EH-9401 Issue No. 1, January 1994 Occupational Safety Observer
JANUARY 1994
Occupational Safety Observer
The descriptions of the incidents included in this compendium are
based on information available at the time of publication.
Articles regarding DOE incidents are drawn from Occurrence
Reporting and Processing System (ORPS) reports, accident
investigation reports, and interviews with site personnel.
DOE 5483.1A, dated June 1983, requires DOE compliance with the
OSHA regulations listed.
If you would like more information about an article, or would
like to submit an article, please contact the coordinating editor
at:
Operations Management Division
(EH-321)
U.S. Department of Energy
Telephone: (301) 903-5516
A style sheet for authors is available on request.
If you would like to receive the Observer in the mail, please
contact:
John Everett
Fax: (206) 528-3552
Telephone: (206) 528-3246
Feel free to reprint articles from the Observer Ä
all we ask is that you give us credit in the reprint.
* Printed on recycled paper *
Cyanide Poisoning Kills Worker:
COMPANY OFFICIALS SENTENCED
The final ruling has been handed down in a case involving
the tragic death of a worker at an Illinois factory. Having had
an earlier murder conviction overturned, the three defendants in
the case pled guilty to manslaughter in the death of a
61-year-old worker. Two of the three defendants were sentenced
to prison terms.
The incident
In February 1983, an incident occurred in which a factory
worker (a Polish immigrant) collapsed and died after inhaling
cyanide vapors. Between three and four dozen employees, mostly
undocumented Mexican immigrants, routinely worked over a large
vat containing a 2-percent cyanide solution. Many of these
workers did not speak English, and several had complained of
dizziness, nausea, vomiting, and fainting--all of which are
common symptoms of cyanide poisoning.
The factory where these workers were employed used cyanide
to extract silver from x-ray and photographic film. The workers
were never informed that they were working with cyanide or that
toxic vapors were being created. They worked in an area where
ventilation was almost nonexistent: a prosecuting attorney
likened the workplace to "huge gas chamber." These workers had
never received any kind of safety training, and their personal
protective equipment consisted solely of cloth gloves and paper
masks that provided no protection from the vapors.
Workers at the factory had complained about the situation
for almost 15 months before the incident occurred. The
prosecution observed that management had exhibited a flagrant
disregard for safety. Workers who complained about the symptoms
they experienced were told to "go out and get some fresh air":
if they didn't like the conditions, they could work elsewhere.
The defendants, an executive and two managers of the
facility, were convicted of murder in 1985. Each was fined
$10,000 and sentenced to 25 years in prison. These convictions
were overturned in 1990. In September 1993, before a retrial
could occur, the defendants pled guilty to the lesser charge of
manslaughter.
Lessons learned
Workers at DOE sites will never work under conditions where
management so blatantly disregards regulations protecting their
health and safety. Nevertheless, this incident offers several
lessons learned related to basic policy for safety in the
workplace, personal protective equipment, hazard recognition
(especially when obvious language barriers exist), and personnel
training.
-- Section 5(a)(1) of the Occupational Safety and Health (OSH)
Act of 1970 requires that employers "furnish a workplace free of
hazards that are likely to cause death or serious injury." This
basic requirement has been expanded and refined since the law was
passed, forcing management to strive continuously to maintain
safe working conditions. Communication barriers and lack of
worker literacy, as evidenced in this event, should not prevent
employees from being provided with a safe workplace.
-- Management must take effective action to resolve hazards in
the workplace. Whenever possible, these hazards should be
eliminated. Risks from hazards that cannot be eliminated should
be minimized through engineered safety systems or through
administrative controls.
-- Protective clothing and equipment must be consistent with
the hazards specific to each activity. Workers must constantly
be on the alert for changing conditions that could necessitate
the use of a different type or level of protection.
-- Workers must be aware of the specific hazards related to
their work activities. Ignorance of the consequences of misusing
dangerous chemicals and substances will be of little comfort
should a tragedy occur.
-- Appropriate training must be provided at all personnel
levels. Such training will allow workers to make better
judgments about changing hazards in the workplace. Informed
workers are the first line of defense against injuries and
fatalities.
Final note
The OSH Act does not preempt State or local laws in the
prosecution of employers who knowingly endanger their workers.
In this instance, State law enforcement agencies decided to
prosecute, and the Illinois Supreme Court recognized their right
to do so. At present, however, only a few States allow this type
of action for accidents in which death or serious injuries occur.
The Comprehensive Occupational Safety and Health Reform Act,
introduced into the U.S. House of Representatives and Senate in
March 1993, would codify the States' ability to conduct criminal
prosecutions for violations of the OSH Act at any facility under
their jurisdiction. In addition, this legislation could bring
DOE operations and facilities under the review of other Federal
agencies, including OSHA.
