Another PRCS double-fatality, with 2 would-be rescuers (O2 Deficiency and CO2)

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. 

Violation Summary
  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

 

CASE FILE

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