normally the condensate is mostly water.7 

Figure 4. Condensate removal, normal operation. 

 

6

 Bethlehem Steel Corporation, Coke Oven Gas Material Safety Data Sheet, January 1997. 

7

 Bethlehem Steel Corporation, Coke Oven Gas Condensate Material Safety Data Sheet, April 1997. 

COG Flow to Batch

Furnaces

COG Condensate to

Condensate Tank

20-Inch COG Line on

Plate Mill Roof

14-Inch COG Line to

Batch Furnaces

COG Flow

Normal

Condensate

Drainage

Condensate Tank

Seal Leg to

Maintain

Header

Pressure

Expanded View

20-Inch COG Line

160-Inch Plate Mill Roof

Ground Level

Drain Lines
18

25 Feet of 10-Inch

Diameter Deadleg Piping

Crack in 10-Inch

Valve (Discovered

January 1)

10-Inch Slip Blind

(Installed January 5)

2.0 DESCRIPTION OF INCIDENT 

2.1 Pre-Incident Events 

2.1.1 Furnace Decommissioning and Demolition 

The #4 batch furnace in the 160-inch plate mill was shut down in 1992, at which time a 

10-inch isolation gate valve was closed to prevent the flow of coke oven gas to the 

furnace. This created a 25-foot vertical deadleg8

 of 10-inch-diameter piping above the 

valve, which was open to the COG distribution piping (Figure 5). Furnace demolition 

began in summer 2000. 

Figure 5. #4 Batch furnace COG piping.

 

8

A deadleg is a section of piping, typically vertical, without flow. In this case, it was connected to the main 

COG piping. 
19

Over the Thanksgiving 2000 weekend, the furnace structure was knocked down. Figure 

6 shows the resulting rubble pile. 

Figure 6. #4 Batch furnace debris pile present before incident. 

2.1.2 Discovery of Leak, January 1, 2001 

On January 1, 2001, around noon, a foreman at the 160-inch plate mill detected a COG 

odor in the furnace area. Upon investigating, he determined that gas was leaking from a 

large crack in the 10-inch gate valve at the #4 furnace. The foreman contacted the utility 

department, which is responsible for the COG distribution system at Burns Harbor. By 

4:00 pm, the main 20-inch manual gate valve located on the roof of the plate mill was 

closed, which stopped the flow of coke oven gas to the building. The fuel for the 

furnaces was switched from coke oven gas to natural gas. 

CSB determined that the 10-inch valve likely cracked when water trapped in the deadleg 

above the valve froze and expanded. The leak became apparent as the ice thawed. 

Although outdoor temperatures remained below freezing for most of December, a 

significant warmup in the month allowed for thawing inside the furnace area. It is 

Cracked Valve 
20

probable that any liquid in the deadleg drained through the crack before the gas was 

detected. As shown in Figure 5, the crack was located at the upper flange of the valve, 

above the gate that blocked flow. 

2.1.3 Installation of Slip Blind, January 5, 2001 

Before the plate mill foreman left work on January 1, he discussed the proposed repairs 

with a foreman from the general services department. (This department is a plant-wide 

group of approximately 85 employees who supplement maintenance activities in each 

operating area.) They determined that the best approach was to remove the cracked 10-

inch valve and replace it with a blind flange fitted with a 1-inch drain valve,9 which 

would serve as the drainage point for the 25-foot deadleg. 

To safely proceed with the job, the foremen agreed that a purge procedure was required. 

At Burns Harbor, a purge procedure is a set of written instructions for preparing a line for 

maintenance. Purge procedures are typically written by combustion technicians,10 in 

consultation with operations and safety personnel, as necessary. The purge procedure 

lists the order for opening and closing specific valves and vents (lockout/tagout) to ensure 

that hazardous gases and liquids are vented and drained prior to beginning maintenance 

work. 

The leaking valve problem was the subject of a meeting of supervisors from the plate mill 

and the utility departments between January 2 and 5. The managers decided to install a 

slip blind in the flange above the leaking valve (Figure 5) instead of the preferred blind 

flange and drain valve assembly. It would have taken additional time to fabricate the 

blind flange and drain valve, and the plant wanted to switch more quickly from natural 

gas to the less expensive coke oven gas. 

 

9

 A blind flange is a solid plate piping component used to close the open end of a pipe. 

