Hazards of deluge foam systems and ignoring the pre-discharge alarm

At 1:30 p.m. on August 7, 2022, a 55-year-old production supervisor was working in his office when the deluge system pre-discharge alarm activated. Approximately 30 seconds after the audible alarm engaged, the foam generators activated and began dispensing 2.2% high-expansion foam. The employee attempted to exit his office to reach a safe point, but he was trapped in the foam. The employee was found unresponsive near one of the outer walls a few hours after the system released. The employee died as a result of asphyxia. An investigation could not determine why the suppression system was activated, as there was no fire at the facility.

29 CFR 1910.160(b)(4): General requirements. The employer shall provide effective safeguards to warn employees against entry into discharge areas where the atmosphere remains hazardous to employee safety or health. a) On or about August 7, 2022, safeguards were not provided to warn employees against entry into the fire suppression foam discharge areas, such as but not limited to, Hangar 1006, in that, employees who were located in the production supervisor’s office did not have an alternate exit out of the building other than through the area where the foam was being released.

29 CFR 1910.160(b)(5): General requirements. The employer shall post hazard warning or caution signs at the entrance to, and inside of, areas protected by fixed extinguishing systems which use agents in concentrations known to be hazardous to employee safety and health. a) On or about August 7, 2022, the employer had not posted warning signs at all entrances to, and inside of Hangar 1006A and 1006B to warn employees that the hangar was protected by a foam deluge fire suppression system, which when released could cause asphyxiation.

29 CFR 1910.1200(h)(2)(ii): Employee information and training. Information. Employees shall be informed of: Any operations in their work area where hazardous chemicals are present; a) On or about August 7, 2022, employees working in Hangar 1006 had not been informed of the hazards of the Buckeye High Expansion Foam 2.2% when released (asphyxiant), which was part of the fire suppression system.

29 CFR 1910.1200(h)(3)(ii): Employee information and training. Training. Employee training shall include at least: The physical, health, simple asphyxiation, combustible dust, and pyrophoric gas hazards, as well as hazards not otherwise classified, of the chemicals in the work area; a) On or about August 7, 2022, employees working in Hangar 1006 had not been trained on the physical, health and simple asphyxiation hazards of the Buckeye High Expansion foam 2.2% when released (asphyxiant), which was part of the fire suppression system.

29 CFR 1910.1200(h)(3)(iii): Employee information and training. Training. Employee training shall include at least: The measures employees can take to protect themselves from these hazards, including specific procedures the employer has implemented to protect employees from exposure to hazardous chemicals, such as appropriate work practices, emergency procedures, and personal protective equipment to be used; a) On or about August 7, 2022, employees working in Hangar 1006 had not been trained that the foam would release 30 seconds after the audible alarm sounded at a rate of 3 cubic feet every 60 seconds for 12 minutes and on appropriate work practices, emergency procedures and personnal protective equipment, such as but not limited to training on the foam abort buttons located next to the manual foam discharge modules and providing emergency escape respirators.

Source: https://www.osha.gov/ords/imis/accidentsearch.accident_detail?id=148589.015