Another tragic ending to a “Line Break” gone bad. This one involved opening a flange on a steam line in an attempt to “bleed off” the steam by loosening flange bolts. IT DID NOT GO AS PLANNED, and two workers perished with 70% burns!
At 6:52 p.m. on August 10, 2020, two (2) employees (30) and a coworker were attempting to remove a blockage from a hydrolyzer. The employees and coworker did not lock out or isolate the stored energy and were unable to release the steam from the pressure vessel.
Employee #1, a senior maintenance worker, decided to open a flange positioned at the bottom of the pressure vessel to release the steam. As Employee #1 slowly loosened the bolts, steam was released, causing the employees and coworker to jump away from the escaping steam to prevent burns. This steam release continued for approximately ten minutes, after which Employee #1 decided to take a break to cool down and let the area clear of steam. Employee #1 instructed Employee #2 and the coworker to take a break as well.
While Employee #1 was taking his break, Employee #2, a maintenance technician, decided to assist in removing the flange and began repeating the process that Employee #1 had used to release the steam. When Employee #1 returned, he noticed Employee #2 performing the same method of steam removal that he had been doing and scolded Employee #2 for not following his directions.
During the course of the argument, both Employee #1 and Employee #2 were loosening the bolts, and suddenly the flange cover broke free, releasing high-pressure steam and engulfing the employees.
The coworkers on site attempted to render first aid, and 911 was called for emergency services. Employee #1 and Employee #2 were transported to the hospital and admitted to the burn center.
Employee #1 and Employee #2 sustained steam burns to over 70 percent of their body and died on August 14, 2020, as a result of their injuries.
| Violations/Penalties | Serious | Willful | Repeat | Other | Unclass | Total |
|---|---|---|---|---|---|---|
| Initial Violations | 1 | 1 | ||||
| Current Violations | 1 | 1 | ||||
| Initial Penalty | $0 | $0 | $75,092 | $0 | $0 | $75,092 |
| Current Penalty | $0 | $0 | $75,092 | $0 | $0 | $75,092 |
| FTA Penalty | $0 | $0 | $0 | $0 | $0 | $0 |
| # | Citation ID | Citaton Type | Standard Cited | Issuance Date | Abatement Due Date | Current Penalty | Initial Penalty | FTA Penalty | Contest | Latest Event | Note |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. | 01001A | Repeat | 19100147 C04 II | 02/09/2021 | 04/15/2021 | $75,092 | $75,092 | $0 | 03/03/2021 | J – ALJ Decision | |
| 2. | 01001B | Repeat | 19100147 C04 II B | 02/09/2021 | 04/15/2021 | $0 | $0 | $0 | 03/03/2021 | J – ALJ Decision |
29 CFR 1910.147(c)(4)(ii): The procedures shall clearly and specifically outline the scope, purpose, authorization, rules, and techniques to be utilized for the control of hazardous energy, and the means to enforce compliance including, but not limited to, the following:
a) On or about August 10, 2020 at the Hydrolyzer processing area, employees removing a clog were exposed to a serious burn hazard from trapped steam and condensation, in that the procedures did not clearly and specifically address appropriate lockout, tagout procedures for steam trapped in hydrolyzer during clog removal.
The business was previously cited for a violation of this occupational safety and health standard or its equivalent standard 29 CFR 1910.147(c)(4)(ii), which was contained in OSHA inspection number 1471984, citation number 1, item number 1a, and was affirmed as a final order on 06-18-2020.
29 CFR 1910.147(c)(4)(ii)(B): The energy control procedures did not clearly and specifically outline the steps for shutting down, isolating, blocking and securing machines or equipment to control hazardous energy.
a) On or about August 10, 2020 at the Hydrolyzer processing area, employees removing a flange on a clogged hydrolyzer vessel were exposed to a serious burn hazard from trapped steam and condensation that was not isolated, blocked and secured.
The business was previously cited for a violation of this occupational safety and health standard or its equivalent standard 29 CFR 1910.147(c)(4)(ii)(B), which was contained in OSHA inspection number 1471984, citation number 1, item number 1b and was affirmed as a final order on 06-18-2020.
Source: https://www.osha.gov/ords/imis/establishment.inspection_detail?id=1488133.015