Pipe failure:
ACID LINE BREAKS--WORKER BURNED
In October 1993, workers at Savannah River Site were
transferring sulfuric acid from a 1,000-gallon storage tank to a
100-gallon "day tank" when a 1-inch transfer line failed. The
failure caused sulfuric acid to be sprayed about 60 feet from the
origin of the leak. A worker walking through the area was
sprayed by the acid mist and received second-degree burns on his
back. After being washed down in a safety shower by fellow
workers, he was taken to a medical facility for treatment.
The investigation
The bulk storage tank, which contained a 93-percent solution
of sulfuric acid, was connected to two tanks, the day tank and an
acid regeneration tank (also called the "dilute" tank), by 1-inch
carbon steel lines. The valve in the line connecting the bulk
storage tank and the dilute tank was located near the dilute
tank. The acid spray was caused by a failure in the line where
it was connected to the valve.
The procedure for transferring acid from the bulk tank to
the day tank requires that the valve at the dilute tank be closed
and that a transfer pump be used to facilitate the transfer of
acid from the bulk tank to the day tank. When the accident
occurred, the valve at the dilute tank was closed and the
transfer pump had been started. The pump built up pressure in
the pipe, causing the mist of acid that sprayed the back of a
nearby worker, who did not realize what had happened until the
acid penetrated his clothing and burned his skin.
An inspection indicated that the failed line was constructed
of carbon steel and appeared to be a Schedule 40 pipe, although
the engineering drawings specified use of Schedule 160 pipe,
which is approximately twice as thick. In addition, it was known
that the flow of acid through the line normally reduces the
thickness of the pipe wall by about 20 mils per year.
The section of line that failed had been replaced
approximately 10 years ago. As soon as the leak was discovered
and the transfer pump shut down, the area was barricaded and
thoroughly washed. All piping was subsequently inspected using
nondestructive evaluation (NDE) techniques, and pipes of
insufficient thickness were replaced.
Lessons learned
This incident provides several lessons learned related to
configuration control and the handling of corrosive materials:
-- Whenever system components are replaced or repaired,
engineering documents must be checked to ensure that the right
materials are used. Engineering documents (especially drawings)
must be carefully managed to ensure that they are kept
up-to-date. However, specifying the correct materials and
components for maintenance and repairs is not enough. Followup
must be conducted to ensure that the entire process is performed
correctly: appropriate replacement items must be ordered,
inspected on receipt, adequately documented in work orders,
installed, and functionally tested.
-- Management must ensure that all hazardous materials and
processes are identified and that procedures are developed and
implemented to ensure safety. A preventive maintenance program,
including a replacement schedule or thorough NDE testing, should
be established to replace components exposed to corrosive
materials.
-- Implementation of 29 CFR 1910.119 requirements related to
mechanical integrity, procedures, and training should have
prevented the use of incorrect schedule piping. Although this
standard applies to facilities with quantities of hazardous
material above certain thresholds, these recommended practices
will prevent accidents even when applied to facilities that are
not covered by the standard.
Reference
SR--WSRC-POD-1993-0036
Enhancing Worker Safety:
TEXACO'S IMPROVED SAFETY PROGRAM
Improved labor-management relations at Texaco's Port Arthur
Chemical Plant have significantly enhanced worker safety and
productivity. Local management's strong commitment to safety and
increased worker involvement in Port Arthur's Safety Program have
proven to be a winning combination.
Teamwork emphasized
This new approach to safety was initiated in 1985, when a
downturn in the American economy resulted in significant layoffs
at the Port Arthur Chemical Plant. At that time, local union
representatives from the International Brotherhood of Electrical
Workers presented management with the concept of using workers to
identify and resolve problems in the field, which in turn would
reduce operating costs and increase overall profitability. The
goal of the new program was to address the long-term needs of
corporate profitability and job security for workers, while
strengthening the corresponding short-term need for safety in the
workplace. Proponents of the new program believed that workers
in the field were closest to the problem and would be best suited
to develop practical solutions for safety hazards. Safety teams
subsequently toured the plant twice a month, identifying and
resolving safety problems.
In addition, Port Arthur employees have become more involved
in the accident investigation process. Before the safety program
was enhanced, only management personnel participated in accident
investigations. Now, a union representative from the work area
in which an accident occurs is routinely assigned to assist the
investigation. This practice was introduced to facilitate
identifying ways to prevent recurrences.
