OSHA Accident Investigation · Summary #779355
HI-SHEAR TECHNOLOGY CORP
SPARKS, NV·
Event description
Employees burned in chemical fire
Investigation abstract
Employees #1 and #2 were adding ammonium perchlorate into a mixer that was mixin ve; nor was there a proper sieve available for use within the room. Also, the st andard operating procedure is to have a mixing employee and supervisor in the mi xing room and another employee in the remote operating station or bunker watchin g a TV monitor to react to any emergency situation, but the remote station was n ot staffed. Further contributing factors which may have influenced this accident include the fact that the employees were adding 2 1/2 micron sized ammonium per chlorine to the mix, causing the humidifier to malfunction. The humidity therefo re dropped down to approximately 5 percent (normal humidity at 75 degrees is bet ween 30 percent and 70 percent) and on-site weather station recorded an abrupt w eather change at approximately the same time as the accident. In addition to the g a batch of solid propellant. A flash fire occurred, causing multiple burns to humidity changes, the wind picked up and a sudden temperature change took place . Employees #1 and #2 stated in a interview that they saw the ammonium perchlora te cling to the sides of the mixer when they were attempting to add it to the ba tch. This should have been a red flag to the employees that a static charge was present, but they were unable to recognize the hazard due to their lack of train ing. Employee #2 and arm burns to Employee #1. They were both hospitalized. Both empl oyees were in on-the-job training and were supposed to be supervised at all time s during any mixing operation. The supervisor had left prior to the mixing opera tion and did not return. The lack of a supervisor and inadequate hazard communic ation resulted in the following violations: non-conductive shoes were worn in a conductive shoe area; the sieve that was used was not provided with a bonding st rap, which would have allowed a bond to form between the mixing unit and the sie
Victims (2)
-
#1 Hospitalized Age 35 M
- Nature of injury
- 5
- Part of body
- 2
- Event type
- 14
- Source
- 14
- Occupation code
- 519
- Human factor
- 18
- Environmental factor
- 10
- Hazardous substance
- 8880
- Task assigned
- 2
-
#2 Hospitalized Age 30 F
- Nature of injury
- 5
- Part of body
- 19
- Event type
- 14
- Source
- 14
- Occupation code
- 224
- Human factor
- 18
- Environmental factor
- 10
- Hazardous substance
- 8880
- Task assigned
- 2
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