At approximately 9:50 a.m. on October 24, 2012, Employees #1 and #2 were working as mechanical engineering technicians at a food cold storage facility. The two workers were troubleshooting a Hansen Technology Model AP08 Auto-Purger. The Auto-Purger removed non-condensable material from the refrigeration system. It was mounted on a wall inside the facility’s anhydrous ammonia compressor room. At the time of the accident, the unit was actively running and leaking liquid onto the floor. The liquid, which contained anhydrous ammonia, was corrosive.
Both employees were standing near the unit. Employee #2 was refitting a cap back onto a bubbler to stop a leak. He was using a wrench to tap the cap onto the pipe section. Within minutes, the bottom pipe section of the cylinder separated from the upper section, resulting in a liquid spray that contacted the eyes, face, and body of both employees. Employees #1 and #2 sustained corneal burns. Employee #1 needed surgery as a result of this injury.
Causal factors to this accident were the failure to maintain the Auto-Purger to the manufacturer’s design specifications, and a clogged drainage pipe leading to a pressure build up in the system. Additionally, the employer did not ensure that employees were using adequate eye and face protection.
Cal OSHA Citations:
5189 J04 C – The employer shall assure that maintenance materials, spare parts and equipment, meet design specifications and applicable codes.
3314 C – Repair Work and Setting-Up Operations
Prime movers, equipment, or power-driven machines equipped with lockable controls or readily adaptable to lockable controls shall be locked out or positively sealed in the “off” position during repair work and setting-up operations. Machines, equipment, or prime movers not equipped with lockable controls or readily adaptable to lockable controls shall be considered in compliance with Section 3314 when positive means are taken, such as de-energizing or disconnecting the equipment from its source of power, or other action which will effectively prevent the equipment, prime mover or machine from inadvertent movement or release of stored energy. In all cases, accident prevention signs or tags or both shall be placed on the controls of the equipment, machines and prime movers during repair work and setting-up operations.
3382 A – Employees working in locations where there is a risk of receiving eye injuries such as punctures, abrasions, contusions, or burns as a result of contact with flying particles, hazardous substances, projections or injurious light rays which are inherent in the work or environment, shall be safeguarded by means of face or eye protection. Suitable screens or shields isolating the hazardous exposure may be considered adequate safeguarding for nearby employees.
342 A – Every employer shall report immediately by telephone or telegraph to the nearest District Office of the Division of Occupational Safety and Health any serious injury or illness, or death, of an employee occurring in a place of employment or in connection with any employment.
Immediately means as soon as practically possible but not longer than 8 hours after the employer knows or with diligent inquiry would have known of the death or serious injury or illness. If the employer can demonstrate that exigent circumstances exist, the time frame for the report may be made no longer than 24 hours after the incident. Serious injury or illness is defined in section 330(h), Title 8, California Administrative Code.
5189 E02 A – The hazard analysis shall address:
The hazards of the process;