OSHA Accident Investigation · Summary #14473672

BURN,VAPOR,GAS,EXPLOSION,PRESSURE RELEASE

1989-09-12T00:00:00

Event: BURN,VAPOR,GAS,EXPLOSION,PRESSURE RELEASE
Linked inspection: No inspection record linked to this accident's victims.
Summary number: 14473672
Report ID: 521400

Event description

EMPLOYEES KILLED AFTER INHALING SUPERHEATED VAPORS

Investigation abstract

Employees responded to a flammable gas or vapor leak during start up of an ethyl ued for control room ventilation problems. ene unit. The leak was isolated and by-passed. Liquid ethylene carried over from the "refluxdrom" into piping and a heat exchange. The depressurization and low temperature caused a brittlement of the exchanger. When a normal pressure was es tablished the heat exchanger ruptured and sprayed liquid ethylene vapor, which i mmediately ignited. Two of the employees died due to internal injuries. The othe rs received burns on most of their bodies. A citation was issued for deficient s tart up production operation. Another was issued for a deficient pressure vessel and power piping inspection and maintenance program. The third citation was iss

Victims (10)

#1 Fatality Age 43 F

Nature of injury
21

Part of body
19

Event type
1

Source
35

Occupation code
999

Human factor
14

Environmental factor
10

Task assigned
2
#10 Hospitalized Age 41 M

Nature of injury
5

Part of body
19

Event type
1

Source
35

Occupation code
999

Human factor
14

Environmental factor
10

Task assigned
2
#2 Fatality Age 40 M

Nature of injury
21

Part of body
19

Event type
1

Source
35

Occupation code
999

Human factor
14

Environmental factor
10

Task assigned
2
#3 Hospitalized Age 32 M

Nature of injury
5

Part of body
19

Event type
1

Source
35

Occupation code
999

Human factor
14

Environmental factor
10

Task assigned
2
#4 Hospitalized Age 34 M

Nature of injury
5

Part of body
19

Event type
1

Source
35

Occupation code
999

Human factor
14

Environmental factor
10

Task assigned
2
#5 Hospitalized Age 29 M

Nature of injury
5

Part of body
19

Event type
1

Source
35

Occupation code
999

Human factor
14

Environmental factor
10

Task assigned
2
#6 Hospitalized Age 34 M

Nature of injury
5

Part of body
19

Event type
1

Source
35

Occupation code
999

Human factor
14

Environmental factor
10

Task assigned
2
#7 Hospitalized Age 46 M

Nature of injury
5

Part of body
19

Event type
1

Source
35

Occupation code
999

Human factor
14

Environmental factor
10

Task assigned
2
#8 Hospitalized Age 32 M

Nature of injury
5

Part of body
19

Event type
1

Source
35

Occupation code
999

Human factor
14

Environmental factor
10

Task assigned
2
#9 Hospitalized Age 30 M

Nature of injury
5

Part of body
19

Event type
1

Source
35

Occupation code
999

Human factor
14

Environmental factor
10

Task assigned
2

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.