OSHA Accident Investigation · Summary #14412878
BURN,REACTOR,FIRE,EXPLOSION,HIGH PRESSURE,HIGH TEMPERATURE
Event description
Employee killed when reactor heater explodes
Investigation abstract
At 6:00 a.m. on August 31, 1986, Employee #1, the chief operator of unit #1944, reset the pressure, and looked inside the heater before calling the controller t o inform her that the fire in the heater looked fine. About 45 minutes later, th e temperature indicating control for unit #168 showed a drop of approximately 30 degrees F. The controller alerted the second operator that the temperature was dropping and that the gas valves were opening in an attempt to bring the tempera ture back up. By this time the valves on the temperature indicating control for units #168 and #147 were about 75 to 85 percent open, but their temperature read ings were still dropping. The controller also told the second operator that two coworkers had reported smoke coming out of the stack. The control operator then began to cut back on the temperature, 10 degrees at a time, trying to close the arrived at work. At the start of the shift, all employees were informed that the valves and put less gas into the heater. Before the valves could be closed, howe ver, a heater exploded. Employee #1, who was at the heater checking out the prob lem, received second- and third-degree burns over 50 percent of his body. He die d on December 7, 1986. day would be spent sweeping the reactor (circulating hot hydrogen through the s ystem). They were instructed to maintain the sweeping process and to keep the hy drogen temperature near 400 degrees F. At approximately 12:00 noon the pressure began to build up in the system, and at about 1:00 p.m. the control board operat or received an alarm that the pressure indicating control for unit #139 was high . The control was set for 50 lb, but was showing 80 lb. The controller informed the second operator about the condition. The second operator went over to D-11,
Victim
-
#1 Fatality Age 56 M
- Nature of injury
- 5
- Part of body
- 19
- Event type
- 2
- Source
- 16
- Occupation code
- 999
- Human factor
- 4
- 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.