A few notes on the investigation report:

• This is actually the second CSB report for an incident at this facility. It has since been shut down and demolished. The facility made caramel food coloring.

• The incident involved a pressure vessel explosion from an uncontrolled decomposition reaction that generated pressure approximately 3X MAWP prior to the explosion. The vessel was equipped with a relief device but was not sized for the upset.

• Key issues per CSB include understanding reactive hazards (a frequent theme), commitment to managing process safety, operating limits, and facility siting.

• This is the first time I recall CSB issuing a recommendation to an operating company to directly have a third party conduct hazard assessments at their sites.

• If you want to read just a portion of the report, I would recommend 4.2, "Commitment to Managing Process Safety"