EH-9410 October 1994 Occupational Safety Observer
Occupational Safety Observer
October 1994
In This Issue
Scissors Lift Topples ............................................... 1
Are We Prepared? .................................................... 2
Falling Tiles Close Kingdom ......................................... 4
Wanted: Authors and Articles ....................................... 7
Close Call at St. James Terminal .................................... 7
SCBA Alert .......................................................... 8
Use the Right Equipment
Scissors Lift Topples
Two workers were recently injured when a scissors lift was used to support
an impromptu rigging arrangement. This accident highlights the need for
pre-job planning to ensure that equipment is used safely and appropriately.
The Accident
On July 16, 1994, two millwrights were disassembling high-bay storage
racks at DOE's Kansas City Plant. The millwrights were working from a
scissors lift about 19 feet above a concrete floor, and the racks consisted
of 24-foot-high vertical trusses connected by horizontal supports.
The millwrights had removed the horizontal supports from two vertical
trusses and were preparing to lower the top of the trusses to the ground.
A rope had been tied near the top of each truss, roughly 17 feet above the
ground, and both ropes ran over the railing of the scissors lift, which
served as a pulley. The millwrights planned to let the ropes out gradually,
lowering the tops of the trusses to the ground.
The combined weight of the trusses was 380 pounds. As the millwrights
lowered the trusses, the weight shifted from the bottom of the trusses to
the ropes and the railing of the scissors lift. Before the trusses reached
the ground, their weight caused the lift to topple. Both millwrights fell
to the ground with the lift.
Two co-workers at the scene immediately called for assistance.
Security and emergency response personnel arrived within minutes. The
millwrights were injured as a result of the fall, but they were conscious
and lucid. They were taken by ambulance to local hospitals, where their
injuries were diagnosed as multiple fractures of the arms and legs.
Lessons Learned
This accident shows how executing a poorly planned task can have
serious consequences. The removal of the trusses was part of a much larger
job. Pre-job planning had focused on the whole job, not on the particular
task that resulted in the millwrights' injuries. Detailed planning for this
task would have indicated that the railing of the scissors lift was not
appropriate for rigging the line to lower the trusses. A scissors lift
should only be used to lift personnel and equipment to elevated areas. The
trusses could have been moved by other hoisting and rigging equipment, such
as a crane or a block-and-tackle device secured to a permanent structure.
Reference
ALO-KC-AS-KCP-1994-0008
Chemical Exposure Kills 5
Are We Prepared?
At the request of Secretary Hazel R. O'Leary, the DOE Office of Environment,
Safety and Health has undertaken an ongoing review of chemical safety
weaknesses confronting the DOE complex. As the following incident
demonstrates, the consequences of a chemical accident can be tragic for an
unprepared work force.
On June 28, 1988, a worker inadvertently unleashed a deadly chemical
reaction. The accident led to the development of OSHA's revised confined-
space standard.
The Accident
The accident occurred at the Bastian Plating Company of Auburn,
Indiana, a small company making dyes and a chromate dip for electroplated
products. These products were treated in a series of open-topped tanks
located in a sub-basement, known as the zinc-plating room, which contained
two parallel rows of tanks separated by a grated walkway. A concrete
drainage pit lay beneath the walkway. Ventilation in the zinc-plating room
was provided by two ceiling exhaust fans; five windows and the door to the
room were closed at the time of the accident.
The last tank in the series, where the accident occurred, was used for
drying parts after they had been electroplated. The tank measured 5 x 4 x
5 feet. The parts were suspended above the tank, and excess zinc cyanide
solution dripped into the tank. Waste zinc cyanide was pumped from the tank
once each year.
On the day before the accident, an industrial cleaning and hauling
company pumped the waste from the tank, leaving a layer of zinc cyanide
sludge in the bottom. At 4:30 a.m. on June 28, the night shift leader began
preparations to clean the remaining sludge by spraying 1 or 2 gallons of
muriatic acid (hydrochloric acid) into the drying tank.
Investigators concluded that the night shift leader unknowingly
created hydrogen cyanide, a highly toxic compound, by combining muriatic
acid and zinc cyanide, two commonly used industrial chemicals. Hydrogen
cyanide acts to block absorption of oxygen by the lungs and can cause death.
After adding the muriatic acid, the night shift leader, who worked
alone and wore no respirator, climbed a ladder and descended into the tank.
He did not test or ventilate the tank before entering. After several
minutes, co-workers saw him struggling to climb out of the tank.
