OSHA Accident Investigation · Summary #14384333
BURN,INADEQUATE MAINT,PRESSURE VESSEL,WORK RULES,STEAM,HIGH PRESSURE,STRUCK BY,DOOR,MECH MALFUNCTION
Event description
Employee killed when pressure vessel door opens prematurely
Investigation abstract
As part of his regularly assigned duties, Employee #1 was operating a retort ves sel as it neared the end of a venting cycle. The vessel was not at full operatin g pressure. Employee #1 was adjusting the door tightness and was standing next t o the door when the door latch mechanism failed. The built-up internal steam pre ssure blew the door open. Employee #1 was struck by the door and was also burned by escaping steam. He suffered first- and second-degree burns over 70 percent o f his body, internal injuries, and a broken leg. Employee #1 died. A defective s crew in the latch mechanism, which had been in place for approximately 10 years, was a causal factor in the accident.
Victim
-
#1 Fatality Age 33 M
- Nature of injury
- 5
- Part of body
- 19
- Event type
- 1
- Source
- 6
- Occupation code
- 999
- Human factor
- 6
- Environmental factor
- 7
- 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.