The authors present the lessons learned from this incident through their direct involvement with the incident investigation as well as a review of previous, similar incidents investigated by the United States Environmental Protection Agency (EPA). The root cause and contributory factors for this explosion are discussed and recommendations provided on how similar incidents might be avoided in the future. One of the authors serves on the NFPA committee responsible for publishing the standard on safe storage, handling and use of ethylene oxide, and the paper concludes with an regulatory and industry perspective on alternative designs and equipment that could have prevented the exp.

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