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Published
Case Study 01
Grain Milling
Combustible Dust
CSB Investigation
5 Fatalities · 14 Injured
9 CSB Recommendations
$135M – $221M Est. Impact
Closed: August 12, 2026
The Governance Gap
What the CSB Required — and What CROS Already Does

On May 31, 2017, a smoldering nest in a corn milling process produced a series of explosions that killed five employees at Didion Milling in Cambria, Wisconsin. The CSB's six-year investigation found thirteen safety failures — all tracing to a single root cause: an organization that could not reliably retain, retrieve, or act on what it already knew. One of its nine recommendations reads like a product specification for CROS.

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Case Study 02
Chemical Storage
FGAN / Ammonium Nitrate
CSB Investigation
15 Fatalities · 260+ Injured
19 CSB Recommendations
3 Still Open — A Decade Later
$100M+ Offsite Damage
West Fertilizer, West Texas — A Gap Map
How Seven CSB Findings Became the CROS Feature Set

On April 17, 2013, a fire at the West Fertilizer Company detonated an estimated 28 to 34 tons of ammonium nitrate, killing fifteen people and injuring more than 260. Seven operational gaps — no incident commander, no command structure, no hazard data in front of the responders — are each grounded in a specific CSB finding. All seven map directly to a CROS faculty. Three of nineteen recommendations remain open a decade later.

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Case Study 03
Kraft Pulp & Paper
White Liquor · CERCLA · PSM / RMP
CSB Investigation Active
11 Fatalities · 8 Injured
Six-Agency Unified Command
37-Day Response
Washington State's Deadliest Industrial Disaster Since 1930
Nippon Dynawave Packaging Co. — The Record That Has to Exist Before the Event
900,000-Gallon White Liquor Tank Implosion · Longview, Washington · May 26, 2026

At 7:15 AM on May 26, 2026, the G Tank at Nippon Dynawave Packaging imploded. Eleven workers were killed. Six agencies coordinated simultaneously — each with a different clock, a different contact, and a different reporting chain. The questions that had to be answered in the first thirty minutes had answers that could not be assembled under pressure. They had to exist before the event. This case study maps what CROS would have surfaced against the documented facts of the incident.

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In Development

Additional case studies drawn from CSB, PHMSA, FERC, and USCG incident records are being prepared. Each maps published regulatory findings to the CROS faculty that closes them.