OSHA Accident Investigation · Summary #14447148
KOCH REFINING COMPANY
PINE BEND, MN—
Event description
PROCESS HEATER EXPLODED WHEN EMPLOYEE TRIED TO LIGHT IT
Investigation abstract
EMPLOYEE #1 WAS ATTEMPTING TO LIGHT A PROCESS HEATER (SIMILAR TO A LARGE FURNACE ) AFTER COMPLETION OF A MAINTENANCE SHUT-DOWN. THE FUEL LINE HAD BEEN LEFT OPEN AND THE PILOT FUEL LINE LEFT CLOSED. THE EMPLOYEE WAS UNDER THE PLENUM, USING AN ACETYLENE TORCH, WHEN THE EXPLOSION OCCURED. EMPLOYEE #2 WAS SEVERAL FEET AWAY. EMPLOYEE #1 WAS STRUCK BY THE FLOOR OF THE PLENUM. THE CORONER'S REPORT STATED THAT THE CAUSE OF DEATH WAS A FRACTURE OF THE SKULL. EMPLOYEE #2 SUFFERED MINOR BURNS OF THE THROAT. CONTRIBUTING FACTORS: THERE WAS NO AVAILABLE METHOD OF "PRO VING" THE PILOT. FUEL GAS WAS ALLOWED THROUGH THE LINES WITHOUT FIRST INSURING T HAT THERE WAS A PILOT LIGHT.
Victims (2)
-
#1 Fatality Age 37 M
- Nature of injury
- 12
- Part of body
- 13
- Event type
- 1
- Source
- 6
- Occupation code
- 779
- Human factor
- 1
- Environmental factor
- 6
- Task assigned
- 1
-
#2 Non-hospitalized injury Age 42 M
- Nature of injury
- 5
- Part of body
- 20
- Event type
- 8
- Source
- 16
- Occupation code
- 779
- Human factor
- 1
- Environmental factor
- 11
- Task assigned
- 1
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.