OSHA Accident Investigation · Summary #14387435
BURN,FRACTURE,FLAMMABLE VAPORS,WORK RULES,EXPLOSION,PROCESS SAFETY,ACCIDENTAL DISCHARGE,CHEMICAL,HIGH TEMPERATURE,LEG
Event description
One employee killed and three injured in explosion and fire
Investigation abstract
Employee #2 was assigned by Employee #4 to make a product coded 76 RES3020X-1. T ere seriously burned; Employee #4 died at a later date. Employee #3 suffered mul tiple bruises. This explosion could possibly have been prevented if Employee #2 had checked the temperature of V211, or if the computer control system had been designed or programmed to check the vessel before allowing it be charged with a flammable monomer. his particular product was being made in the #5 reactor room. The primary vessel s used in making this product were reactor #5 and vessels 209 and 211. Employee #2 began to make the product by charging V211 with vinyl acetate. However, he di d not know that V211 was heated to a temperature that exceeded the boiling point of vinyl acetate. When the vinyl acetate was charged into the heated vessel, it vaporized and escaped through an open hatch. Pockets of vapors were allowed to accumulate and eventually exploded when ignited by an unknown ignition source. A s a result of the explosion, Employee #1's leg was broken. Employees #2 and #4 w
Victims (4)
-
#1 Hospitalized Age 27 M
- Nature of injury
- 12
- Part of body
- 16
- Event type
- 6
- Source
- 9
- Occupation code
- 999
- Human factor
- 11
- Environmental factor
- 10
- Task assigned
- 1
-
#2 Hospitalized Age 31 M
- Nature of injury
- 5
- Part of body
- 4
- Event type
- 14
- Source
- 9
- Occupation code
- 999
- Human factor
- 11
- Environmental factor
- 10
- Task assigned
- 1
-
#3 Hospitalized Age 23 M
- Nature of injury
- 3
- Part of body
- 2
- Event type
- 6
- Source
- 9
- Occupation code
- 999
- Human factor
- 11
- Environmental factor
- 10
- Task assigned
- 1
-
#4 Fatality Age 40 M
- Nature of injury
- 5
- Part of body
- 4
- Event type
- 14
- Source
- 9
- Occupation code
- 999
- Human factor
- 11
- Environmental factor
- 10
- 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.