AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 58:568576 (2015)

Case Cluster of Pneumoconiosis at a

Coal Slag Processing Facility
Kathleen M. Fagan,

1

MD, MPH,

Erin B. Cropsey,

BS, IH,

and Jenna L. Armstrong, MPH, PhD3

Background During an inspection by the Occupational Safety and Health

Administration (OSHA) of a small coal slag processing plant with 12 current workers,
four cases of pneumoconiosis were identied among former workers.
Methods The OSHA investigation consisted of industrial hygiene sampling, a review of
medical records, and case interviews.
Results Some personal sampling measurements exceeded the OSHA Permissible
Exposure Limit (PEL) for total dust exposures of 15 mg/m3, and the measured
respirable silica exposure of 0.043 mg/m3, although below OSHAs current PEL for
respirable dust containing silica, was above the American Conference of Governmental
Industrial Hygienists Threshold Limit Value (TLV). Chest x-rays for all four workers
identied small opacities consistent with pneumoconiosis.
Conclusion This is the rst known report of lung disease in workers processing coal slag
and raises concerns for workers exposed to coal slag dust. Am. J. Ind. Med. 58:568576,
2015. 2015 Wiley Periodicals, Inc.
KEY WORDS: coal slag; OSHA; silica; dust; pneumoconiosis

INTRODUCTION
Coal combustion remains one of the largest fuel sources
for the generation of electricity in the United States. It
produces large volumes of by-products including y ash,
bottom ash, and coal (boiler) slag. Although coal slag makes
up only 2% of coal combustion residue from coal-red power
plants nationally, in specic types of furnaces (e.g., wetbottom furnaces), 7080% of the combustion residue may be
retained as slag [Stultz, 2005]. Each year, over 2 million tons
of coal slag are available for recycling. Coal slag downstream

1
Office of Occupational Medicine, Occupational Safety and Health Administration,
Washington, DC
2
Aurora Area Office, Occupational Safety and Health Administration, North Aurora,
Illinois
3
Division of Respiratory Disease Studies, National Institute for Occupational Safety
and Health, Morgantown, West Virginia


Correspondence to: Kathleen M. Fagan, MD, MPH, 200 Constitution Avenue, N.W.,
Rm N3457, Washington, DC. E-mail: fagan.kathleen@dol.gov

Accepted 9 February 2015

DOI 10.1002/ajim.22444. Published online in Wiley Online Library
(wileyonlinelibrary.com).

2015 Wiley Periodicals, Inc.

products include abrasive blasting agents, roong granules,

snow and ice control, and construction materials like road base
and structural ll materials [ASTM, 2009; ACAA, 2011].
Coal slag collects at the bottom of coal furnaces after
combustion. It is a black, molten material in wet-bottom
furnaces and is discharged into quenching water where it
crystallizes and fractures into black glassy pellets [FHA,
2002; PCA, 2005]. These pellets may be sent to processing
facilities that prepare various downstream products. The coal
slag processing and recycling industry employs between
6,600 and 14,200 workers nationwide [NAICS, 2007]. This
section of the coal industry often goes unrecognized because
the nature of the work is seasonal and many of the companies
are small businesses with less than 25 workers.
The purpose of this report is to describe a case cluster of
pneumoconiosis discovered during an inspection of a coal
slag processing plant by the Occupational Safety and Health
Administration (OSHA). The report will detail OSHAs
industrial hygiene observations, sampling results, and
medical ndings; review the chemical constituents and
toxicity of coal slag; and raise concerns about coal slag
exposure for workers, particularly those using abrasive
blasting agents containing coal slag.

Pneumoconiosis in Coal Slag Processing

METHODS
OSHA Inspection
In 2010, an OSHA compliance safety and health ofcer
(CSHO) opened an inspection of a coal slag processing plant
in the Midwest in response to worker complaints. Workers
alleged multiple safety and health hazards including
amputations, electrical hazards, unsafe work at heights,
noise, conned space hazards, combustible dust hazards, and
exposures to elevated dust levels. The CSHO performed
several on-site walk-throughs, interviewed management
personnel and employees, reviewed company records, and
took compliance samples for airborne total and respirable
dust, silica, and metals.
The inspection led to a number of citations, including
citations for worker exposures above the OSHA PEL for total
dust [OSHA, 2006], inadequate engineering and administrative controls for dust exposure, lack of adequate respiratory
protection per the OSHAs Respiratory Protection standard
[OSHA, 2011], and several safety issues.

