OSHA Accident Investigation · Summary #511055
BURN,LUNG,FLAMMABLE VAPORS,EXPLOSIVE MIXING,CLEANING,FIRE,TORSO,FACE,UNTRAINED
Event description
FLASH FIRE AT EXPLOSIVES MANUFACTURING PLANT
Investigation abstract
AT 10 AM ON MAY 19, 1986, EMPLOYEES #1 THROUGH #3 WERE USING WATER AND ACETONE T EMPLOYEE'S WORK PLATFORM AND FOR THE WALLS OF THE PROCESS BUILDING. THE EMPLOYEE S WERE GIVEN NO FORMAL TRAINING ON THE HAZARDS OF THE CHEMICALS THEY WERE USING. EMPLOYEE #1 DIED 29 DAYS LATER AND EMPLOYEE #2 DIED 5 DAYS LATER. THEY WERE BUR NED OVER 88% OF THEIR BODIES, ESPECIALLY THE FACE, UPPER TRUNK, AND EXTREMITIES, AND EXPERIENCED RENAL FAILURE AND EDEMA OF THE LUNGS. EMPLOYEE #3 ALSO EXPERIEN CED EXTENSIVE BURNS BUT SURVIVED, AND WAS RELEASED FROM THE HOSPITAL 2 MONTHS LA TER ON AN OUTPATIENT BASIS. O CLEAN A SIMPSON MULLER-MIXER. THE MIXER CONTAINED LESS THAN 10 POUNDS OF RESID UE FROM A MAGNESIUM-TEFRON-FLUOREL-ACETONE MIXTURE. THEY WERE LOCATED IN THE PRO CESS BUILDING AT A REMOTE LOCATION. A FLASH FIRE OCCURRED, APPARENTLY WHEN FLAMM ABLE VAPORS WERE IGNITED BY STATIC ELECTRICITY. THE EMPLOYEE'S SHIFT HAD STARTED AT 7 AM. AT 8 AM, IN ACCORDANCE WITH COMPANY POLICY, THEY BEGAN THE SHUT-DOWN P ROCESS BECAUSE OF HIGH WINDS AND 20% HUMIDITY. AT 8:30 THEY WERE ORDERED TO STOP THE BATCH PROCESS AND CLEAN UP. THERE WAS NO MONITORING OF FLAMMABLE VAPORS AT THE PROCESS BUILDING. COMBUSTIBLE MATERIAL WAS USED FOR THE CONSTRUCTION OF THE
Victims (3)
-
#1 Fatality Age 19 M
- Nature of injury
- 5
- Part of body
- 4
- Event type
- 12
- Source
- 16
- Occupation code
- 999
- Human factor
- 17
- Environmental factor
- 10
- Hazardous substance
- 0040
- Task assigned
- 1
-
#2 Fatality Age 36 M
- Nature of injury
- 5
- Part of body
- 4
- Event type
- 12
- Source
- 16
- Occupation code
- 999
- Human factor
- 20
- Environmental factor
- 10
- Hazardous substance
- 0040
- Task assigned
- 1
-
#3 Hospitalized Age 36 M
- Nature of injury
- 5
- Part of body
- 4
- Event type
- 14
- Source
- 16
- Occupation code
- 999
- Human factor
- 4
- Environmental factor
- 10
- Hazardous substance
- 0040
- 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.