OSHA Accident Investigation · Summary #14308332
FLAMMABLE VAPORS,WORK RULES,BOILER,EXPLOSION,CHEST,STRUCK BY,FLYING OBJECT
Event description
EMPLOYEE KILLED IN BOILER EXPLOSION
Investigation abstract
THE REFRACTOR LINING OF A BOILER HAD BEEN REPAIRED. TO GAIN ACCESS TO THE BOILER KILLING HIM. THE BOILER WAS MANUFACTURED BY THE H.B. SMITH COMPANY, OF THE 28 SE RIES, MODEL C3-GO-25. THE BURNER UNIT WAS MADE BY POWER FLAME, INC. THE DAY AFTE R ACCIDENT, A TEST OF THE UNIT'S OPERATION WAS CONDUCTED AT THE REQUEST OF THE M IDDLESEX COUNTY PROSECUTORS OFFICE. WITH THE MAIN GAS VALVE CLOSED, THE BURNER W AS STARTED. IT WAS FOUND THAT THE GAS FEED VALVE TO THE BURNER WAS OPENING CONCU RRENTLY WITH THE PURGE. NORMALLY THE FEED VALVE OPENS AFTER A 90 SECOND PURGE AN D DETECTION OF THE PILOT FLAME. AN EXAMINATION OF THE WIRING SHOWED THAT THERE W AS A MISTAKE MADE WHEN THE WIRING WAS RECONNECTED, SUCH THAT THE SAFETY MEASURE (PURGE-FLAME DETECTION) HAD BEEN BYPASSED. PROPER START-UP PROCEDURES WERE NOT F OLLOWED. THE REWIRING JOB SHOULD HAVE BEEN CHECKED AGAINST THE WIRING DIAGRAM. A , THE WIRING FOR THE BURNER CONTROLS HAD BEEN DISCONNECTED AND THE MAIN GAS VALV START-UP CHECK TO CHECK THE SAFETY MEASURE SHOULD HAVE BEEN DONE WITH THE MAIN GAS VALVE CLOSED. E SHUT OFF. AFTER THE REPAIRS WERE COMPLETED THE WIRING WAS RECONNECT BY A MECHA NIC. THE MECHANIC HAD COMPILED AN INCOMPLETE LIST OF THE CONNECTIONS. THE MAIN G AS VALVE WAS THEN OPENED. EMPLOYEE #1 WAS CALLED TO START THE BOILER. HE CLOSED THE BREAKERS, BUT NOTHING HAPPENED. HE CHANGED A FUSE AND ATTEMPTED ANOTHER STAR T-UP. EMPLOYEE #1, ALONG WITH 2 EMPLOYEES OF THE REPAIR COMPANY, WAS STANDING IN FRONT OF BURNER UNIT. AT THE POINT WHEN THE PILOT IS IGNITED, THE UNIT BLEW UP. A COVER PLATE ON THE BURNER UNIT BLEW OFF AND STRUCK EMPLOYEE #1 IN THE CHEST,
Victims (2)
-
#1 Fatality Age 62 M
- Nature of injury
- 18
- Part of body
- 5
- Event type
- 1
- Source
- 6
- Occupation code
- 999
- Human factor
- 9
- Environmental factor
- 5
- Task assigned
- 1
-
#981 Degree 0 Age 0
- Nature of injury
- 0
- Part of body
- 0
- Event type
- 0
- Source
- 0
- Occupation code
- 0
- Human factor
- 0
- Environmental factor
- 0
- Task assigned
- 0
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