Industrial Hygiene Monitoring

The CSHO obtained 10 personal samples on nine
workers over the course of 2 days. The sampling times
ranged from 5.8 to 7.5 hours. Samples were analyzed for total
dust [OSHA, 2003a] and respirable dust [OSHA, 2003b]
using polyvinyl chloride (PVC) lters with ow rates
ranging from 1.7 to 2.0 liters per minute (LPM). The total and
respirable dust lters were then analyzed by gravimetric
analysis. Air monitoring was also performed for silica
respirable fraction [OSHA, 1981] with a pre-weighed low
ash PVC lter at 1.7 LPM. The lter was analyzed for
crystalline silica using x-ray diffraction (XRD). Finally, in
order to sample for metals, monitoring was performed
according to the protocol used for welding fumes [OSHA,
1988] and for arsenic [OSHA, 1982] using mixed cellulose
ester lters (0.8 mm) with a ow rate of 2.0 LPM. The
welding fumes lter was analyzed for metals (antimony,
beryllium, cadmium, chromium, cobalt, copper, iron oxide,
inorganic lead, manganese, molybdenum, nickel, vanadium,
and zinc oxide) by inductively coupled argon plasma-atomic
emission spectroscopy (ICAP-AES), and the arsenic lter
was analyzed by atomic absorption spectroscopy (AAS).
Time weighted averages (TWAs) were calculated for
individual samples.

Worker Interviews and Medical Records

Review
During the initial plant inspection, the CSHO discovered
that four workers had left employment at the plant due to

569

respiratory problems, all of whom had applied for Black

Lung benets. The CSHO obtained releases for their medical
records, and OSHA received the physicians reports for
Black Lung benets and pulmonary function testing for three
of the four cases (Workers 1, 2, and 4). Chest x-ray reports
were obtained for all four cases, but the actual lms were not
obtained. B-reading forms were completed by B-readers for
three cases and by an experienced A-reader in the fourth case
(Worker 2). The records were reviewed by a medical ofcer
in OSHAs Ofce of Occupational Medicine. The medical
ofcer interviewed three of the four workers (Workers 1, 3,
and 4) but was unable to contact the nal worker (Worker 2).
The interviews included medical and occupational histories
with specic questions on respiratory symptoms, smoking
status, job duties at the coal slag processing plant, and any
past occupational or environmental exposures to coal, silica,
asbestos, or other recognized brogenic dusts. This
information was collected under OSHAs enforcement
authority pursuant to the Occupational Safety and Health
Act [1970]. Per 45 CFR 46.102 under the Protection of
Human Subjects rule [DHHS, 2009], information collected
under other government authority is excluded from coverage.
Therefore, this report does not require Institutional Review
Board approval.

RESULTS
Description of Plant Operations and
Work Activities
The plant, located 200300 m from a large coal-burning
power generating plant, processes the coal slag from the
power plant to produce abrasive blasting and roong
products. The plant employed 12 workers at the time of
the inspection. The coal slag is transported from the power
plant to the coal slag plant using trucks and rail cars. Once it
arrives at the plant, front end loaders are used to move the
material around the plant for processing. The coal slag is
dried, crushed into specic sizes, screened, bagged, and
loaded onto trucks for shipment.
Plant operators run the machines that dry, crush, and
screen the coal slag. Their job duties include operating the
conveyors, changing out the screens, and lling hoppers and
trucks with material. Occasionally, a plant operator must
enter the bag house to check on or change lters. Equipment
operators drive trucks and front-end loaders throughout the
plant. Maintenance workers trouble-shoot equipment
throughout the plant. Clean-up crew workers shovel coal
slag and clean out rail cars. The plant supervisor is primarily
an administrative job, although the supervisor may be in the
plant frequently.
The CSHO noted visible airborne dust and settled dust
on workers and around operating equipment throughout the

570

Fagan et al.

plant; this included the screen house, the crusher machine

area, and the bag house. During interviews, the workers
conrmed that these were the dustiest areas of the plant. The
compliance ofcer also learned that both the power plant and
the nearby community had led complaints about emissions
attributable from the coal slag processing plant.
At the time of the OSHA visit, the plant did not have a
respiratory protection program. No t-testing and no
respirator training were provided. The workers were supplied
with ltering facepiece (N-95) respirators for voluntary use,
but the CSHO noted that dirty facepiece respirators were
commonly re-used rather than replaced.

