OSHA Accident Investigation · Summary #691220
BURN,FURNACE,LEAK,FLAMMABLE VAPORS,INADEQUATE MAINT,PIPE
Event description
Employee burned by vapor cloud
Investigation abstract
Employee #1 and a coworker, both operators in the tcc and alkylation control roo m, saw a vapor cloud forming around a broken and leaky 1 in. pipe (swedge nipple ). They ran to the alky furnace, which was 50 ft away from the leaky pipe, to sh ut the furnace down, thereby eliminating an ignition source. The coworker went t o one side of the furnace, while Employee #1 went to the other side toward the f ront. The vapor cloud moved to the area around the furnace, engulfed Employee #1 , ignited, flashed, and burned. He was hospitalized. The employees were followin g the refinery's emergency procedures, which required them to eliminate sources of ignition first, then eliminate the source of the vapors.
Victim
-
#1 Hospitalized Age 29 M
- Nature of injury
- 5
- Part of body
- 4
- Event type
- 14
- Source
- 16
- Occupation code
- 699
- 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.