Ford and UAW Complete Joint Report on Rouge Powerhouse Explosion
2 September 1999
Ford Motor Company and UAW Complete Joint Report on Rouge Powerhouse Explosion
DEARBORN, Mich., Sept. 2 -- Ford Motor Company and
the United Auto Workers released to family members and employees today a joint
report citing an accidental buildup of natural gas as the cause of the Feb. 1
boiler explosion that resulted in the death of six workers at Ford's Rouge
complex.
The report was issued the same day that a settlement agreement among the
state of Michigan, Ford and the UAW takes effect.
"It is with great sorrow and sympathy for the families that we issue these
findings," said James J. Padilla, Ford group vice president, Manufacturing.
"Today's Ford-UAW report addresses a commitment we made to the families and to
all of our employees to do a complete and thorough investigation of this
tragedy.
"We have learned a great deal," Padilla said. "We are working hard with
our UAW colleagues and all of our employees to make sure that a tragedy like
this never takes place again, and that all Ford facilities become safer."
The joint report was based on more than 160 employee interviews, 30,000
photographs, 75 hours of videotape and 500,000 pages of documentation.
In addition, the settlement agreement that takes effect today was reached
among the Michigan Department of Consumer and Industry Services (which
includes MIOSHA), Ford and the UAW. It calls for Ford to spend $5 million on
burn care at area hospitals, occupational health and safety measures, and a
union scholarship fund in memory of those who perished in the explosion.
The agreement also includes a $1.5 million civil penalty.
"This settlement agreement allows the company and the union to focus our
efforts on prevention," Padilla said. "We cannot change the terrible events
of the past, but we can work hard to make our workplaces safer in the future."
During the investigations, Ford embarked on a global initiative to inspect
every one of the company's boilers and boiler houses worldwide, as well as all
other types of combustion-fired equipment in the company. The initiative
includes routine inspections on an ongoing basis and an enhanced training
program for employees who operate or maintain boilers and other combustion-
fired equipment.
Independent consultants were brought in to audit boiler houses.
In order to emphasize safety, production lines recently were stopped at
Ford plants so that a special safety message could be delivered to employees.
The explosion occurred in Boiler No. 6 at the Rouge Powerhouse, which is
part of the industrial complex in Dearborn that is shared by Ford and Rouge
Steel Co. One employee died in the explosion and 19 employees were
hospitalized that day with serious burns. Five of those employees
subsequently died.
The boiler was being shut down for a planned inspection and overhaul.
The cause of the explosion was an inadvertent buildup of natural gas in
the boiler, the Ford-UAW report said. Like many disasters, no one factor or
event was responsible for the gas buildup. The report identified a number of
contributing factors, including the equipment and facilities, training and
work procedures.
The joint Ford-UAW report didn't determine a source of the gas ignition.
Among the other findings of the joint Ford-UAW report:
-- The common method for shutting down a natural-gas boiler like No. 6 is
to extinguish pilots and ignitors; close and "blank" the natural gas mains;
and purge the natural gas from the gas mains through the boiler and into the
atmosphere. But gas inadvertently went into the furnace for one to two
minutes.
-- There were no posted written procedures for shutting down the boiler,
and the procedures, sequence and responsibility of tasks for shutting down
boilers in the powerhouse varied by shifts.
-- Several safety devices, such as pressure-relief valves and related
audible and visual alarms, had been defeated or removed, and a safety lockout
procedure for stopping fuel flow during maintenance was not used.
The Ford-UAW investigation was conducted over a six-month period by a team
of health and safety experts operating under the jurisdiction of the City of
Dearborn's fire marshal.
The joint report contains many recommendations, ranging from evaluation of
control systems of boilers and other combustion-fired equipment, to updating
and maintaining all safety procedures.
"These recommendations are being implemented at Ford facilities," Padilla
said. "A worldwide safety initiative, in cooperation with our local unions,
is focusing the company and employees on the need for a higher awareness of
safety procedures.
"We take this event very seriously," Padilla said. "We are determined to
learn from the harsh lessons that are contained in this report and move
forward, assisting the families who have had to bear a terrible burden, and
committing ourselves to safer workplaces."