Industrial Hygiene Monitoring

Results of personal monitoring at the plant included
several measurements for total dust that were above the
OSHA PEL of 15 mg/m3 [OSHA, 2006] (Table I), ranging
from 3.3 to 47.6 mg/m3. The highest total dust samples were
collected from plant operators and maintenance workers. The
respirable dust sample was 0.50 mg/m3, an order of
magnitude below the PEL of 5 mg/m3 [OSHA, 2006]. The
sampling result for silica (quartz) containing respirable dust

on a maintenance worker was 1.35 mg/m3. This 6-hr sample

was adjusted as an 8-hr TWA, which assumed a zero
exposure for the remainder of the time. Calculations
performed by OSHAs Salt Lake Technical Center multiplied
the sample concentration by the percent silica (1.35 mg/
m3  0.032 [3.2%]) and determined that the 8-hr time
weighted average respirable silica level for this sample was
0.043 mg/m3. Although this sample was below OSHAs
current PEL for respirable dust containing silica, it was above
the American Conference of Governmental Industrial
Hygienists (ACGIH) Threshold Limit Value (TLV) of
0.025 mg/m3 [ACGIH, 2014]. Analysis for metals identied
levels of both copper and iron oxide (0.003 and 0.450 mg/m3,
respectively). All measurements for other metals (including
arsenic) were below limits of detection.

Worker Interviews and Medical Records

Review
The four former workers with pneumoconiosis ranged in
age from 40 to 53 years old. Three were male and one was
female. The three interviewed workers (Workers 1, 3, and 4)
described respiratory symptoms that began within months to

TABLE I. OSHA Inspection Personal Sampling Results

OSHA inspection sampling results
Job group

Result (mg/m3)

Current exposure limits

Sample

OSHA PEL
(mg/m3)

CalOSHA PEL
(mg/m3)

NIOSH REL
(mg/m3)

ACGIH TLV (mg/m3)

Total dust

15

10

Equipment operator
Plant operator
Maintenance
Maintenance
Maintenance
Maintenance

5.6
47.6
31.7
27.9
5.4
3.3

Plant operator

0.5

Respirable dust

Maintenance

0.043a

Respirable
silica (quartz)
Respirable dust
containing
silica(quartz)
Welding fumes
Arsenic

0.05b

0.05

0.05

0.9 for bituminous or lignite; 0.4

for anthracite (respirable
coal dust)
0.025

1.92c

1.0 Cu; 5.0 FeO

0.01

1.0 Cu; 5.0 FeO

0.01

1.0 Cu; 5.0 FeO

0.002

1.0 Cu; 5.0 FeO

0.01

1.35

Plant operator
Equipment operator

0.003 Cu; 0.45 FeOd

< LODe

Bold, italics indicate samples above one of the exposure limits.

ACGIH, American Conference of Governmental Industrial Hygienists; CalOSHA, California OSHA; LOD, Limit of Detection; REL, Recommended Exposure Limit.
a
The reported sample is for respirable silica (OSHA Salt LakeTechnical Center calculation).
b
The OSHA proposed PEL is 0.05 mg/m3 (78 FR 56273).
c
(10 mg/m3 /[%SiO2 2]).
d
This samplewas <LOD for antimony (Sb),beryllium (Be),cobalt (Co),chromium (Cr),cadmium (Cd),nickel (Ni),lead (Pb), manganese (Mn), molybdenum (Mo),vanadium (V),
and zinc oxide (ZnO).
e
LOD 0.0004 mg/m3.

