At approximately 2:30 p.m. on April 1, 2010, Employee #1, Employee #2 (leadman) and Employee #3 were preparing product involving the use of fermented molasses as one of the ingredients. The workers were having problems moving the molasses from tank #2 to tank #1. According to the employer, he told Employee #2 via telephone, to add water to the molasses to bring it to a level where the container contents could be transferred to tank #1. Due to the low volume of fermented molasses in tank #2, Employee #1 entered and was descending a rope ladder into the storage tank to attempt to push the molasses through the piping into tank #1. While descending the ladder, Employee #1 fell or slipped off the ladder, falling to the bottom of the tank. Employee #2 heard Employee #1 fall and went on top of the tank to see what happened. Employee #2 called for assistance via 911, and then entered the tank to attempt to rescue Employee #1 when he collapsed, falling into the tank. Employee #3 heard Employee #2 drop into the tank and went to the top of the tank. Employee #3 began to enter the tank through the top, but stopped because he was not sure how he would get Employees #1 and #2 out through the manhole. Employee #3 climbed down off the tank and found an electric saw. Employee #3 cut a hole in the bottom side of the tank and entered the tank. While trying to pull one of the two Employees out, Employee #3 was overcome and passed out, falling to the outside of the tank.
Upon arrival, the Lawrence Fire Department and EMS began treatment of Employee #3 and transported him to hospital, where he was treated and released. The Lawrence Fire Department extracted Employee #1 and #2 from the tank and attempted to revive them. Employee #1 was taken to hospital and pronounced dead, and Employee #2 was pronounced dead at the scene.
The molasses tanks #1 and #2 measured approximately 14 feet in height, 120 inches in diameter, with domed tops, and single manhole measuring 21 inches in diameter. A rope ladder was used to enter/egress the interior of the tanks and was either attached to the top of the tank or the ceiling bracing of the structure. Access to the tanks from the outside was by ladder to the top of tank #1. The employees would then jump across to tank #2. There is no catwalk and insufficient space to access the top of tank #2 with a ladder.
During the investigation, oxygen levels in the molasses storage tank #2 was measured and found to be 9.9% while carbon dioxide levels were found to be between 56,977 and 97,932 parts per million. The employer did not have any equipment or devices to monitor the atmosphere in the tanks, and used a box fan to ventilate for an hour or two before entering into product tanks.
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Violation Summary
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|---|---|---|---|---|---|
| Serious | Willful | Repeat | Other | Total | |
| Initial Violations | 11 | 11 | |||
| Current Violations | 10 | 10 | |||
| Initial Penalty | $73,000 | $0 | $0 | $0 | $73,000 |
| Current Penalty | $63,000 | $0 | $0 | $0 | $63,000 |
| Violation Items | ||||||||
|---|---|---|---|---|---|---|---|---|
| ID | Type | Standard | Issuance | Abate | Curr$ | Init$ | Contest | Last Event |
| 01001 | Serious | 19100023 C01 | 07/16/2010 | 09/20/2011 | $4,500 | $5,000 | 08/10/2010 | F – Formal Settlement |
| 01002 | Serious | 19100024 B | 07/16/2010 | 09/01/2010 | $5,000 | $5,000 | 08/10/2010 | F – Formal Settlement |
| 01003 | Serious |
19100146 C02 – If the workplace contains permit spaces, the employer shall inform exposed employees, by posting danger signs or by any other equally effective means, of the existence and location of and the danger posed by the permit spaces. |
07/16/2010 | 09/20/2011 | $6,500 | $7,000 | 08/10/2010 | F – Formal Settlement |
| 01004 | Serious |
19100146 C04 – If the employer decides that its employees will enter permit spaces, the employer shall develop and implement a written permit space program that complies with this section. The written program shall be available for inspection by employees and their authorized representatives. |
07/16/2010 | 09/20/2011 | $6,500 | $7,000 | 08/10/2010 | F – Formal Settlement |
| 01005 | Serious | 19100146 D03 III – Isolating the permit space | 07/16/2010 | 09/20/2011 | $6,500 | $7,000 | 08/10/2010 | F – Formal Settlement |
| 01006 | Serious |
19100146 D05 I – Test conditions in the permit space to determine if acceptable entry conditions exist before entry is authorized to begin, except that, if isolation of the space is infeasible because the space is large or is part of a continuous system (such as a sewer), pre-entry testing shall be performed to the extent feasible before entry is authorized and, if entry is authorized, entry conditions shall be continuously monitored in the areas where authorized entrants are working; |
07/16/2010 | 09/20/2011 | $6,500 | $7,000 | 08/10/2010 | F – Formal Settlement |
| 01007 | Serious | 19100146 E01 –
Before entry is authorized, the employer shall document the completion of measures required by paragraph (d)(3) of this section by preparing an entry permit. |
07/16/2010 | 09/20/2011 | $6,500 | $7,000 | 08/10/2010 | F – Formal Settlement |
| 01008 | Serious |
19100146 G01 – The employer shall provide training so that all employees whose work is regulated by this section acquire the understanding, knowledge, and skills necessary for the safe performance of the duties assigned under this section. |
07/16/2010 | 09/20/2011 | $6,500 | $7,000 | 08/10/2010 | F – Formal Settlement |
| 01009 | Serious |
19101200 E01 – Employers shall develop, implement, and maintain at each workplace, a written hazard communication program which at least describes how the criteria specified in paragraphs (f), (g), and (h) of this section for labels and other forms of warning, safety data sheets, and employee information and training will be met, and which also includes the following: |
07/16/2010 | 09/20/2011 | $6,500 | $7,000 | 08/10/2010 | F – Formal Settlement |
| 01010 | Serious |
19101200 F05 – Chemical manufacturers, importers, or distributors shall ensure that each container of hazardous chemicals leaving the workplace is labeled, tagged, or marked in accordance with this section in a manner which does not conflict with the requirements of the Hazardous Materials Transportation Act (49 U.S.C. 1801 et seq.) and regulations issued under that Act by the Department of Transportation. |
07/16/2010 | 09/20/2011 | $6,500 | $7,000 | 08/10/2010 | F – Formal Settlement |
| 01011 | Serious |
19101200 H01 – Employers shall provide employees with effective information and training on hazardous chemicals in their work area at the time of their initial assignment, and whenever a new chemical hazard the employees have not previously been trained about is introduced into their work area. Information and training may be designed to cover categories of hazards (e.g., flammability, carcinogenicity) or specific chemicals. Chemical-specific information must always be available through labels and safety data sheets. |
07/16/2010 | 09/20/2011 | $6,500 | $7,000 | 08/10/2010 | F – Formal Settlement |

