OSHA Accident Investigation · Summary #14199806
KENNECOTT REFINING CORP.
BALTIMORE, MD—
Event description
EXPOSED TO ALCOHOL AND TRICHLOROETHANE FUMES IN TANK
Investigation abstract
ON THE EVENING OF MARCH 28, 1985, FIVE EMPLOYEES ENTERED ONE OF THE THREE SOLUBL AVITY DRAIN LINES. WHEN EMPLOYEE #1 PNUEMATICALLY VACUUMED THE TANK'S RESIDUE, T HE AGITATION CAUSED THE VAPORIZATION OF THE TRICHLOROETHANE UNDER THE WATER-SOLU BLE OIL. THE THREE EMPLOYEES WHO RESCUED EMPLOYEE #2 POSITIVELY IDENTIFIED THE V APORS AS TRICHLOROETHANE. NO RESPIRATORS WERE WORN DURING THE CLEANING OR DURING THE RESCUE. THE TANK HAD NOT BEEN VENTILATED BY FORCED AIR METHOD PRIOR TO OR D URING ENTRY. NO TESTING OF THE TANK'S ATMOSPHERE FOR ISOPROPYL ALCOHOL, 1,1,1, T HRICHLOROETHANE OR OXYGEN DEFICIENCY WAS DONE. THE EMPLOYEES WERE NOT TRAINED IN RESCUE PROCEDURES OR CPR. NO LIFELINES OR HARNESS WAS USED. THE LUBRICANT DRAIN LINES AND OTHER LINES INTO THIS SECTION WERE NOT BLANKED OR DISCONNECTED. EMPLO YEE SYMPTOMS INCLUDED SEVERE HEADACHE, LOSS OF MEMORY, FAINTNESS AND DIZZINESS. E OIL SECTIONS OF THE DRAINED SOLUBLE OIL LUBRICANT/COOLANT TANK ON THE CONTINUO A BULK SAMPLE ANALYSIS SHOWED 0.63% V/V ISOPROPYL ALCOHOL AND 0.29% V/V 1,1,1, T RICHLOROETHANE. US COPPER CASTING-TO-ROD MILLING LINE. EMPLOYEE #1 ENTERED THE SECTION TO CLEAN IT OF COOPER OXIDE PARTICULATE AND LUBRICANT. AFTER A HALF HOUR HE SMELLED ALCOH OL AND LEFT THE SPACE. HE TOLD NO ONE ABOUT THE ALCOHOL SMELL. EMPLOYEE #2 ENTER ED THE SECTION. HE WAS RENDERED UNCONSCIOUS WITHIN A FEW MINUTES. EMPLOYEES #3 T HROUGH #5 THEN ENTERED THE SECTION TO RESCUE EMPLOYEE #2. THE SOLUBLE OIL CONTAI NS WATER, 5% OIL AND 1% ISOPROPYL ALCOHOL. 1,1,1, TRICHLOROETHANE WAS USED TO CL EAN THE LINE'S ROLLER MILL. SOME OF IT HAD DRAINED BACK INTO THE TANK THROUGH GR
Victims (5)
-
#1 Hospitalized Age 51 M
- Nature of injury
- 21
- Part of body
- 29
- Event type
- 8
- Source
- 9
- Occupation code
- 719
- Human factor
- 17
- Environmental factor
- 7
- Hazardous substance
- 1720
- Task assigned
- 2
-
#2 Hospitalized Age 49 M
- Nature of injury
- 21
- Part of body
- 29
- Event type
- 8
- Source
- 9
- Occupation code
- 873
- Human factor
- 17
- Environmental factor
- 7
- Hazardous substance
- 1720
- Task assigned
- 2
-
#3 Hospitalized Age 48 M
- Nature of injury
- 21
- Part of body
- 29
- Event type
- 8
- Source
- 9
- Occupation code
- 719
- Human factor
- 17
- Environmental factor
- 7
- Hazardous substance
- 1720
- Task assigned
- 2
-
#4 Hospitalized Age 45 M
- Nature of injury
- 21
- Part of body
- 29
- Event type
- 8
- Source
- 9
- Occupation code
- 719
- Human factor
- 17
- Environmental factor
- 7
- Hazardous substance
- 1720
- Task assigned
- 2
-
#5 Hospitalized Age 50 M
- Nature of injury
- 21
- Part of body
- 29
- Event type
- 8
- Source
- 9
- Occupation code
- 633
- Human factor
- 17
- Environmental factor
- 7
- Hazardous substance
- 1720
- Task assigned
- 2
Codes shown verbatim from OSHA's accident-investigation database. A human-readable decoder is coming in a future release once the accident_lookup2 dictionary is loaded.