Pneumoconiosis in Coal Slag Processing

years before the end of their employment at the coal slag

plant. Some symptoms improved after termination. All
workers were consistent in their descriptions of dusty
working conditions, lack of effective environmental controls, and lack of respiratory protection. All three noted
coughing up black-colored sputum at the end of the workday
and denied experiencing respiratory symptoms at previous
jobs. None of the workers had ever worked in a coal mine,
and all denied prior exposure to asbestos, coal, or silica. Two
workers (3 and 4) had previously worked at a rock quarry for
1 year and 2 months, respectively. Both stated that the quarry
work was not as dusty as the coal slag plant. Worker 3 also
worked previously at an auto body repair company, where he
did welding, epoxy work, and painting. There he wore a
respirator and denied respiratory symptoms. He also denied
exposure to asbestos (such as brake work). Table II presents
demographics, job, and exposure histories, co-morbidities,
medications, symptoms, smoking history, pulmonary function testing (PFT), and chest x-ray B-readings gathered from
the medical records, and/or worker interviews.
The physician reports available for three cases (Workers
1, 2, and 4) included medical and occupational histories,
physical examination, PFT, chest x-ray readings, and
physicians assessments and diagnoses. The physical
examinations of workers 1 and 4 were normal. Worker 2
also had a normal physical examination except for an
elevated body mass index of 36.2 and a rash on one hand that
the physician assessed as possible psoriasis. The only
laboratory testing available was a normal complete blood
count (CBC) for worker 1 and normal pulse oximetry for
workers 2 and 4 (96% and 97%, respectively).
Workers 2 and 4 had pre- and post-bronchodilator
spirometry, and both sets met the American Thoracic
Society/European Respiratory Society criteria for acceptability and repeatability [Miller et al., 2005]. Worker 1 had
spirometry, lung volumes, diffusion capacity (DLCO), and a
methacholine challenge test; however, the records were
incomplete and repeatability could not be assessed.
Spirometry results for the three workers were interpreted
using the ATS/ERS algorithm [Pellegrino et al., 2005;
Townsend et al., 2011]. Chest x-ray readings were remarkably similar in all four cases. The primary opacities recorded
in the three B-readings were small (1.5 mm), rounded (p)
opacities, and all four readings noted opacities in the mid
lung elds bilaterally. Workers 1, 2, and 4 were diagnosed
with coal workers pneumoconiosis by the evaluating
physicians who had presumably assumed that the coal slag
exposure represented coal mine dust.

DISCUSSION
This case cluster of pneumoconiosis, discovered during
OSHAs inspection of a coal slag processing plant, suggests

571

the possibility of lung disease associated with coal slag dust

exposure. Future health surveillance of workers who process
and use coal slag at other sites may clarify the risk of
pneumoconiosis in this industry.
Although many studies have examined the chemical
components of combustion products, such as y and bottom
ash, fewer have analyzed bulk components of coal slag,
which is produced from the same processes. Unburned coal
represents less than 5% of coal slag composition, and some
power plants report levels of iron oxides ranging from 3% to
25% by weight in coal slag [FHA, 2002]. Bulk samples of
coal slag have been analyzed for silica and a broad range of
metals (using different methods, including NIOSH Method
7,300 by inductively coupled plasma mass spectrometry
(ICP), proton-induced x-ray emission (PIXE), and Method
7,500 for crystalline silica by XRD for crystalline silica
[Mackay et al., 1980; Stettler et al., 1982; NIOSH and KTATator, Inc., 1998; Hubbs et al., 2001; Alvarez-Ayuso et al.,
2006; Meeker et al., 2006]. All studies found notable
amounts of beryllium, chromium, and manganese in bulk
samples. Arsenic, cadmium, cobalt, iron, lead, titanium, and
vanadium were also present in some studies. Silver,
platinum, and cristobalite or quartz silica (SiO2) were often
below the limits of detection (<LOD) in bulk samples, but
the limits of detection varied by study. In each study, the
levels of elements in bulk samples of slag were different
because element partitioning depends on individual power
plant combustion rates, mineral enrichment, and natural
geographic variation of coal types across the United States.
Very little information is available about the inhalational
toxicity of coal slag exposure, despite its widespread use in
abrasive blasting. The reported Mohs hardness of coal slag
(>7) indicates that its granules are similar to silica quartz in
their potential to fracture into smaller particulate sizes,
depending on how they are used [Momber, 2008]. Studies of
coal slag have demonstrated pulmonary injury, brosis, and
pneumoconiosis in animal models. For example, rats develop
pulmonary interstitial brosis after high-dose (2040 mg)
intra-lobular or intra-tracheal instillation of coal slag
[Mackay et al., 1980; Stettler et al., 1995]. Four weeks after
intra-tracheal instillation of 10 mg of respirable (1 mm
particle diameter) coal slag, Hubbs et al. [2001] demonstrated markers of pulmonary inammation and brosis in rats
that exceeded the response to blasting sand itself.
In 2005, Hubbs et al. reviewed the known toxicity of
abrasive blasting agents, including coal slag, and outlined a
comprehensive research protocol, including chronic inhalation studies, to further investigate their toxicity and relative
risk and facilitate extrapolation to human exposures. The
National Toxicology Program (NTP) has begun general
toxicology assessments of coal slag and other blasting
agents. Preliminary 2-week coal slag inhalation studies in
rats demonstrated cellular inltrates, and three rats had
proteinosis in the lung. The cellular inltrates were similar to