An example of how this process works can be illustrated by
the Port Arthur Chemical Plant's response to a recent
confined-space fatality. The accident occurred when a contractor
employee entered a tank being purged with nitrogen and was
asphyxiated. The victim entered the tank despite warning
placards and the existence of well-established confined-space
entry procedures. In response to this tragedy, Port Arthur
workers developed a special safety net to cover entry hatchways
and thereby prevent inadvertent access. Use of the net has been
included in a revision of Texaco's confined-space entry
procedure. The new device was developed by modifying a shrimp
net used by local watermen.
According to W.A. "Buddy" Elmore, Committee Chairperson for
the International Brotherhood of Electrical Workers, the Texaco
Port Arthur Chemical Plant has always been a "productive plant,"
but workers also wanted a "safe plant." Development of the
worker safety teams has been a means of attaining the dual goals
of profitability and worker safety, and the new program has set
the stage for Port Arthur to achieve "Star" status under the OSHA
Voluntary Protection Program.
Workers who helped develop the new safety net have
demonstrated its use at several conferences and seminars across
the country, including the DOE Safety Conference held in Chicago
on October 6-8, 1993.
Lessons learned
The safety program used at the Port Arthur Chemical Plant
illustrates how the combined efforts of management and labor can
create the potential for innovative and effective solutions to
workplace problems. Managers should always be on the lookout for
opportunities to use personnel resources more effectively. As
this program confirms, such an approach increases worker
ownership and buy-in on changes needed to improve workplace
safety.
Prompt Response:
TRAINING PAYS OFF IN MEDICAL EMERGENCY
The appropriate emphasis of any good safety program must be
on preventing incidents and accidents. Prudent safety managers
implement training and procedures for coping with credible
incidents. This article describes an incident in which training
on emergency procedures resulted in a nearly flawless response to
a medical emergency.
The incident
On September 21, 1993, a worker at the Colonie Interim
Storage Site near Albany, New York (one of 44 sites included in
the Formerly Utilized Sites Remedial Action Program, or FUSRAP),
was performing maintenance inside an industrial metal shredder
used to reduce the volume of contaminated metal wastes.
The job involved replacing the shredder's grinding teeth--a
routine, but physically demanding, procedure. The work had been
properly authorized, and appropriate lockout/tagout procedures
had been followed. Because the work was being performed in an
area contaminated with low-level radioactive waste, site
procedures required (1) that the worker wear personal protective
clothing and a respirator and (2) that he be accompanied by
another worker.
For no obvious reason, the worker performing this task
suddenly collapsed. The other worker promptly used a two-way
radio to notify the site supervisor that his buddy was "down."
On receiving this information, the supervisor immediately
requested emergency medical support from the emergency response
unit in the local community.
The radio was tuned to a commonly used frequency, and many
workers overheard the call. One of these was an on-duty
certified first aid responder, who immediately rushed to the
scene of the emergency. (The duty first aid responder would have
been subsequently called over the radio; however, because she
heard the initial call, she was able to respond even more
quickly.) She found the downed worker complaining of chest pains
and displaying symptoms associated with heart attack. After
evaluating the downed worker, the first aid responder determined
that the victim was stable enough to be moved. She then directed
several other workers who had arrived on the scene to get a
stretcher from the nearest medical aid station, and together they
moved the downed worker to the nearest access control point.
At the access point, the rescue party quickly removed the
victim's protective clothing and equipment and took him to a less
contaminated area. The first aid responder continued tending to
the worker, while health physicists scanned him for radiological
contamination and verified that he could be transported as a
noncontaminated patient. Emergency vehicles arrived at the site
just as the health physicists finished their scan. The worker
was turned over to emergency medical technicians and was
subsequently transported to an area hospital via ambulance. An
observer at the scene estimated that no more than 15 minutes had
passed from the time the worker collapsed until he was en route
to the hospital.
Results of the investigation
It was determined at the hospital that the worker was
suffering from an acute case of bronchitis, which reduces the
lungs' ability to transfer oxygen to the blood and makes
breathing difficult. The strenuous nature of the task being
performed, plus the additional restriction on breathing imposed
by his protective clothing and the full-face respirator, caused
the worker to faint.
The worker had been experiencing flu-like symptoms but
because of his strong work ethic he continued to report to work.
Both the worker and his supervisor were fully trained and
qualified in respiratory protection requirements. However,
neither individual had fully assessed the impact of the worker's
impaired physical condition on his ability to perform strenuous
tasks. The worker either did not recognize or did not
acknowledge the severity of his illness and the supervisor
remained unaware of the worker's condition.
