105,313Records 71,083Employers 85,290Hospitalizations 27,770Amputations 2015-01-01 2025-10-31
Safety Incidents OSHA Severe Injury Reports · 2015–2025

OSHA Accident Investigation · Summary #14527659

BURN,FLAMMABLE VAPORS,HEATER,FIRE,EXPLOSION,GAS LEAK,PROPANE

Event
BURN,FLAMMABLE VAPORS,HEATER,FIRE,EXPLOSION,GAS LEAK,PROPANE
Linked inspection
No inspection record linked to this accident's victims.
Summary number
14527659
Report ID
419400

Event description

LEAKING PROPANE GAS EXPLODED; 6 EMPLOYEES BURNED

Investigation abstract

DIES AND PUNCHES AT THE ALUMINUM OGIVE (POINTED TOPS FOR 155 MM PROJECTILES) AND ORMALLY, BUT WAS SHUT DOWN PRIOR TO 8 AM TO ALLOW THE PUNCH TIP AT THE OGIVE (NO RTH) PRESS TO BE CHANGED. SHORTLY AFTER RESUMING PRODUCTION, AND AFTER FORMING T HE 138TH OGIVE, AN EXPLOSION OCCURRED. AFTERWARDS, AN INVESTIGATION TEAM FOUND T HAT THE TWO BALL VALVES WHICH CONTROL THE FLOW OF GASEOUS PROPANE TO THE LIGHTIN G WAND AT THE BASE (MIDDLE) PRESS WERE IN THE OPEN (ON) POSITION. APPARENTLY, PR OPANE LEAKED AT THE MIDDLE PRESS AND GOT MIXED IN SWIRLING AIR CURRENTS NEAR THE TOP OF THE PIT UNDER THE THREE ALUMINUM PRESSES. IT PROBABLY WAS CARRIED TOWARD THE NORTH (OGIVE) PRESS, WHERE IT WAS IGNITED. IT THEN FLASHED BACK SOUTH TOWAR D THE MIDDLE AND SOUTH PRESSES. SIX EMPLOYEES WERE INJURED. BASE FORGING PRESSES HAVE TO BE PREHEATED TO ABOUT 400 DEGREES FOR PROPER OPERA TION. STATIONARY PROPANE HEATERS HEAT THE DIES AND PORTABLE PROPANE "TIP" BURNER S HEAT THE PUNCH FOR ABOUT 2 HOURS PRIOR TO THE 7 AM PRODUCTION STARTUP. THE STA TIONARY DIE HEATER AT THE BASE (MIDDLE) PRESS WAS TURNED OFF PRIOR TO START-UP B ECAUSE OF EXCESSIVE SMOKE. THAT PROPANE HEATER WAS RELIT 30 MINUTES BEFORE START -UP BY ANOTHER EMPLOYEE, AS DIRECTED BY THE FOREMAN. EMPLOYEES IN THE VICINITY O F THESE TWO PRESSES RECALL A STRONG ODOR OF PROPANE BEFORE START-UP. THE PRESSES STRADDLE A 15 FOOT WIDE BY 35 FOOT LONG BY 15 FEET DEEP PIT. PRODUCTION BEGAN N

Victims (6)

  1. #1 Hospitalized Age 32 M

    Nature of injury
    5
    Part of body
    19
    Event type
    2
    Source
    35
    Occupation code
    999
    Human factor
    17
    Environmental factor
    7
    Hazardous substance
    2150
    Task assigned
    1

  2. #2 Hospitalized Age 29 M

    Nature of injury
    5
    Part of body
    19
    Event type
    2
    Source
    35
    Occupation code
    999
    Human factor
    17
    Environmental factor
    7
    Hazardous substance
    2150
    Task assigned
    1

  3. #3 Hospitalized Age 38 M

    Nature of injury
    5
    Part of body
    19
    Event type
    2
    Source
    35
    Occupation code
    999
    Human factor
    17
    Environmental factor
    7
    Hazardous substance
    2150
    Task assigned
    1

  4. #4 Hospitalized Age 37 M

    Nature of injury
    20
    Part of body
    3
    Event type
    2
    Source
    5
    Occupation code
    999
    Human factor
    17
    Environmental factor
    7
    Hazardous substance
    2150
    Task assigned
    1

  5. #5 Hospitalized Age 39 M

    Nature of injury
    5
    Part of body
    5
    Event type
    2
    Source
    35
    Occupation code
    999
    Human factor
    17
    Environmental factor
    7
    Hazardous substance
    2150
    Task assigned
    1

  6. #6 Hospitalized Age 32 M

    Nature of injury
    5
    Part of body
    19
    Event type
    2
    Source
    35
    Occupation code
    999
    Human factor
    4
    Environmental factor
    7
    Hazardous substance
    2150
    Task assigned
    1

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