20

14

20

2i

DOE

DOE, occasional
cough and wheezing

ES 1PY

CS 30 PY

Quarry, equipment operator

(1year); autobody repair (3
years); Assembly (<1
year); tow truck driver (<1
year)
Clean-up crew ^ 7 Food packaging; HVAC
manufacture; Quarry (2
years; Plant
mos.)
supervisor ^ 1year

DOE

Symptoms

DOE, morning cough,

phlegm, occasional
wheezing

ES 12 PY

SHc

CS 33 PY

Flour mill (4 months)

Work history

Warehouse (1year); scrap

yard (2 years); unspecified
factory (3 years)

Plant operator,
Equipment
operator,
maintenance
Equipment
operator,
maintenance

Plant operator

Plant job(s)

COPD; No medications

HPN, HPL; Medications

not known

AF, MI, PE; Medicationmetoprolol, Coumadin,

thyroid supplement

None

Co-morbidity
medication

16

21

17

20

LTd

p/p1/1
U, M

p/p1/0
M, L

s/p1/0
U, M, L

p/s1/0
U, M, L

CXRe

BPP

None

NAg

COPD

None

2f

Film
quality CXR-Addf

Borderline obstruction;
no restriction; no airways
hyperreactivity.

NA

Normal spirometry;
DLCO 72% predicted;
methacholine challenge
negative.
Borderline obstruction;
no restriction; no airways
hyperreactivity.

PFTi

AF, atrial fibrillation; BPP,bilateral pleural plaques; COPD, chronic obstructivepulmonary disease; CS,current smoker; DOE,dyspnea on exertion; ES,ex-smoker; HPN,hypertension; HPL,hyperlipidemia; MI, myocardial infarction;
NA, not available; PY, pack-years; PE, pulmonary embolism.
a
Years Employed at coal slag plant.
b
Smoking history.
c
Latency in years-from time first employed at coal slag plant to time of diagnosis.
d
Chest x-ray primary opacities/secondary opacities, then profusion, then location of opacities (UUpper, MMid, LLower); all opacities were read as bilateral.
e
B-reading results are listed as follows: primary opacities/secondary opacities, then profusion, then location of opacities (UUpper, MMid, LLower); all opacities were read as bilateral.
f
underpenetrated.
g
no grade marked, no reason given.
h
Pulmonary FunctionTesting (spirometry results are listed first, then other findings).
i
The B-reading form in this case was completed by the examining physician, an experienced A-reader. B-readings for the other three cases were performed by certified B-readers.

