OSHA Accident Investigation · Summary #912550

KNAPE & VOGT MFG

GRAND RAPIDS, MI· 1989-04-13T00:00:00

Event: VENTILATION, IDLH, SODIUM CYANIDE, INHALATION, CHEMICAL REACTION, NITRIC ACID, CYANIDE, INATTENTION, RESPIRATOR
NAICS: 000000
Inspection type: Accident-driven
Activity number: #108051848
Employer profile: KNAPE & VOGT MFG
Summary number: 912550
Report ID: 552621

Event description

Eleven employees present during hydrogen cyanide release

Investigation abstract

At approximately 5:00 a.m. on April 13, 1989, Employee #2 accidentally added 5 t the hospital as a precautionary measure. They were evaluated by a doctor and rel eased from the hospital. Employees wearing full-face air line respirators then p roceeded to clean up the area by draining the contents of the tank into four 55 gallon drums. The plant was ventilated; HCN tests were negative; and the employe es were permitted back into the plant. o 9 gallons of concentrated nitric acid to a 200 gallon tank containing 14 to 16 oz of sodium cyanide at the barrel line. Employee #3, without wearing a respira tor or protective clothing, took a detector tube reading over the cyanide tank; the result showed an HCN level greater than 165 mg/m3, which is about three time s the IDLH level of 60 mg/m3. The only other employees near the HCN release were Employee #1 and Employees #4 through #11, who were approximately 70 ft away at a break area. They were told to evacuate the plant immediately. None of the elev en employees experienced any ill health affects, but all were told to report to

Victims (11)

#1 Non-hospitalized injury Age 43 Male

Nature of injury
Poisoning(Systemic) (17)

Part of body
LUNG (28)

Accident type
INHALATION (8)

Source of injury
GASES (19)

Occupation
Occupation not reported (999)

Human factor
OTHER (14)

Environmental factor
CHEMICAL ACTION/REACTION EXPOS (9)

Hazardous substance
1440

Task assigned
Task regularly assigned (1)
#10 Non-hospitalized injury Age 33 Male

Nature of injury
Poisoning(Systemic) (17)

Part of body
LUNG (28)

Accident type
INHALATION (8)

Source of injury
GASES (19)

Occupation
Occupation not reported (999)

Human factor
OTHER (14)

Environmental factor
CHEMICAL ACTION/REACTION EXPOS (9)

Hazardous substance
1440

Task assigned
Task regularly assigned (1)
#11 Non-hospitalized injury Age 40 Male

Nature of injury
Poisoning(Systemic) (17)

Part of body
LUNG (28)

Accident type
INHALATION (8)

Source of injury
GASES (19)

Occupation
Occupation not reported (999)

Human factor
OTHER (14)

Environmental factor
CHEMICAL ACTION/REACTION EXPOS (9)

Hazardous substance
1440

Task assigned
Task regularly assigned (1)
#2 Non-hospitalized injury Age 30 Male

Nature of injury
Poisoning(Systemic) (17)

Part of body
LUNG (28)

Accident type
INHALATION (8)

Source of injury
GASES (19)

Occupation
Occupation not reported (999)

Human factor
OTHER (14)

Environmental factor
CHEMICAL ACTION/REACTION EXPOS (9)

Hazardous substance
1440

Task assigned
Task regularly assigned (1)
#3 Non-hospitalized injury Age 49 Male

Nature of injury
Poisoning(Systemic) (17)

Part of body
LUNG (28)

Accident type
INHALATION (8)

Source of injury
GASES (19)

Occupation
Occupation not reported (999)

Human factor
OTHER (14)

Environmental factor
CHEMICAL ACTION/REACTION EXPOS (9)

Hazardous substance
1440

Task assigned
Task regularly assigned (1)
#4 Non-hospitalized injury Age 26 Male

Nature of injury
Poisoning(Systemic) (17)

Part of body
LUNG (28)

Accident type
INHALATION (8)

Source of injury
GASES (19)

Occupation
Occupation not reported (999)

Human factor
OTHER (14)

Environmental factor
CHEMICAL ACTION/REACTION EXPOS (9)

Hazardous substance
1440

Task assigned
Task regularly assigned (1)
#5 Non-hospitalized injury Age 27 Male

Nature of injury
Poisoning(Systemic) (17)

Part of body
LUNG (28)

Accident type
INHALATION (8)

Source of injury
GASES (19)

Occupation
Occupation not reported (999)

Human factor
OTHER (14)

Environmental factor
CHEMICAL ACTION/REACTION EXPOS (9)

Hazardous substance
1440

Task assigned
Task regularly assigned (1)
#6 Non-hospitalized injury Age 39 Male

Nature of injury
Poisoning(Systemic) (17)

Part of body
LUNG (28)

Accident type
INHALATION (8)

Source of injury
GASES (19)

Occupation
Occupation not reported (999)

Human factor
OTHER (14)

Environmental factor
CHEMICAL ACTION/REACTION EXPOS (9)

Hazardous substance
1440

Task assigned
Task regularly assigned (1)
#7 Non-hospitalized injury Age 33 Male

Nature of injury
Poisoning(Systemic) (17)

Part of body
LUNG (28)

Accident type
INHALATION (8)

Source of injury
GASES (19)

Occupation
Occupation not reported (999)

Human factor
OTHER (14)

Environmental factor
CHEMICAL ACTION/REACTION EXPOS (9)

Hazardous substance
1440

Task assigned
Task regularly assigned (1)
#8 Non-hospitalized injury Age 34 Male

Nature of injury
Poisoning(Systemic) (17)

Part of body
LUNG (28)

Accident type
INHALATION (8)

Source of injury
CHEM LIQUIDS/VAPORS (9)

Occupation
Occupation not reported (999)

Human factor
OTHER (14)

Environmental factor
CHEMICAL ACTION/REACTION EXPOS (9)

Hazardous substance
1440

Task assigned
Task regularly assigned (1)
#9 Non-hospitalized injury Age 28 Male

Nature of injury
Poisoning(Systemic) (17)

Part of body
LUNG (28)

Accident type
INHALATION (8)

Source of injury
GASES (19)

Occupation
Occupation not reported (999)

Human factor
OTHER (14)

Environmental factor
CHEMICAL ACTION/REACTION EXPOS (9)

Hazardous substance
1440

Task assigned
Task regularly assigned (1)

Labels are OSHA's own, from the code dictionary published with the accident-investigation file. The raw code is shown beside each one so this page can be reconciled against OSHA's bulk data. OSHA notes that nature of injury, part of body, source of injury and accident type in this file are not coded to the Occupational Injury and Illness Classification System, and that the occupation titles are not standardised — so these values are not directly comparable with the OIICS-coded severe injury reports.