OSHA Accident Investigation · Summary #14449680
KOCH OIL REFINING COMPANY
PINE BEND, MN·
Event description
EMPLOYEE FELL FROM FIXED LADDER ONTO ANOTHER EMPLOYEE
Investigation abstract
AT APPROXIMATELY 9:30 AM ON SEPTEMBER 13, 1986, EMPLOYEE #1 WAS PERFORMING A FLA N TO COLLAPSE, HE FOLDED OVER INSIDE THE CAGE AND THEN FELL APPROXIMATELY 25 FEE T THROUGH THE CAGE, LANDING HEAD FIRST ON TOP OF EMPLOYEE #2, WHO WAS STANDING A T THE BASE OF THE LADDER ON A LANDING APPROXIMATELY 17 1/2 FEET ABOVE GROUND LEV EL. EMPLOYEE #1 SUSTAINED A SKULL FRACTURE, FOR WHICH HE WAS HOSPITALIZED. EMPLO YEE #2 SUSTAINED A BRUISED LEFT HIP AND FRACTURED LEFT THUMB. HE WAS TREATED AT THE HOSPITAL EMERGENCY ROOM AND RELEASED. NGE BLINDING OPERATION ON A PIPE CONNECTED TO A COKER FRACTIONATOR TOWER. THE TO WER HAD PREVIOUSLY BEEN PURGED WITH STEAM. THE PIPE WAS LOCATED APPROXIMATELY 47 FEET ABOVE GROUND LEVEL. EMPLOYEE #1 WAS WORKING FROM A LANDING AT THE LEVEL OF THE PIPE. WHEN THE FLANGE WAS OPENED, OIL, STEAM AND GAS ESCAPED FROM THE FLANG E OPENING. EMPLOYEE #1 AND ANOTHER EMPLOYEE CONTINUED TO INSTALL THE BLIND. A WI TNESS AT GROUND LEVEL OBSERVED EMPLOYEE #1 STAND UP, SLOWLY WALK APPROXIMATELY 7 FEET TO THE GATE AT THE DESCENDING CAGED LADDER, OPEN THE GATE, STEP OUT TO THE LADDER, TAKE 2 TO 4 STEPS DOWN, STOP, LOOK TO HIS LEFT AND COLLAPSE. AS HE BEGA
Victims (2)
-
#1 Hospitalized Age 37 M
- Nature of injury
- 12
- Part of body
- 13
- Event type
- 5
- Source
- 9
- Occupation code
- 539
- Human factor
- 1
- Environmental factor
- 7
- Task assigned
- 1
-
#2 Hospitalized Age 57 M
- Nature of injury
- 3
- Part of body
- 14
- Event type
- 1
- Source
- 34
- Occupation code
- 864
- Human factor
- 14
- Environmental factor
- 6
- 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.