YEb

Worker

TABLE II. Medical and Occupational Information for Four Pneumoconiosis Cases

572
Fagan et al.

Pneumoconiosis in Coal Slag Processing

ndings using blasting sand, although the proteinosis was not

noted in lungs of rats inhaling blasting sand for 2 weeks.
Final study interpretations and chronic (39 week) inhalational studies have not been completed [NTP, 2013].
In this investigation, OSHAs air sampling indicated
high levels of exposure to total dust containing iron oxide,
copper, and silica. Iron oxide exposure can cause a
pneumoconiosis termed siderosis, which usually is not
brotic [Chong et al., 2006]. Exposure to dust containing
both iron oxide and silica or silicates can cause mixed dust
pneumoconiosis (MDP) or siderosilicosis. The most
common radiographic changes in siderosilicosis are small
nodules in the middle lung elds, and the most common
symptoms are cough and dyspnea [Chong et al., 2006]. An
international consensus report proposed criteria for the
diagnosis of MDP that included exposure to dust containing
silica mixed with silicates, iron oxide, and/or non-coal
carbon particles [Honma et al., 2004]. The report classies
siderosilicosis as a subset of MDP. Lesions found on lung
biopsy are similar to those seen with coal workers
pneumoconiosis. Tests of breathing function may be normal
or may show restriction, obstruction, or mixed decits.
Radiologic ndings seen in MDP include small rounded and
irregular opacities. Therefore, the four cases described in this
report are consistent with MDP or siderosilicosis.
On the other hand, the four cases may represent a case
cluster of silicosis identied in a new industry. Although the
sampling result for respirable dust containing silica was
below the current OSHA PEL, the calculated respirable silica
level of 0.043 mg/m3 is near or above other occupational
exposure limits (Table I), including OSHAs proposed PEL
of 0.05 mg/m3 [OSHA, 2013a]. Silica exposure levels in this
range have been associated with the development of silicosis
[Kreiss and Zhen, 1996; Steenland, 2005].
Workers at this coal slag processing plant were exposed
to high dust levels, and the employer had no respiratory
protection program in place. A review of occupational health
and safety in smaller enterprises reported that lack of health
and safety programs is common, as facilities with less than
50 workers often have limited resources for operating and
complying with occupational safety and health regulations
[Hasle and Limborg, 2006]. The authors stress the need for
effective intervention strategies for small employers.
As much of the work at the coal slag processing plant is
outside and the plant is located close (<0.5 km) to the power
plant, environmental exposure to air contaminants may be a
confounding factor. The nearest local air monitoring station
(80 km from the work site) reported average levels of
<0.015 mg/m3 for ambient PM 2.5 [EPA, 2010]. The
processing plant workers may be at increased risk of
exposure to ne particles from power plant emissions
including y ash, metals, sulfur dioxide, and nitrogen
dioxide. However, since the facility was located on power
plant property, it is likely that some of these major pollutants

573

are dispersed at further distances as a result of smoke stack

height. In future studies, ambient air quality monitoring will
be required in additional to personal occupational monitoring
to clearly differentiate occupational and environmental
contributions to exposure. On the other hand, exposures to
silica, iron, and high total dust levels are more specic to
slag.
Although dust exposure levels found in this coal slag
processing plant were high, downstream workers using coal
slag as abrasive blasting agents may experience much higher
levels. In 1974, NIOSH recommended that abrasive blasting
materials containing >1.0% crystalline silica (quartz) be
replaced by alternatives to prevent the occurrence of silicosis
in workers performing blasting [NIOSH, 1974]. Since coal
slag abrasives have similar performance to silica sand
abrasives during blasting, it is an affordable and growing
alternative product in the construction industry [Meeker
et al., 2006]. In two industrial hygiene surveys conducted
during abrasive blasting with coal slag, much higher levels of
total and respirable dust were measured when compared to
levels measured by OSHA at the coal slag processing facility
(over 9,000 and 5,000 mg/m3, respectively [NIOSH and
KTA-Tator, Inc., 1998; Meeker et al., 2006]). The exposure
scenarios encountered at coal slag processing facilities will
differ greatly when compared to abrasive blasting work,
which produces a large amount of dust from the abrasive
product, the substrate being removed, and from the surface
itself. OSHA recently published health and safety recommendations for abrasive blasting [OSHA, 2013b], but less is
known regarding if similar recommendations are needed at
coal slag processing and recycling facilities.