According to a worker in the room, "That's when I knew something was
wrong. He tried again and fell. He couldn't call for help. [Other
workers] were right there . . . and climbed in to help. They were in there
30 seconds--1 minute--1 1/2 minutes before they had problems." None of the
other workers in the room realized the nature of the hazard, and none had
appropriate protection.
Four other workers attempted to help and were quickly overcome. Two
were forced back by the vapors. The other two collapsed, one inside the
tank and the other with his head hanging over the edge of the tank.
The Emergency Response
No one called for outside help until about 30 minutes after the night
shift leader collapsed. The first police officer on the scene was unaware
of the danger and entered the zinc-plating room without wearing personal
protective equipment. He subsequently required hospitalization.
Firefighters arrived shortly thereafter, wearing standard turnout gear.
Because they were unaware that hydrogen cyanide was involved, none of the
emergency responders--neither firefighters nor police--were adequately
protected.
As a result of the chaotic accident scene, medical care for the
injured was unnecessarily delayed. The various agencies responding to the
emergency did not have clearly defined roles and responsibilities.
According the Auburn Fire Chief, who was in charge of the scene, "I didn't
know one guy from the next." The accident scene was not secured; survivors,
onlookers, and relatives of victims milled about; and anyone who entered the
building required medical treatment.
The Consequences
The accident was categorized as one of the worst industrial accidents
in Indiana history. All five workers who attempted to enter the tank died--
four at the scene and one in the hospital 2 day later. In addition to the
deaths, 30 persons were injured. Two other workers were hospitalized, and
10 were treated for hydrogen cyanide exposure and released. The first
police officer at the scene was hospitalized. Thirteen firefighters, three
more police officers, and a medical examiner were also treated and released.
Lessons Learned
Chemical Safety. Management must ensure that good chemical safety
practices are followed in the workplace.
o Chemicals must be clearly labeled. The Indiana Occupational
Safety and Health Administration attributed this accident to
"inadequate labeling." Labels must be legible and in English.
Warnings should be provided in other languages, as necessary.
o More emphasis must be placed on dangers that can result from
combining chemicals. Workers should be trained to recognize and
anticipate hazardous chemical reactions. For example, the
National Institute for Occupational Safety and Health (NIOSH)
warns against placing muriatic acid and zinc cyanide in close
proximity.
o Material safety data sheets required under OSHA's hazard
communication standard, 29 CFR 1910.1200(g), provide necessary
warnings as well as other important information on chemical
hazards.
Confined Spaces. Management must ensure that confined spaces are
clearly identified and that workers can perform tasks safely within these
areas.
o Workers must be trained to recognize confined spaces, and
management must take appropriate precautions to ensure that work
in performed safely. A NIOSH report on this accident indicates
that the tank was not recognized as a confined space. This
tragedy was a major factor leading to the revision of OSHA's
confined-space standard, 29 CFR 1910.146(b).
o A confined-space work plan must include a method or plan for
rescue. The safest methods for confined-space rescue do not
require that rescuers enter these hazardous areas. Body
harnesses, safety lines, and reliance on the buddy system can
prevent unnecessary risks.
Emergency Response. It is management's responsibility to ensure that
all personnel know what to do in the event of an emergency.
o Notify authorities immediately when an emergency occurs.
Workers or supervisors who are likely to witness or discover an
injured or collapsed co-worker should be trained to initiate an
emergency response sequence.
o Ensure that workers (first-responders at the operations level)
are trained to take appropriate actions and precautions. OSHA
requirements provided in 29 CFR 1910.120, "Hazardous Waste
Operations and Emergency Response," establishes guidelines for
required training levels for emergency responders. Sections 472
of the National Fire Protection Act also contains guidance for
firefighters involved in hazardous materials incidents.
o Ensure that all emergency response personnel are properly
trained. In this instance, emergency response crews were
initially unaware that hydrogen cyanide was involved. NIOSH
recommends that emergency responders develop a data base for
confined spaces and for toxic and explosive substances that
might be encountered in the areas they serve. (In this case, by
the time emergency responders learned that zinc cyanide and
acids were used at the plant, it was too late to prevent
exposure.) Title III of the Superfund Amendments and
Reauthorization Act of 1986 contains similar requirements.
Executive Order 12856, which was signed in 1993, extends the
requirements of Title III to many Federal facilities, including
DOE sites, although they are exempt from Title III enforcement
provisions.
o In an emergency, a pre-assigned incident commander has
responsibility for, and authority over, the entire scene.
Emergency response agencies should make arrangements in advance
for establishing jurisdiction over accident scenarios.
Jurisdictional decisions should be updated as necessary to
reflect the roles of all agencies likely to respond to an
emergency.