Lessons learned
Managers of all good safety programs recognize the need to
anticipate that incidents and accidents will occur, and workers
are trained to respond effectively. In this instance, excellent
personnel training, prior planning by management, and regular
exercises involving emergency responders from the surrounding
community facilitated a "textbook" response. As this incident
suggests, existing emergency response training must be
periodically reviewed to ensure that site personnel are prepared
to deal with the unexpected. In this case, a sound knowledge of
first aid and emergency response procedures made significant
contributions to a successful rescue operation. Managers would
be wise to regularly review all routine training programs (e.g.,
respirator training) for adequacy.
Management is also responsible for ensuring the
fitness-for-duty of its work force and for maintaining an
awareness of the physical and mental health of workers. In
addition, management should ensure that the workplace environment
fosters the two-way communication necessary to recognize when
workers are at risk.
Managers should ensure that workers understand the potential
consequences of working when their health is impaired. In this
instance, the worker ignored the seriousness of his illness and
failed to request relief from a strenuous assignment. Although
his intentions were noteworthy, his decision to "tough out" his
illness resulted in a significant work disruption and caused him
to spend a night in the hospital.
Reference
ORO--BNI-FUSRAPCISS-1993-0001
FEATURE ARTICLE
Personnel at the Advanced Photon Source (APS) at Argonne
National Laboratory-East have recently instituted a new safety
effort aimed at encouraging workers to take the initiative for
ensuring their own safety.
In a memo to all APS personnel, the Associate Laboratory
Director for the APS Project, David E. Moncton, asked every APS
employee to "conduct a Personal Safety Assessment and make a
commitment to work safely." Using the principles of total
quality management, APS's efforts are driven by a strong
management commitment to worker safety. As Dr. Moncton stated in
his memo, "No work is so important that it need be done without
due consideration for safety."
The safety envelope
At the core of the APS effort is the concept of a safety
envelope. This innovative approach was designed to define the
predetermined individual limits within which workers can function
safely. It is not acceptable for an APS employee to work beyond
his or her safety envelope--even when requested to do so by
management.
APS management recognizes that only the individual worker
can define his or her safety envelope. Accordingly, Dr.
Moncton's memo asked each of APS's 450 employees to perform a
personal safety assessment that would define his or her safety
envelope. APS management supports workers in this effort by
providing assistance from supervisors and safety professionals at
general and focus-group meetings.
To complete the personal safety assessment, each worker must
answer the questions shown in the diagram on the facing page.
This assessment is conducted informally; in fact, handwritten
responses to questions are encouraged.
In addition to having workers identify hazards, plus the
training and policies that protect them from those hazards,
workers are asked how they communicate their safety concerns.
APS management recognizes that safety is often an issue of
communication: workers must communicate the existence of safety
hazards to management so that appropriate actions can be taken,
and management must communicate to workers that safety is
important.
Enthusiastic response
According to Richard Hislop, Environment, Safety, and Health
Program Manager for the APS, reaction to the program has been
very positive, although there was some early resistance by
first-line management. Mr. Hislop acknowledged that supervisors
initially complained that they already had too much to do and
that the new program was just another burden on their time.
After meeting with their workers, however, many supervisors
were convinced that the safety envelope effort was useful.
Workers made many suggestions that supervisors believed would not
have been offered had the meetings not occurred. For ex-ample,
one worker suggested putting emergency interrupt buttons on power
supplies to disengage power quickly in the event of an emergency.
Another suggested providing wet/dry shop vacuums to clean up
water spills, and a third worker suggested standing down 1 hour
early on Fridays to do housekeeping so that workers would return
to a clean job site on Monday mornings.
Mr. Hislop reports that personnel safety awareness has
increased at APS. His office has received several calls from
site personnel identifying various safety deficiencies, including
slippery stairs, low volume on public address systems, and the
need for specific types of safety training.
In an effort to follow up on the personal safety
assessments, APS management provides each employee who takes the
time to list specific safety concerns with a personalized reply.
In addition, all training recommendations have been forwarded to
the Argonne National Laboratory training section. Finally, group
meetings are being held to establish safety goals for 1994.
Lessons learned
APS's efforts offer the DOE complex positive evidence about
the importance of worker participation in the safety culture:
-- Management commitment is a prerequisite to an effective
safety initiative, especially in an interactive program.
-- Worker input is an important part of any effective safety
effort. By asking workers to consider safety, managers tapped
into a valuable resource. Workers can be the "eyes and ears" of
a safety program. Moreover, they are likely to know where many
hazards are and what must be done to eliminate them.
-- Management must provide followup to ensure that corrective
actions are implemented and that the emphasis on safety is not
temporary.
Have You Moved?
We're always trying to keep our mailing list current. If
your address has changed, or you would like to be added to or
deleted from our mailing list, please let us know. You can reach
our circulation department by sending a fax to John Everett at
(206) 528-3552 or by leaving a message on John's voice mail at
(206) 528-3246.