10 Combustion technicians are responsible for instrumentation and for the equipment that controls and 

monitors the fuel gases used at Burns Harbor. 
21

On January 5, managers and staff from the 160-inch plate mill and the utility and general 

services departments met on the elevated walkway at the valve to discuss installation of 

the slip blind. Three millwrights from the general services department were assigned to 

the job. They were informed that the main 20-inch COG valve was closed and that coke 

oven gas had been vented from the plate mill system piping. The isolation and venting 

were done without written pre-job planning, which is required by Burns Harbor 

maintenance procedures when hazardous gas might be present. 

The millwrights began the work by removing two bolts and checking the flange area for 

flammable gases with a combustible gas detector. No hazardous gases were detected. 

They then proceeded with the slip blind installation. As they loosened and removed the 

remaining bolts, a tar-like residue with a molasses consistency began to ooze from the 

flange, hindering installation of the blind. The millwrights hammered the blind into the 

flange opening, and then reinstalled and tightened the bolts. 

At some time during the following week, a foreman placed a 250-watt infrared heat lamp 

near the line, just above the 10-inch valve. The lamp was intended to keep the line warm, 

prevent freezing, and thus prevent failure of the piping and the release of additional 

material. Heat lamps are one of the devices commonly used at the Burns Harbor facility 

to prevent lines from freezing.

2.2 The Incident

On the morning of February 2, 2001, another meeting of management and staff from the 

utility and plate mill departments was held at the cracked 10-inch valve to plan the valve 

removal job. Personnel discussed the need to drain the line above the blind, but this 

could not be done safely with the blind installed. However, they decided to proceed 

because they believed that the condensate was nonflammable. Two potential ignition 

sources were located in the area when the job began–a natural gas-fired space heater and 

the infrared heat lamp. 
22

The job was assigned to five general services department millwrights, including two who 

had originally installed the slip blind on January 5. Burns Harbor management also 

assigned a four-man crew from Onyx Industrial Services to capture COG condensate that 

might be released when the line was opened. The crew consisted of two supervisors and 

two vacuum truck operators. 

At this time, the workers were located as shown in Figure 7. Two millwrights were 

balanced on the piping behind the valve, off the walkway. Another millwright was 

standing on the walkway. The Onyx supervisor was standing to the side of the valve. 

The fourth millwright was working near the end of the walkway, and the fifth millwright 

and three of the Onyx personnel were located on the ground. 

Figure 7. Location of personnel at time of release, February 2, 2001.

To begin the work, the millwrights removed the bolts on the bottom side of the valve, 

which opened up about 6 inches of space below the valve. They then loosened the bolts 

Onyx Vac Truck

Crane

Onyx Pickup Truck

#5 Furnace

Natural Gas Fired

SpaceHeater

Control

Room

Bathroom

Beam

Onyx Supervisor Millwrights

Millwrights

#4 Furnace Debris Pile

10-Inch Valve

Millwright Onyx Workers

Elevated Walkway

N
23

on the top flange of the valve, around the slip blind. A small stream of liquid began to 

seep from the flange, in addition to black tar-like material; and the valve suddenly 

dropped down several inches against the loosened bolts (Figure 8). Flammable 

condensate sprayed out and soaked the two millwrights positioned on the piping and the 

Onyx supervisor. The condensate ignited. Another millwright observed the flame move 

from the north and below him along the wall to the south, toward the valve. As the flame 

reached the valve and the now open pipe, there was a blast and flammable liquid sprayed 

in all directions.

Figure 8. #4 Batch furnace COG piping, release of flammable liquid, 

February 2, 2001. 

The two millwrights on the piping were engulfed in the flames and fell behind the 

furnace structure. One of these millwrights died; the other was injured, with burns and 

25 Feet of 10-Inch

Diameter Deadleg Piping

10-Inch Slip Blind

Release of

Flammable

Liquid
24

contusions. The Onyx supervisor fell off of the east side of the walkway onto the furnace 

debris pile and suffered fatal burns. (There was no railing on the east side of the walkway 

due to the demolition activities.). The third millwright ran down through the flames 

across the debris pile and was seriously burned. The fourth millwright suffered smoke 

inhalation as he ran down the stairs through the flames. 
25

3.0 ANALYSIS OF INCIDENT 

CSB identified four major problem areas in the Burns Harbor 160-inch plate mill that 

contributed to the February 2 incident: 

Lack of understanding of the condensate’s potential flammability 

Maintenance job planning and execution 

Condensate composition and removal 

Hazard communication and training. 

