At approximately 8:45 a.m. on March 4, 1986, Employee #1, at a cannery, attempted to remove chlorine gas cylinders from a distribution point located beneath a stairwell. Eight of the cylinders were mostly full and simply in storage. The system had not been used for five (5) years. One 150-lb cylinder was still connected to a gas chlorinator regulator and the manifold.
While Employee #2 was removing a loose cylinder to another area, Employee #1 attempted to remove the connected cylinder. When Employee #1 could not turn the cylinder valve with the wrench, he assumed it had been closed years ago when the systems were shut down. He did NOT observe the indicator on the chlorinator, which should have shown that there was still pressure on the unit. When Employee #1 loosened the single bolt on the chlorinator, there was an immediate full flow of chlorine gas, which spread quickly into a production area on the first and second floors.
In addition to Employees #1 and #2, Employees #3-#10 were exposed either while attempting to stem the flow of gas or in passing through the gas cloud as they exited. No respiratory protection was used by any of the employees involved.
All ten employees were hospitalized.
| Violations/Penalties | Serious | Willful | Repeat | Other | Total |
|---|---|---|---|---|---|
| Initial Violations | 2 | 4 | 6 | ||
| Current Violations | 2 | 4 | 6 | ||
| Initial Penalty | $740 | $0 | $0 | $0 | $740 |
| Current Penalty | $740 | $0 | $0 | $0 | $740 |
| # | Citation ID | Citaton Type | Standard | Issuance Date | Abatement Due Date | Current Penalty | Initial Penalty | Contest |
|---|---|---|---|---|---|---|---|---|
| 1. | 01001A | Serious | 19100134 A02 | 03/28/1986 | 05/30/1986 | $560 | $560 | |
| 2. | 01001B | Serious | 19100134 B01 | 03/28/1986 | 05/30/1986 | $0 | $0 | |
| 3. | 01001C | Serious | 19100134 B03 | 03/28/1986 | 04/30/1986 | $0 | $0 | |
| 4. | 01001D | Serious | 19100134 B07 | 03/28/1986 | 04/15/1986 | $0 | $0 | |
| 5. | 01001E | Serious | 19100134 B09 | 03/28/1986 | 05/30/1986 | $0 | $0 | |
| 6. | 01001F | Serious | 19100134 B10 | 03/28/1986 | 04/30/1986 | $0 | $0 | |
| 7. | 01001G | Serious | 19100134 B11 | 03/28/1986 | 04/15/1986 | $0 | $0 | |
| 8. | 01001H | Serious | 19100134 E03 | 03/28/1986 | 04/15/1986 | $0 | $0 | |
| 9. | 01002 | Serious | 19100212 A01 | 03/28/1986 | 05/12/1986 | $180 | $180 | |
| 10. | 02001 | Other | 19100023 C01 | 03/28/1986 | 04/14/1986 | $0 | $0 | |
| 11. | 02002 | Other | 19100178 Q07 | 03/28/1986 | 04/30/1986 | $0 | $0 | |
| 12. | 02003 | Other | 19100212 A01 | 03/28/1986 | 04/14/1986 | $0 | $0 | |
| 13. | 02004 | Other | 19100219 D01 | 03/28/1986 | 04/14/1986 | $0 | $0 |
Source: https://www.osha.gov/ords/imis/establishment.inspection_detail?id=101059558