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The CSB investigated an ethylene oxide explosion at the Sterigenics International medical sterilization facility in Ontario, California. The investigation found that engineering controls did not prevent an explosive concentration of EO from reaching oxidizing air pollution control equipment, and that employees did not fully understand the hazards associated with the process. The investigation also found that the facility's control room and Process Hazard Analysis were less than adequate. The CSB issued recommendations based on these root and contributing causes.
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