3.1 Condensate Incidents in 160-Inch Plate Mill 

Between the time of the initial leak on January 1 and the fire on February 2, three 

incidents demonstrated that the amount of condensate in the COG system was unusually 

high and that the liquid was not the typical nonflammable composition the workforce had 

come to expect. Management did not recognize the relationship between these 

condensate problems and the hazards presented by repair of the cracked valve. 

3.1.1 Fuel Switchover Problems at #5 Furnace, January 5, 2001 

During the evening shift on January 5, after the slip blind was installed, the operators 

reopened the main 20-inch COG valve to switch the furnaces from natural gas back to 

coke oven gas. After successfully switching the #1 and #2 continuous furnaces and the 

#7 batch furnace, the operators made the following entry into their shift log sheet: 

“Attempted (twice) to switch #5 furnace over to coke gas, but each time it would not light 

and spewed heavy black smoke – filling the mill aisle. Because headers are apparently 

filled with water, it was switched back over to natural gas.” This was the first indication 

of condensate buildup in the COG piping to the furnaces. 
26

3.1.2 Fire at #2 Furnace, January 30, 2001

On January 30, flammable COG condensate reached the burners at the #2 continuous 

furnace (located to the north of the demolished #4 furnace), causing a large surge of fire 

that escaped from the doors of the furnace. Burning liquid was also observed spewing 

from the furnace, and the flames engulfed a walkway. Although Burns Harbor 

employees were in the area of the furnace, no one was injured. 

In investigating the January 30 incident, Burns Harbor staff determined–prior to February 

2–that condensate was not draining to the plate mill’s condensate tank. A section of the 

condensate drain lines on the roof of the mill had likely frozen; temperatures had been 

below freezing, and approximately 15 feet of insulation was missing from the lines. (The 

missing insulation was not discovered until January 31.) Because of these conditions, the 

COG piping was likely full of ice, water, and flammable liquid. These conditions were 

not communicated by management to the personnel responsible for the planned deadleg 

repairs. 

3.1.3 Condensate Leakage at #1 Furnace, January 31, 2001 

On January 31, millwrights were installing a blind11 in the COG line to isolate the #1 

continuous furnace for routine maintenance. About 20 gallons of condensate leaked out. 

The millwrights stated that they had never seen this much condensate leak when opening 

the flange. 

The millwrights who installed the slip blind on January 5 and worked the valve removal 

job on February 2 were not aware that excessive amounts of condensate were present in 

the COG piping system. 

 

11 The isolation blinds on the COG lines to the furnaces were “spectacle blinds,” which can be pivoted in a 

flange. One side of the blank is open, allowing full flow; the other side is solid, preventing flow. Thus, 

looking at the portion of the blind that is visible outside the flange allows you to determine the flow 

condition inside the piping. 
27

3.2 Job Planning 

Planning of the maintenance work on both January 5 and February 2 was inadequate, as 

discussed in Sections 3.2.1 through 3.2.6. 

3.2.1 Deadleg Hazard Control 

The cracked valve discovered on January 1 was located at the bottom of a 25-foot-long 

vertical deadleg of 10-inch-diameter piping created when the #4 furnace was shut down. 

The creation of a pocket where liquid could potentially, accumulate, freeze, and 

subsequently crack the valve should have been addressed by removing the deadleg or by 

taking steps to eliminate the potential for freezing, such as external heating and 

insulation. 

3.2.2 Written Purge Procedure 

Before doing maintenance work that called for COG line opening, Burns Harbor required 

a job-specific purge procedure in accordance with the facility’s Gas Hazard Control 

Program. The Burns Harbor Lockout, Blue Flag, and Tag policy was also not followed. 

That policy states: “Job pre-planning for work that involves confined space entry, 

hazardous gas work, pressure vessel work, piping work, etc., should be detailed in writing 

to ensure that proper Lockout, Blue Flag and Tag procedures are followed.” And, 

“Comply with Job Safety Analysis, Purge Procedure, etc., when working on steam, gas, 

oil, air, acid or water lines and associated equipment. Such equipment must be 

neutralized, purged, disconnected, blanked and bled of any excess energy which could 

cause injury.” 

The January 5 and February 2 jobs were conducted without a written purge procedure. 

