OSHA Accident Investigation · Summary #14390967
VENTING,NITROGEN,CLOGGED,CRUSHED,EXPLOSION,HIGH PRESSURE,STRUCK BY,FLYING OBJECT,PRESSURE RELEASE,REFINERY
Event description
One employee killed, two injured during reactor repair
Investigation abstract
Employees #1 through #3 were in the vicinity while a crew of seven contract mech and #3. Seven coworkers were also hospitalized after being struck by the flying debris. anics under the supervision of three refinery workers were using a crane to remo ve a reactor head from a plugged reactor in a crude alcohol refining unit. A nit rogen purge of approximately 300 psi was being used to maintain an inert atmosph ere inside the 41 in. diameter by 40 ft tall reactor. The nitrogen was inadequat ely vented, and after the bolts on the reactor head had been removed, the pressu re built up and blew the head off the reactor as it was being lifted. The 11-ton head fell onto Employee #1, killing him. Distribution trays and catalyst materi al were blown out of the top of the reactor, striking and injuring Employees #2
Victims (10)
-
#1 Fatality Age 44 M
- Nature of injury
- 12
- Part of body
- 19
- Event type
- 2
- Source
- 6
- Occupation code
- 999
- Human factor
- 1
- Environmental factor
- 15
- Task assigned
- 1
-
#10 Hospitalized Age 26 M
- Nature of injury
- 18
- Part of body
- 9
- Event type
- 1
- Source
- 14
- Occupation code
- 999
- Human factor
- 1
- Environmental factor
- 5
- Task assigned
- 1
-
#2 Hospitalized Age 35 M
- Nature of injury
- 7
- Part of body
- 16
- Event type
- 1
- Source
- 14
- Occupation code
- 999
- Human factor
- 1
- Environmental factor
- 15
- Task assigned
- 1
-
#3 Hospitalized Age 37 M
- Nature of injury
- 10
- Part of body
- 11
- Event type
- 6
- Source
- 42
- Occupation code
- 999
- Human factor
- 1
- Environmental factor
- 15
- Task assigned
- 1
-
#4 Hospitalized Age 50 M
- Nature of injury
- 4
- Part of body
- 9
- Event type
- 1
- Source
- 14
- Occupation code
- 999
- Human factor
- 1
- Environmental factor
- 5
- Task assigned
- 1
-
#5 Hospitalized Age 28 M
- Nature of injury
- 4
- Part of body
- 9
- Event type
- 1
- Source
- 14
- Occupation code
- 999
- Human factor
- 1
- Environmental factor
- 5
- Task assigned
- 1
-
#6 Hospitalized Age 35 M
- Nature of injury
- 4
- Part of body
- 9
- Event type
- 1
- Source
- 14
- Occupation code
- 999
- Human factor
- 1
- Environmental factor
- 5
- Task assigned
- 1
-
#7 Hospitalized Age 34 M
- Nature of injury
- 20
- Part of body
- 21
- Event type
- 1
- Source
- 28
- Occupation code
- 999
- Human factor
- 1
- Environmental factor
- 5
- Task assigned
- 1
-
#8 Hospitalized Age 32 M
- Nature of injury
- 4
- Part of body
- 3
- Event type
- 1
- Source
- 14
- Occupation code
- 999
- Human factor
- 1
- Environmental factor
- 5
- Task assigned
- 1
-
#9 Hospitalized Age 27 M
- Nature of injury
- 18
- Part of body
- 9
- Event type
- 1
- Source
- 14
- Occupation code
- 999
- Human factor
- 1
- Environmental factor
- 5
- 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.