Maintenance Mechanic Dies After Being Burned by Hot Boric Acid Solution While Removing Pump

Details

• Personal Author:
  Clark, Randy ; Rappin, Christina ; Schoonover, Todd
• Corporate Authors:
  Washington (State). Fatality Assessment and Control Evaluation (WA FACE) ; Washington (State). Department of Labor and Industries ; Washington (State). Safety and Health Assessment and Research for Prevention
• Description:
  In July 2012, a 64-year-old maintenance mechanic at an aluminum foil processing facility died after being exposed to an approximately 180-degree Fahrenheit solution of boric acid and water while trying to remove a recirculation pump from its housing. The pump was part of a boric acid evaporation system. Workers believed that the system had been completely drained. As the victim and other workers used two 1.5-ton "come-along" puller devices to free the pump from its housing, a small amount of hot water/boric acid solution fanned out from around the seal. Seconds later, the force of the solution pushed the pump out of the housing, and hundreds of gallons of hot liquid flowed out. The victim fell to the floor and was covered with the solution. He was wearing no personal protective equipment other than safety glasses, and received severe burns to over 80% of his body. Some of the workers were able to get him to an emergency shower and began removing his soaked clothing, while others called 911. Emergency responders arrived within fifteen minutes and the victim was airlifted to a burn trauma unit. He died two days later due to his injuries. RECOMMENDATIONS - Washington State Fatality Assessment and Control Evaluation investigators concluded that to protect employees from similar exposure hazards, employers should: 1. Design new equipment for manufacturing processes using the concept of Prevention through Design (PtD) to control risks by incorporating prevention methods in the final product. 2. Enforce a comprehensive written hazardous energy control program. Train all potentially exposed workers in the hazardous energy control procedures for the system, and document training. 3. Develop written standard procedures for regular maintenance operations. These should include information about hazards, required PPE, necessary safety checks, lockout/tagout procedures, and coordination with other workgroups to be done prior to beginning the task. Ensure that all workers performing maintenance tasks are trained on the procedures. 4. Ensure that workers who may be exposed to hot liquids are provided with and use the proper personal protective equipment (PPE) for the job, including appropriate eye/face, hand, and body protection. CONTRIBUTING FACTORS: 1. Incomplete draining of the evaporation system before pump removal. 2. No method to identify the potential for solution to remain in the system after standard draining procedures were conducted. 3. No way to adequately determine the level and temperature of solution left in system. 4. No method to estimate the time need for cooling of the system to a safe level. 5. No mechanism to lock out the pump from other stored energy, such as solution under pressure. 6. The pump was located directly behind the heat exchange support column, leading to limited access and egress for workers during pump maintenance. 7. Not wearing appropriate personal protective equipment.
• Subjects:
  Accident Prevention Accidents Accidents, Occupational Acids Aluminum Compounds Burns Hazardous Substances Manufacturing And Industrial Facilities Men Mortality Occupational Health Personal Protective Equipment Risk Assessment Safety Staff Development

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• Keywords:
  Accident Analysis Accident Prevention Acid Drainage Aluminum Chemical Burns Chemical Hazards Emergency Egress Equipment Design Equipment Maintenance Fatalities Force Hazard Communication Hazard Identification Hazardous Materials Hazard Recognition Humans Injury Prevention Lockout Tagout Manufacturing Mechanics OSHA Region 10 Personal Protective Equipment PPE Protective Measures Pumps Risk Management Safety Practices Safety Programs Temperature Regulation Training Traumatic Injuries Work Practices

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• FACE - NIOSH and State:
  FACE ; Other ; Prevention through Design (PtD)
• Series:
  Fatality Assessment and Control Evaluation Reports (FACE)
• Subseries:
  State
• DOI:
  https://doi.org/10.26616/NIOSHSFACE18WA052
• Publisher:
  National Institute for Occupational Safety and Health
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Field Study
• Place as Subject:
  Washington ; OSHA Region 10
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  1-12
• NIOSHTIC Number:
  nn:20053106
• Citation:
  Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 18WA052, 2018 Jul ; :1-12
• CAS Registry Number:
  Boracic acid (CAS RN 10043-35-3)
• Federal Fiscal Year:
  2018
• Performing Organization:
  Washington State Department of Labor and Industries
• Peer Reviewed:
  False
• NAICS and SIC Codes:
  31-33 - Manufacturing - (NAICS)
• Start Date:
  2005/07/01
• End Date:
  2021/06/30
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:ebeb8370fb7f47c2f06e79fb481619a394a39d6f0444803f31a2a1df615c028053aaed3de8498eda76ccdd5cc99fc6267ba51fa3e6790e90d2a2837109c91382
• Download URL:
  https://stacks.cdc.gov/view/cdc/164960/cdc_164960_DS1.pdf
• File Type:
  [PDF - 1.21 MB ]