OSHA Accident Investigation · Summary #673590
FURNACE,LEAK,MAINTENANCE,FLAMMABLE VAPORS,WORK RULES,EXPLOSION,GAS LEAK,UNTRAINED
Event description
GAS EXPLOSION IN REFORMER FURNACE
Investigation abstract
EMPLOYEES #1 THROUGH #6 WERE PREPARING A LARGE REFORMER FURNACE FOR FIRING UP. T HE FURNACE HAD BEEN SHUT DOWN FOR ABOUT 5 MONTHS. BECAUSE THERE WAS A LACK OF CO MMUNICATION BETWEEN THE WORKERS, AND BECAUSE SOME OF THE EMPLOYEES WERE NOT FAMI LIAR WITH THE FURNACE OPERATOR'S MANUAL, THE FURNACE WAS LIT WHILE 10 MANUALLY O PERATED GAS VALVES WERE OPEN. THE FLAME IGNITED THE GAS WHICH HAD BUILT UP IN TH E FURNACE, CAUSING AN EXPLOSION. THE PROPER PROCEDURE IS TO OPEN THE VALVE ON EA CH BURNER, AND LIGHT EACH BURNER, SEPARATELY. ALSO, A FIVE MINUTE PRESSURE TEST IS CALLED FOR TO DETECT ANY LEAKS IN THE SYSTEM. THE EXPLOSION PROBABLY WOULD HA VE BEEN PREVENTED IF THE PRESSURE TEST HAD BEEN RUN.
Victims (2)
-
#1 Fatality Age 42 M
- Nature of injury
- 6
- Part of body
- 13
- Event type
- 6
- Source
- 8
- Occupation code
- 699
- Human factor
- 1
- Environmental factor
- 7
- Hazardous substance
- 1640
- Task assigned
- 2
-
#2 Hospitalized Age 44 M
- Nature of injury
- 12
- Part of body
- 5
- Event type
- 6
- Source
- 42
- Occupation code
- 699
- Human factor
- 1
- Environmental factor
- 7
- Hazardous substance
- 1640
- 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.