This decision was made by management and staff based on the mistaken assumption that 

the COG condensate was not flammable and thus that the condensate remaining in the 
28

line posed no threat to personnel. The requirement to execute a purge procedure was 

sometimes waived by operations or maintenance personnel for small jobs or jobs that 

were considered to be nonhazardous. However, there was no formal system for 

determining when the requirements could be waived.

The National Safety Council recommends: “Before working on a pipeline, shut off the 

line, lock and tag the valves, relieve pressure from the section of the line, and drain it.” 

(National Safety Council, 1997; p. 117) The Occupational Safety and Health 

Administration’s (OSHA) standard for control of hazardous energy (lockout/tagout) 

states: “Following the application of lockout or tagout devices to energy isolating 

devices, all potentially hazardous stored or residual energy shall be relieved, 

disconnected, restrained, and otherwise rendered safe.”12 Although a Burns Harbor blue 

flag (a tagout device) was placed on the 20-inch valve on the roof of the plate mill, the 

line was not drained. 

3.2.3 Installation of Slip Blind 

After the COG distribution piping was closed on January 1, the furnaces in the 160-inch 

plate mill were switched over to natural gas. Management’s initial plan was to remove 

the cracked valve and replace it with a blind flange containing a 1-inch fitting and drain 

valve. This would have provided a condensate drainage point. However, on January 5, 

management instead decided to install a slip blind into the flange above the cracked 

valve. 

Installation of a slip blind rather than the blind flange and drain assembly allowed the 

mill to more quickly return the furnaces to less expensive COG service. 

 

12 29 CFR 1910.147 (d)(5)(i), Control of Hazardous Energy (Lockout/Tagout). 
29

However, the slip blind eliminated the possibility of safely draining liquid that might 

accumulate in the deadleg.13 Installation of the blind flange and drain valve would have 

provided a way to safely drain the deadleg. The United Kingdom’s Health and Safety 

Executive (HSE) states in its book, The Safe Isolation of Plants and Equipment: “Bleeds 

and vents allow the safe depressurization of parts of the plant when it has been isolated 

and also enable the integrity of isolations to be checked. Inadequate provision of bleeds 

or vents may compromise the safety of the isolation.” (HSE, 1997; p. 47)

Managers from the utility and plate mill departments recognized the risk of another line 

failure if the deadleg refilled with liquid and refroze. Therefore, they scheduled the 

installation of the blind flange and drain assembly for February 2. As an interim measure 

to prevent the deadleg from refreezing, an infrared heat lamp was placed next to the 10-

inch piping, just above the blind. 

3.2.4 Ignition Sources 

 

There were two potential ignition sources in the area when the job began, though CSB 

could not determine which source ignited the fire: 

A natural gas-fired space heater was located 28 feet horizontally and 18 feet 

below the 10-inch valve. These heaters were used as part of the Burns Harbor 

freeze protection program for piping containing water. 

 

13 Burns Harbor personnel briefly considered, but ultimately rejected, the use of a hot tap to drain the 

deadleg above the slip blind. Hot tapping is a technique for creating an opening in piping that is in service 

by welding a fitting onto the pipe and then cutting or drilling a hole through the welded fitting. Hot tapping 

is normally done only when there is sufficient flow in the piping to safely dissipate heat or a sufficient 

amount of liquid above the weld point, and when it can be ensured that the piping does not contain a 

flammable atmosphere. The line above the dead leg had no flow through it, and there was no way to 

ascertain that the contents of the pipe would not ignite. 
30

An infrared heat lamp was positioned next to the 10-inch piping, above the 

cracked valve. CSB determined that the lamp was on at the time of the 

release. 

Because the work involved opening a line that potentially contained flammables, job 

planning should have included removal of potential ignition sources. Although the Burns 

Harbor Gas Hazard Control Program required that representatives from the fire and safety 

departments assist in job planning, no one from either department was consulted in 

preparing for the maintenance work. 

3.2.5 Hazards Created by Demolition Activity 

The #4 furnace was shut down in 1992. In summer 2000, mill management decided to 

remove the furnace structure. No procedure was written for demolition of the furnace, 

and no safety review was conducted to consider the possible hazards created by the 

demolition activities. 

Over the Thanksgiving 2000 weekend, the mill’s crane was used to knock down the 

furnace. Figure 6 shows the resulting rubble pile (for comparison, see the photo of an 

operating furnace in Figure 2). 