Conclusion
This accident could have been prevented if all parties involved had received
some basic safety training. Unfortunately, according to NIOSH, "any
training at the plant was on-the-job, with little emphasis on safety and
health." A proper training program would have (1) reinforced the importance
of proper labeling; (2) ensured that workers recognized the danger of mixing
muriatic acid and zinc cyanide, both of which were used at the plant; and
(3) enabled workers to recognize that the tank posed dangers as a confined
space. Proper training would also have benefited emergency responders.
Even without training, the accident could have been prevented through a
fundamental awareness about safety that would have led workers to be more
cautious about labeling and mixing chemicals. In the final analysis, this
accident can be attributed to the prevalence of a poor safety culture.
NIOSH summarized the Bastian Plating Company's approach to safety as
follows: "At the time of the incident the employer had no written safety
program, no plant emergency procedures, no ongoing safety training, no
confined-space entry procedures, and did not conduct safety meetings with
employees."
This accident occurred just as OSHA regulations concerning hazard
communications and confined-space entry were being written. The many
deficiencies at Bastian Plating are potential problems at every DOE site.
Ask yourself whether a similar situation could happen at your facility.
What would you do? Do you have the equipment and training? How would you
evaluate potential chemical hazards associated with a particular task? How
does your facility rate?
Work Platform Falls
Falling Tiles Close Kingdom
Seattle's sports stadium, the Kingdom, was recently closed for ceiling
repairs. The shutdown has been costly to King County, Washington, which
owns and operates the stadium. More important, two workers lost their lives
during the repair effort.
Falling Tiles
On July 19, 1994, the Seattle Mariners baseball team was warming up in
the Kingdom before an evening game against the Kansas City Royals. About 25
minutes before the Kingdom's doors were to open, four acoustic ceiling tiles
fell from the roof, hitting several empty seats. The tiles were constructed
of wood fiber, each measuring 3 x 4 feet and weighing 26 pounds. One tile
fell with sufficient force to break a seat. The Kingdom's ceiling is
covered with about 40,000 of these tiles. Because of the risk that other
tiles might fall, King County officials canceled the game and closed the
stadium.
To many, the situation was not a surprise. Over the past 18 years,
the Kingdom has had numerous problems related to falling tiles, a leaking
roof, and the attendant problems caused by water damage. Water damage to
the underside of the tiles were first observed only 3 months after the
Kingdom opened.
When the July 1994 incident occurred, King County officials faced the
inevitable expenses of around-the-clock work to replace the tiles; moreover,
the shutdown meant millions of dollars in lost revenue. The impact of
negative public opinion was also costly. County officials responded to this
unfortunate situation by being forthright with the public and stated that
the Kingdom would not be reopened until it was safety for occupancy.
The Fatal Accident
Inside the Kingdom, workers removing the tiles were using baskets
suspended from large cranes to reach much of the ceiling, which was 250 feet
above the floor. Once the tiles were removed, the ceiling was sandblasted
to remove an oily residue for the material used on the back of the tiles.
This work was conducted on an around-the-clock basis.
Around 8:00 p.m. on August 17, two workers entered a lift basket that
would be raised to the dome near its highest point. The crane operator
extended the crane's boom, lifting the workers in place near the ceiling, at
which point the lift basket fell. Because the crane boom was extended
vertically, the basket fell onto the crane's cab. The two workers in the
basket were killed instantly on impact, and the crane operator suffered cuts
and bruises.
Work was halted indefinitely, and an investigation began immediately.
King County officials emphasized that safety was their only concern. At a
press conference, King County executive Gary Locke said, "Two people have
died. I'm not concerned about the Mariners or the Seahawks or about an
opening game."
To date, investigators have released few details, saying only that the
crane's cable failed. It is not known whether this failure was a cause or
a consequence of the accident. According to a spokesman from the Washington
State Department of Labor and Industries, "On a preliminary basis, it
appears that . . . cable failure resulted in the [crane arm and basket]
collapsing. What we don't know is why the cable broke."
Speculation by workers about the cause of the accident emphasized wear
and tear on the cranes by the around-the-clock sandblasting. Specifically,
workers suggested that the pins holding the jib, a 116-foot extension of the
crane's boom, had failed because of the continuous vibration. One worker
said that "this crane [was] used to holding up all that weight, but cranes
aren't made for that kind of shaking that was going on with the
sandblasting." Dust was also a concern to crane operators, and vital parts
of the crane had been shrouded in plastic for protection. Tiles also struck
the cranes.
In addition, worker fatigue may have played a role in the tragedy; the
workers who were killed were working sever 12-hour shifts per week.
