OSHA Accident Investigation · Summary #14250526
PRESSURE VESSEL,UNSECURED,HIGH PRESSURE,STRUCK BY,FLYING OBJECT,DOOR
Event description
AUTOCLAVE DOOR BLEW OFF, STRIKING EMPLOYEE
Investigation abstract
EMPLOYEE #1 WAS SERIOUSLY INJURED WHEN THE DOOR OF AN AUTOCLAVE BLEW OFF DURING THE START UP CYCLE (UNLOADED) OF AN EQUIPMENT CHECK. EMPLOYEE #1 WAS MERELY PASS ING THROUGH THE STERILIZING DEPARTMENT AND WAS 50 FEET AWAY FROM THE AUTOCALVE W HEN THE DOOR BLEW OFF. SUBSEQUENT INVESTIGATION REVEALED THAT THE DOOR WAS NOT F ULLY SECURED BEFORE IT WAS PRESSURIZED. THE LOCKING MECHANISM WAS MISALIGNED, IN THAT THE SERIES OF ROLLERS DOWN EACH SIDE OF THE DOOR DID NOT LINE UP CORRECTLY WITH THE DOOR LUG STRIKER PLATES. AS THE INTERNAL PRESSURE INCREASED, THE PARTI ALLY SECURED DOOR SLID PAST THE PLATES AND BLEW ACROSS THE ROOM.
Victim
-
#1 Hospitalized Age 51 M
- Nature of injury
- 21
- Part of body
- 19
- Event type
- 1
- Source
- 6
- Occupation code
- 518
- Human factor
- 14
- Environmental factor
- 5
- Hazardous substance
- 8420
- 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.