As a result of this destruction, the working area around the cracked valve was hazardous. 

The following problems were present on February 2, 2001: 

No railing was in place on the east side of the walkway; there was a 6-foot 

drop from the walkway to the rubble pile (Figure 9). 

Piping from the demolition blocked the stairway landing to the walkway. 

The stairway did not connect with the walkway. 

These obstructions and lack of handrails made it difficult for workers to escape the area 

when the leak and fire started. It is probable that the loss of life and injuries would have 
31

been lessened if an easier means of exit was available. The job planning process should 

have addressed exit routes. 

Figure 9. Elevated walkway looking south (note absence of handrail on left side). 

3.2.6 Communication of Safety and Maintenance Procedures 

Safety information was ineffectively transferred from management to the millwrights and 

contractors performing the maintenance work. All communication between the plate mill 

and millwright supervisors and between the supervisors and the millwrights and 

contractors was verbal. The millwrights and Onyx personnel stated that neither on 

January 5 nor February 2 were they informed of any flammables that might be present or 

of the previous incidents. 

As explained by the National Safety Council and OSHA, good practice includes the use 

of safety permits to spell out the safety requirements of maintenance jobs. Safety permits 

Cracked Valve 
32

are developed by supervision or authorized individuals and provide details on how a job 

is to be done, what hazards are involved, and any other special safety considerations. The

permits are then reviewed with maintenance workers at the job site to ensure that they 

understand the scope and hazards of each job. The millwrights performing the work on 

January 5 and February 2 received no written instructions. 

Had safety permits been written for the jobs, it is likely that the lack of a drain would 

have been identified. This would have prompted personnel to look at alternative ways to 

set up the work and would likely have prevented the incident or lessened its severity. 

The process of preparing and following a safety work permit or a purge procedure would 

also have given Burns Harbor staff an opportunity to take other safety measures that 

might have prevented the incident or mitigated its consequences, such as removing 

sources of ignition, improving egress from the work area, or providing a fire watch with a 

charged fire hose. 

3.3 Condensate Composition and Removal 

3.3.1 Deadleg 

When the #4 furnace was shut down in 1992, the 10-inch COG isolation valve leading to 

the furnace was closed, which created a 25-foot-long deadleg of vertical piping above the 

valve. As explained in Section 2.1.1, a deadleg is a section of piping, typically vertical, 

without flow. In a COG piping system, liquids may collect in deadlegs. 

CSB determined that the 10-inch valve probably cracked due to the freezing and 

expansion of water. The crack was located at the upper flange of the valve, above the 

valve gate that blocked flow. After the slip blind was installed on January 5, the deadleg 

was still present and provided a site for COG condensate to continue to accumulate. 
33

3.3.2 Presence of Flammable Liquids in COG Piping 

The coke oven gas leaving the coal chemical unit, at an average temperature of 100o

F, 

typically contained 10 percent water vapor. As the gas stream passed through the COG 

distribution system and the temperature dropped, the water and heavier hydrocarbons 

(including benzene, toluene, and xylenes) condensed out of the gas. The condensate 

drained from the bottom of the piping and into tanks located along the piping route. 

Vacuum trucks periodically emptied the tanks. Figure 3 depicts the normal operation of 

condensate drains on the COG line. 

In August 1999, millwrights removed insulation from the COG condensate drain lines, 

located on the roof of the plate mill, to perform maintenance. The insulation was not 

replaced. The winterization program for the plate mill consisted of a checklist of 

preventive measures for locations known to be susceptible to freezing, but it did not call 

for a survey or inspection to identify other areas that might require or might have lost 

freeze protection.

The ambient temperature at the Burns Harbor mill between mid-December and midJanuary was generally below freezing. Around the middle of December 2000, the COG 

condensate stopped draining to the tank at the plate mill. Without pipeline insulation, the 

water in the condensate probably froze, plugging the drain lines. It is likely that water 

then began to build up and freeze in the COG distribution piping. As the water froze, 

flammable material remained in the liquid state and floated on top of the water and ice 

(Figure 10). 
34

Figure 10. Probable flammable liquid buildup scenario-ice formation. 

As the liquid/ice level in the COG piping increased, it is likely that the flammable liquid 

phase either flowed over the top of it or was entrained with the coke oven gas into the 

furnace lines (Figure 11). This flammable liquid carryover probably settled in the lowest 

points of the piping, such as the deadleg at the #4 furnace–from which it was 

subsequently released and ignited. 

