OSHA Accident Investigation · Summary #14464226
RESPIRATORY,TOXIC ATMOSPHERE,INHALATION,VALVE,PHOSGENE,RUPTURE,GAS LEAK
Event description
EXPOSURE TO PHOSGENE GAS
Investigation abstract
AT APPROXIMATELY 4 PM ON AUGUST 20, 1985, A PRESSURE BUILDUP IN THE REACTOR IN B #2 DROVE A VEHICLE THROUGH THE PHOSGENE CLOUD AND THEN ALONG THE EAST SIDE OF BU ILDING 14 TO ANOTHER PART OF THE PLANT. EMPLOYEES #3 AND #4 WERE LOCATED ALONG T HE EAST SIDE OF BUILDING 14, CLEANING A SEWER LINE. EMPLOYEE #5 WAS LOCATED AT T HE SOUTH DOCK OF BUILDING 14, PUTTING HIS TOOLS AWAY AND QUITTING WORK FOR THE D AY. ALL FIVE EMPLOYEES WERE KEPT OVERNIGHT AT THE PLANT'S MEDICAL FACILITY AND O BSERVED BY THE PLANT'S PHYSICIAN. THE FIVE EMPLOYEES SUSTAINED NO INJURIES OR IL LNESSES AS A RESULT OF THEIR EXPOSURE TO PHOSGENE GAS. UILDING NUMBER 14 CAUSED A SAFETY VALVE TO RUPTURE. THE REACTOR, WHICH CONTAINED BISPHENOL A (BPA) AND PHOSGENE GAS, VENTED THROUGHT THE SAFETY VALVE AND INTO L INES LEADING TO AN EMERGENCY SCRUBBER. THE PHOSGENE GAS LEAKED AROUND SOME LOOSE BOLTS IN A FLANGE ON THE LINE LEADING TO THE SCRUBBER. CONTRACTOR PERSONNEL WHO HAD WORKED ON THE LINE A FEW WEEKS AGO HAD NOT ADEQUATELY TIGHTENED THE FLANGE BOLTS. FIVE EMPLOYEES WERE EXPOSED TO THE LEAKING PHOSGENE GAS. EMPLOYEE #1 WAS ON HIS WAY TO BUILDING 45 TO QUIT WORK FOR THE DAY. HE WAS PROCEEDING ALONG THE EAST SIDE OF BUILDING 14 TO WARN OTHER EMPLOYEES TO EVACUATE THE AREA. EMPLOYEE
Victims (5)
-
#1 Hospitalized Age 38 M
- Nature of injury
- 17
- Part of body
- 28
- Event type
- 8
- Source
- 9
- Occupation code
- 216
- Human factor
- 14
- Environmental factor
- 15
- Hazardous substance
- 2070
- Task assigned
- 1
-
#2 Hospitalized Age 28 M
- Nature of injury
- 17
- Part of body
- 28
- Event type
- 8
- Source
- 9
- Occupation code
- 57
- Human factor
- 14
- Environmental factor
- 15
- Hazardous substance
- 2070
- Task assigned
- 1
-
#3 Hospitalized Age 29 M
- Nature of injury
- 17
- Part of body
- 28
- Event type
- 8
- Source
- 9
- Occupation code
- 453
- Human factor
- 14
- Environmental factor
- 15
- Hazardous substance
- 2070
- Task assigned
- 1
-
#4 Hospitalized Age 35 M
- Nature of injury
- 17
- Part of body
- 28
- Event type
- 8
- Source
- 9
- Occupation code
- 453
- Human factor
- 14
- Environmental factor
- 15
- Hazardous substance
- 2070
- Task assigned
- 1
-
#5 Hospitalized Age 51 M
- Nature of injury
- 17
- Part of body
- 28
- Event type
- 8
- Source
- 9
- Occupation code
- 453
- Human factor
- 14
- Environmental factor
- 15
- Hazardous substance
- 2070
- 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.