OSHA Accident Investigation · Summary #14401913
OXYGEN DEFICIENCY,AIR LINE RESPIRATOR,ASPHYXIATED,WORK RULES,SANDBLASTING,CONFINED SPACE,NITROGEN
Event description
EMPLOYEE BREATHED NITROGEN SUPPLIED BY AIR LINE RESPIRATOR
Investigation abstract
A PETROCHEMICAL REFINERY WAS UNDERGOING TURNAROUND. A CONTRACTOR CREW HAD BEEN A ED THE SANDBLAST RESPIRATOR HOOD ON HIS HEAD AND BEGAN SANDBLASTING. HE WAS ASPH YXIATED WITHIN FIVE MINUTE'S TIME. ATTEMPTS TO REVIVE EMPLOYEE # WITH OXYGEN FAI LED. SSIGNED THE JOB OF SANDBLASTING THE INSIDE SURFACES OF A REACTOR VESSEL (CONFINE D SPACE). ALTHOUGH UNWRITTEN COMPANY POLICY CALLED FOR THE USE OF AIR COMPRESSOR S FOR SUPPLYING RESPIRATOR AIR, THIS CREW, WITH THE SUPERVISOR'S KNOWLEDGE, HAD PREVIOUSLY USED PLANT AIR TO SUPPLY BREATHING AIR. THE CREW MISTAKENLY HOOKED UP AN AIR FILTER TO AN UNLABELED NITROGEN LINE (ONLY THE SHUTOFF VALVE WAS LABELED ) USED BY THE REFINEREY FOR PURGING CONFINED SPACES. PLANT NITROGEN LINES AND AI R LINES WERE IDENTICAL AND BOTH HAVE CROW'S FOOT COUPLINGS COMPATIBLE WITH THE C OUPLING ON THE AIR FILTER. EMPLOYEE #1 CLIMBED TO THE BOTTOM OF THE VESSEL, PLAC
Victims (2)
-
#1 Fatality Age 56 M
- Nature of injury
- 2
- Part of body
- 28
- Event type
- 8
- Source
- 19
- Occupation code
- 599
- Human factor
- 6
- Environmental factor
- 7
- Hazardous substance
- 1900
- 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
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.