COG Flow to Batch

Furnaces

COG Drain to

Condensate Tank

20-Inch COG Line on

Plate Mill Roof

14-Inch COG Line to

Batch Furnaces

Drain Line Insulation

COG Flow

Initial Ice Buildup Missing Insulation
35

Figure 11. Probable flammable liquid carryover scenario. 

There was a previous incident at Burns Harbor of ice buildup in COG condensate lines. 

In January 1997, a 72-inch-diameter overhead COG line to the blast furnace failed and 

fell to the ground due to the weight of ice in the piping; there was no ignition. 

On February 14, 2001, CSB obtained a sample of liquid from the condensate drain at the 

#5 batch furnace. Because this drain was last emptied in early January, the sample was 

probably similar in composition to the material that was released from the deadleg at the 

#4 furnace and ignited on February 2. The sample had a flash point of 29o

F.14, 15

 

14 Flash point is the minimum temperature at which a liquid gives off sufficient vapor to form an ignitable 

mixture with air near the surface. 

15 The sample contained 22.4 percent benzene, 16.8 percent toluene, 13.7 percent xylenes, and 0.08 percent 

water. The specific gravity of the mixture was 0.92. The balance of the sample consisted of heavier 

organics, mostly tars. 

COG Flow to Batch

Furnaces

COG Drain to Condensate

Tank

20-Inch COG Line on Plate

Mill Roof

14-Inch COG Line to Batch

Furnaces

Drain Line Insulation

COG Flow

Initial Ice Buildup Missing Insulation

Ice/Water

Layer

Flammable

Layer
36

3.3.3 Change in Condensate Removal Rate 

Onyx Industrial Services used vacuum trucks to empty the COG condensate tanks. On a 

weekly basis, Onyx supplied the utility department with a printed summary of the amount 

of condensate withdrawn from each tank each day. However, neither the tanks nor the 

vacuum trucks were equipped with level or flow gauges to measure the amount of 

material transferred. If no condensate was withdrawn from a tank, the Onyx daily 

summary indicated a zero for that vessel. 

The condensate tanks were normally emptied several times per week. No condensate was 

withdrawn from the plate mill tank from December 11, 2000, until the end of January 

2001. However, during the same period, twice the normal amount of condensate was 

withdrawn from a condensate tank located along the COG distribution piping upstream of 

the plate mill’s tank– indicating that condensate was backing up in the piping behind the 

ice buildup. No actions were taken to investigate or correct the problem. 

Changes in operating parameters, such as condensate removal rates, should be analyzed 

to determine if they might have a significant effect on safety. Management should 

compare such data to a previously defined acceptable range and investigate deviations. 

By not having accurate data and by not responding to the information that was available, 

Burns Harbor missed an opportunity to take corrective action, which could have 

prevented the incident on February 2.

3.4 Hazard Communication and Training 

The majority of the Bethlehem Steel employees interviewed by CSB did not believe that 

COG condensate presented a flammability hazard. Of 11 Burns Harbor supervisors 

interviewed by CSB, only four considered COG condensate to be potentially flammable 

and one did not know. Eight of 18 hourly employees considered it to be potentially 

flammable, and seven did not know. Most of the Onyx Industrial Services personnel 
37

interviewed also considered COG condensate to be mostly water. Workers familiar with 

the coal chemical area were aware of the potential flammability of the condensate. 

Bethlehem Steel employees attended OSHA-required hazard communication training, 

which covered the flammability of coke oven gas and the fact that it contained a large 

amount of carbon monoxide. However, there was no discussion of the potential 

flammability hazards of the condensate. 

The Bethlehem Steel MSDS for COG condensate does not mention flammability as a 

hazard. It was considered to be normally nonflammable. However, the liquid in the #4 

furnace on February 2 was flammable because of the separation of water and flammable 

hydrocarbons into layers (as described in Section 3.3.2). 
38

4.0 ROOT AND CONTRIBUTING CAUSES

4.1 Root Causes 

1. Management systems for the supervision, planning, and execution of 

maintenance work were inadequate.

Burns Harbor mill personnel often bypassed the Lockout, Blue Flag, and Tag and 

Gas Hazard Control Program procedures when performing COG line maintenance 

in the steel handling areas of the facility. Company requirements for written 

planning, job setup, and line isolation and purging were not followed on January 5 

or February 2. 

