OSHA Accident Investigation · Summary #848648
RESPIRATORY,HYDROCHLORIC ACID,UNCONSCIOUSNESS,CONFINED SPACE,SODIUM CYANIDE,WORK RULES,INHALATION,TANK CLEANING,UNTRAINED,SLUDGE
Event description
EMPLOYEE KILLED BY CYANIDE EXPOSURE DURING TANK CLEANING
Investigation abstract
ON FEBRUARY 5, 1988 A PLATING TANK CONTAINING ABOUT 800 GALLONS OF SODIUM CYANID EE #1 WAS FOUND LYING, UNCONSCIOUS, ON THE BOTTOM OF THE TANK. UPON ARRIVING AT THE HOSPITAL, HE WAS FOUND TO HAVE A BLOOD CYANIDE LEVEL OF 1.6 MG/L. EMPLOYEE # 1 WAS ESSENTIALLY "BRAIN DEAD." LIFE SUPPORT WAS DISCONTINUED ON FEBRUARY 9, 198 8. NO AMYL NITRATE WAS AVAILABLE AT THE PLANT FOR EMERGENCY TREATMENT. THERE WAS NO HAZARD COMMUNICATION TRAINING, NO TANK LABELING, NO PROCEDURES FOR CONDUCTIN G CLEANING OPERATIONS, INADEQUATE PERSONAL PROTECTIVE EQUIPMENT, ETC. E SOLUTION WAS BEING DRAINED SO THAT THE ANODE BARS COULD BE CLEANED AND THE TAN K REFILLED WITH A ZINC PLATING SOLUTION. AFTER BEING EMPTIED, THE TANK WAS REFIL LED WITH WATER TO DILUTE THE REMAINING SODIUM CYANIDE AND SLUDGE. ON FEBRUARY 6 THE CLEANING OPERATION WAS CONTINUED AND THE TANK AGAIN DRAINED. THE TANK CONTAI NED APPROXIMATELY 4 TO 6 INCHES OF WATER AND "SLUDGE." EMPLOYEE #1, A PLATER, WA S ASSIGNED TO CLEAN THE ANODE BARS. HE SUPPOSEDLY USED A SOLUTION OF WATER AND S ODIUM HYDROXIDE FOR CLEANING, BUT ANOTHER EMPLOYEE STATED THAT EMPLOYEE #1 HAD A CTUALLY OBTAINED SOME HYDROCHLORIC ACID FROM A COMPLETELY UNLABELED TANK. EMPLOY
Victim
-
#1 Fatality Age 41 M
- Nature of injury
- 2
- Part of body
- 4
- Event type
- 8
- Source
- 19
- Occupation code
- 999
- Human factor
- 18
- Environmental factor
- 9
- Hazardous substance
- 1440
- Task assigned
- 1
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.