OSHA Accident Investigation · Summary #14348361
TANK,BURN,WORK RULES,CONSTRUCTION,RUPTURE,HIGH PRESSURE
Event description
TANK RUPTURED AND SPEWED HOT LIQUOR ON EMPLOYEES
Investigation abstract
ON FEBRUARY 4, 1885, AT 9:30 AM, THE PRIME CONTRACTOR WAS RUNNING AN EXPERIMENT, LVE FOR "CLOSED". CONTRACTOR PERSONNEL WORKING ON OR AROUND THE TANK SHOULD HAVE BEEN NOTIFIED OF THE EXPERIMENT AND INSTRUCTED TO TAKE THE REQUIRED ACTIONS TO PROTECT THEMSELVES. BY COMPUTER, ON THE #10 DIGESTER. A SUBCONTRACTOR AND A PLANT EMPLOYEE WERE ASS ISTING. A BLOW LINE PLUGGED. AIR AND STEAM FAILED TO CLEAR THE LINE. A SUBCONTRA CTOR EMPLOYEE PULLED THE CARDS FROM THE BAILEY CONTROL NET 90 DISTRIBUTIVE CONTR OL SYSTEM (COMPUTER). REMOVAL OF THE CARDS CAUSED THREE VALVES TO OPEN. THE OPEN ING OF TWO OF THESE VALVES CAUSED THE WARM LIQUOR ACCUMULATOR TANK TO OVERPRESSU RIZE. THE TANK RUPTURED AT THE TOP WELDED SEAMS, BLOWING HOT BLACK LIQUOR ONTO E MPLOYEES #1 THROUGH #9, WHO WERE WORKING IN PROXIMITY TO THE TANK. THE CARDS SHO ULD NOT HAVE BEEN PULLED AND THEN PLUGGED BACK IN WITHOUT SETTING THE DEFAULT VA
Victims (11)
-
#1 Non-hospitalized injury Age 36 M
- Nature of injury
- 4
- Part of body
- 8
- Event type
- 1
- Source
- 9
- Occupation code
- 999
- Human factor
- 14
- Environmental factor
- 6
- Task assigned
- 1
-
#2 Non-hospitalized injury Age 30 M
- Nature of injury
- 4
- Part of body
- 19
- Event type
- 1
- Source
- 9
- Occupation code
- 999
- Human factor
- 14
- Environmental factor
- 6
- Task assigned
- 1
-
#3 Hospitalized Age 36 M
- Nature of injury
- 21
- Part of body
- 19
- Event type
- 1
- Source
- 9
- Occupation code
- 999
- Human factor
- 14
- Environmental factor
- 6
- Task assigned
- 1
-
#4 Non-hospitalized injury Age 42 M
- Nature of injury
- 4
- Part of body
- 8
- Event type
- 1
- Source
- 9
- Occupation code
- 999
- Human factor
- 14
- Environmental factor
- 6
- Task assigned
- 1
-
#5 Non-hospitalized injury Age 25 M
- Nature of injury
- 4
- Part of body
- 11
- Event type
- 1
- Source
- 9
- Occupation code
- 999
- Human factor
- 14
- Environmental factor
- 18
- Task assigned
- 1
-
#6 Hospitalized Age 21 M
- Nature of injury
- 4
- Part of body
- 19
- Event type
- 1
- Source
- 9
- Occupation code
- 999
- Human factor
- 14
- Environmental factor
- 18
- Task assigned
- 1
-
#7 Non-hospitalized injury Age 23 M
- Nature of injury
- 4
- Part of body
- 19
- Event type
- 1
- Source
- 9
- Occupation code
- 999
- Human factor
- 14
- Environmental factor
- 18
- Task assigned
- 1
-
#8 Hospitalized Age 43 M
- Nature of injury
- 4
- Part of body
- 19
- Event type
- 1
- Source
- 9
- Occupation code
- 999
- Human factor
- 14
- Environmental factor
- 6
- Task assigned
- 1
-
#9 Fatality Age 52 M
- Nature of injury
- 4
- Part of body
- 19
- Event type
- 1
- Source
- 9
- Occupation code
- 999
- Human factor
- 14
- Environmental factor
- 6
- 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
-
#982 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
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.