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The August 2025 explosion at U.S. Steel's Clairton Coke Works didn't happen because employees weren't following the rules.
It happened because there weren't rules to follow.
This week, the U.S. Chemical Safety and Hazard Investigation Board released its report on the tragedy that killed two employees -- Timothy Quinn, 39, and Steven Menefee, 52 -- and injured 11 others.
A series of three explosions caused $52.5 million in damage to the facility. The Occupational Safety and Health Administration has levied 10 violations and $118,000 in fines. The Chemical Safety and Hazard Investigation Board findings point to overpressurization of a 72-year-old cast iron valve -- built in 1953 and refurbished in 2013. That valve was part of a piping system that channeled coke oven gases.
All of the citations are for things under the company's control.
OSHA noted inadequate safety procedures. It pointed out employee training. It indicated equipment was not isolated from energy sources.
Contractor MPW Industrial Services also was fined $61,000 for nine violations, likewise tied to procedures and training.
The main problem identified was that while U.S. Steel regularly had valves like the one at Battery 13 opened and closed, employees reported valves could be difficult to close because of a buildup of coke oven residue.
Workers would solve this problem by cleaning with steam or high-pressure water, not because that was the company's procedure but because there was no procedure. It had, however, become practice. When this happened before the explosion, water in the space between two valve gates built up pressure. That was the first domino in a chain leading to failed valve, released gas and, ultimately, ignition.
This autopsy of a disaster is no different than examining the black box of a plane crash or the National Transportation Safety Board's investigation of the Fern Hollow Bridge collapse. It picked at the threads and followed where they led, determining the various catalysts that collided at the wrong time.
An employee may have cleaned the valve, but it was the same action taken regularly to correct a mundane issue. That was practice.
Procedure would have been a set of steps to address that officially, taking into account the dangers of the cast iron valve. The report notes brittle cast iron is "either prohibit(ed) or warn(ed) against" for many hazardous uses including around coke oven gas.
But does that mean U.S. Steel is alone in neglecting to take steps? Policy can be a step beyond procedure, and in this case could have been governmental regulations requiring a different system entirely.
The report makes recommendations but does not have the power to force change. That may seem toothless.
But one argument for keeping the Chemical Safety and Hazard Investigation Board when it was in danger of being disbanded a year ago was its track record of making recommendations that industry followed because they were good ideas.
"They have no interest in their plants blowing up," Jordan Barab, a former board official, said last year.
U.S. Steel's $15 billion sale to Nippon Steel was just weeks old when the explosion occurred. A year later, Nippon -- along with MPW and Valves Inc. of Pittsburgh -- is being sued by both victims' families.
"Safety is our core value and shapes every part of our business, influences how we lead and anchors our responsibility to ensure that every employee returns home safely, every single day," U.S. Steel spokeswoman Amanda Malkowski said.
She noted safety protocols have been strengthened and best practices for valve cleaning established, and employees have been trained on both.
That's good because the practices that evolve without guidance are no substitute for the well-lit path of smart procedures.