However, industry experts point out that many construction projects proceed
around the clock, and workers were accustomed to and often prefer the 12-
hour shifts. It should be noted, moreover, that the accident occurred at
the beginning of a shift, when worker fatigue is less likely.
External pressures may also have played a role. Kingdom management
was under intense financial and public pressure to finish the job quickly.
As of the OBSERVER's press time, however, there is no evidence of specific
safety violations. Further, before the accident occurred, the job was
inspected by the Department of Labor and Industries: "We were pleased with
what we saw. The contractor in there was responsible and was paying a lot
of attention to safety standards."
Lessons Learned
Because the results of the investigation have not yet been released,
it is too early to present conclusive lessons learned pertaining
specifically to the crane accident. The OBSERVER will publish a followup
when that information becomes available.
It is not too early, however, to apply some of the practical concerns
faced by Kingdom management to the DOE complex. As with the Kingdom,
accidents at DOE facilities are subject to intense public scrutiny--and
answers to difficult questions are not always available. In a potential
worst-case scenario (for example, an accident involving fatalities or
widespread environmental damage), management must deal with public pressure
and doubts, as well as with costly investigations and repairs. As Kingdom
official demonstrated, part of the focus of a healthy safety culture should
be on management's ability to deal honestly and openly with the difficult
questions when accidents occur.
Wanted: Authors and Articles
The articles you write, the topics you suggest, the questions you pose, and
your letters to the editor combine to make the OBSERVER a timely, relevant,
and informative newsletter.
Out staff values you contributions. This issue of the OBSERVER
includes an insert titled "Guidance for Content and Style" to assist those
readers who may wish to submit a manuscript. If you need further
assistance, contact a Coordinating Editor or John Everett at (206)528-3246.
Fall Protection Equipment
Close Call at St. James Terminal
On June 26, 1994, the St. James Terminal at the Strategic Petroleum Reserves
was shut down when a subcontractor employee was found working outside a
platform area over the Mississippi River without using the required fall
protection or a personal flotation device. The failure to use appropriate
personal protective equipment represented a condition of imminent danger and
violated OSHA regulations stipulated in 29 CFR 1926.106(a) and 29 CFR
1026.104(a). A field construction specialist intervened and directed the
worker to a safe location. The facility manager stopped work at the site
until a corrective action plan could be submitted, approved, and
implemented. The next day, all subcontractor personnel were retrained on
the importance and proper use of personal fall protection and flotation
equipment.
Although the St. James Terminal incident resulted only in a near-miss
occurrence, it could easily have ended in a serious injury or fatality.
Falls are a leading cause of traumatic death in the workplace. Fatal falls
from scaffolds during the period 1980 to 1985 accounted for 461 of 2,705
falls from elevations.
Beginning in 1971, OSHA implemented a series of regulations to protect
workers form this type of hazard. Nonetheless, falls continue to occur
because of failure to take appropriate precautions.
Lessons Learned
To prevent accidents, management must do more than post signs and
provide training on the use of fall protection and safety procedures. An
environment that actively nurtures an awareness of safety at all personnel
levels is also necessary. Such an environment will emphasize safety over
production, and workers will be able to recognize and question any
potentially unsafe instruction or action without fear of reprisal.
References
HQ--SPR-SJ-1994-0005
NIOSH ALERT #92-108
DOT-E 7325 4500 PSA Cylinders
SCBA Alert
The National Institute of Occupational Safety and Health (NIOSH) has issued
a report on a fatality that occurred when a compressed air cylinder in a
self-contained breathing apparatus (SCBA) exploded during recharging. Other
incidents have also occurred with the model DOT-E 7235 4500 PSI cylinder,
including leakage and explosions, because of metal fatigue in the neck area.
Since October 1985, NIOSH and the Department of Transportation have required
these cylinders to be retrofitted with a steel reinforcing ring. The 1993
fatality indicates that cylinders of this model, without proper
retrofitting, are still is use.
NIOSH required the following corrective actions:
(1) Immediately inspect all SCBA compressed air cylinders.
(2) Immediately removed from service any DOT-E 7235 4500 PSI
cylinder that does not have a steel reinforcing ring on the neck
area.
(3) Immediately remove from service any DOE-E 7235 4500 PSI
cylinders that have exceeded their 15-year service life. This
can be determined by the earliest date stamped on the neck of
the cylinder.
[NOTE: Hydrostatic (pressure) testing cannot extend the 15-year
service life.]
(4) Identify the last hydrostatic retest date stamped on the neck
and remove the cylinder from service, if the date is more than
3 years old.
(5) Provide documentation to demonstrate that these required steps
have been completed.