The work on January 5 and February 2 should not have been scheduled without a 

plan to control the hazards created by the potential for flammables and by the lack 

of a low point drain in the deadleg. 

Personnel performing the work were not made aware of the possible presence of 

flammables, nor were they informed of the condensate incidents that occurred 

prior to February 2. 

Obstructed exit routes due to demolition work on the #4 furnace were not 

considered during job planning. 

Insulation was not reinstalled after the completion of maintenance work on an 

outdoor section of system piping. This allowed water in the COG condensate to 

freeze. The freezing blocked drains and led to the accumulation of a flammable 

phase in the furnace system. 

2. The Burns Harbor facility did not have a system for monitoring and controlling 

hazards that could be caused by changes in COG condensate flammability or 

accumulation rates. 

Changes in the amount of condensate being collected were not taken into account 

by management. By not examining or responding to these changes, the facility 

missed opportunities to take corrective action, which could have prevented the 

February 2 incident. 
39

Employees were not generally aware of the potential flammability of COG 

condensate under certain operating conditions.

4.2 Contributing Cause

 The Burns Harbor facility did not have a program to identify and address 

hazards that might be created by decommissioning and demolition operations. 

The hazards created by the deadleg were not considered when the #4 furnace was 

decommissioned in 1992. The deadleg was not removed or protected from 

freezing at that time or when demolition activities began in 2000. 

The demolition work resulted in the creation of hazards, such as lack of railings 

on the elevated platform and obstructed egress. 
40

5.0 RECOMMENDATIONS 

Bethlehem Steel Corporation, Burns Harbor Mill 

1. Implement a work authorization program that requires higher levels of 

management review, approval, and oversight for jobs that present higher levels of 

risk, such as opening lines potentially containing flammable liquids where there is 

no low point drain. (2001-02-I-IN-R1) 

2. Monitor the accumulation and flammability of COG condensate throughout the 

mill. Address potentially hazardous changes in condensate accumulation rates 

and flammability. (2001-02-I-IN-R2) 

3. Survey the mill for deadlegs and implement a program for resolving the hazards. 

Develop guidance for plant personnel on the risks of deadlegs and their 

prevention. Include deadlegs in plant winterization planning. (2001-02-I-IN-R3) 

4. Provide drains at low points in piping to allow for the safe draining of potentially 

flammable material. (2001-02-I-IN-R4) 

5. Ensure that Burns Harbor and contractor employees are trained with regard to the 

potential presence of flammable liquids when working with or opening COG or 

condensate piping and equipment. (2001-02-I-IN-R5) 

6. Establish procedures to ensure that insulation is replaced when removed for 

maintenance. (2001-02-I-IN-R6) 

Bethlehem Steel Corporation 

1. Conduct periodic audits of work authorization, line and equipment opening, 

deadleg management programs, and decommissioning and demolition activities at 
41

your steelmaking facilities. Share findings with the workforce. (2001-02-I-INR7) 

2. Revise the Material Safety Data Sheet (MSDS) for COG condensate to highlight 

the potential flammability hazard. Ensure that management at your steelmaking 

facilities trains employees and informs contractors with regard to the potential 

presence of flammable liquids when working with or opening COG condensate 

piping and equipment. (2001-02-I-IN-R8) 

3. Communicate findings of this report to the workforce and contractors at 

Bethlehem Steel’s steelmaking facilities. (2001-02-I-IN-R9) 

American Iron and Steel Institute, Association of Iron and Steel Engineers, United 

Steelworkers of America, AFL-CIO Building Trades Council 

Communicate findings of this report to your membership. (2001-02-I-IN-R10) 

By the 

U.S. Chemical Safety and Hazard Investigation Board 

Gerald V. Poje, Ph.D. 

Member 

Isadore Rosenthal, Ph.D. 

Member 

Andrea Kidd Taylor, Dr. P.H. 

Member 

December 6, 2001
42

6.0 REFERENCES 

Health and Safety Executive (HSE), 1997. The Safe Isolation of Plants and 

 Equipment, Oil Industry Advisory Committee, Norwich, U.K.: HSE Books. 

National Safety Council, 1997. Accident Prevention Manual for Business and 

 Industry, Engineering, and Technology, 19th Edition. 
43

Appendix A: Incident Timeline