Limitations
There are several limitations to the medical records
information. The physicians reports and chest x-ray were in
the context of claims for black lung benets, possibly
introducing bias. However, no signicant differences in the
physicians reports of past work histories or workplace
exposures were found by the OSHA medical ofcer during
her interview of three workers.
Two workers did have previous exposure to dust likely
to contain silica while working at a rock quarry. No further
information was available on the type of rock. Some rock,
such as sandstone and granite, can contain signicant amount
of silica. Silicosis has been described in quarry workers [Ng
and Chan, 1994; Mathur, 2005]. One of these two workers,
Worker 3, also had a 3-year past work history in an auto body
shop where asbestos exposure is a possibility. Although
Worker 3 denied asbestos exposure, the chest x-ray reading
noted bilateral pleural plaques (a potential sign of asbestosis)
although the parenchymal opacities were described as
rounded rather than irregular. It is possible this worker

574

Fagan et al.

could have been unaware of such exposures, and that

asbestos may have been an additional exposure and potential
cause of pneumoconiosis in this worker.
All four workers used the same law rm to le for Black
Lung benets; however, the evaluating physicians, pulmonary function laboratories, and B-readers were not the same
in all cases. Workers 2 and 4 saw the same physician and had
PFTs performed at the same facility but did not share the
same chest x-ray reader. The B-reading form for worker 2
was completed by a physician who was not a B-reader but
was an experienced A-reader. The chest x-rays of Workers 1
and 4 were read by the same B-reader, while Worker 3s chest
x-ray was read by a different B-reader. The lm quality was
not optimum in one case (Worker 2) and was not noted in
another case (Worker 4). OSHA was unable to obtain the
chest x-rays lms for independent interpretation. OSHA was
also unable to interview one of the four workers, and in
another case, no medical report or pulmonary function
testing was available. Only two of the three PFTs had enough
data to evaluate validity.

CONCLUSIONS
OSHAs investigation of a coal slag processing and
recycling plant uncovered a case cluster of pneumoconiosis
possibly attributable to coal slag dust exposure. These
cases raise new concerns for workers exposed to coal slag
dust during upstream processing of abrasive blasting and
roong materials, particularly those workers involved in
size selective screening and crushing. Initial toxicology
studies of abrasive blasting agents suggest that coal slag
may cause pulmonary damage similar to silica itself.
Further research is needed, including surveillance of all
kinds of coal slag-exposed workers, and more in depth air
monitoring in a variety of workplace settings in which coal
slag and coal slag products are being produced or used.
Surveillance conducted at smaller slag processing facilities
may be difcult, as many of them are small businesses with
limited economic resources. Studies of coal slag and other
abrasive materials, such as those being conducted by NTP,
will be important for the identication of human health
hazards. Currently, there are useful guidelines for administrative and engineering controls, personal hygiene practices, respiratory protection, and personal protective
equipment for abrasive blasting work [OSHA, 2013b].
However, it remains less clear whether similar recommendations are needed in coal slag processing and
recycling facilities and for other upstream uses of coal
slag, such as snow and ice removal, roong, and
construction industries. This case report raises concern
that inhalation of coal slag during coal slag processing may
be the cause of pneumoconiosis in four workers at one
processing plant.

ACKNOWLEDGMENTS
The authors would like to thank Kathleen Kreiss and
Anna-Binney McCague from the NIOSH Division of
Respiratory Disease Studies, Ann Hubbs from the NIOSH
Health Effects Laboratory Division, as well as Michael
Hodgson from the OSHA Ofce of Occupational Medicine
for their scientic comments and thoughtful review of this
report.

DISCLAIMER
OSHA: Two of the authors of this paper, Kathleen Fagan
and Erin Cropsey, are a medical ofcer and a compliance
safety and health ofcer, respectively, with the Occupational
Safety and Health Administration at the United States
Department of Labor. This paper is based on their work at
OSHA and on OSHA data; however, any opinions or
recommendations expressed in this paper do not necessarily
reect ofcial views or policy of OSHA. This paper is not a
standard or regulation, and it neither creates new legal
obligations nor alters existing obligations created by OSHA
standards or the Occupational Safety and Health Act (OSH
Act). NIOSH: The ndings and conclusions in this case report
are those of the authors and do not necessarily represent the
views of the National Institute for Occupational Safety and
Health.

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Disclosure Statement: The authors report no conflicts of interest.