Inspection Detail

Inspection: 101433647 - Oklahoma City Air Logistics Center

Inspection Information - Office: Oklahoma City Area Office

Investigation Summary

Employees #1 and #2 were attempting to unjam the 100017 conveyor's carrier in a two-story freon vapor degreaser. Their efforts to move the jammed conveyor up and down allowed the conveyor chain to slacken. When the chain was raised, the connecting hook rolled out so only the jammed parts' containers held up the carrier. The employees, unaware the hook had rolled out, continued to work at the jam until they freed the carrier. The carrier then fell, catching Employee #1 at waist between the top of the carrier and the door frame. He sustained multiple traumatic injuries and was killed. Employee #2 fell into the freon solution and died of acute trifluoroethane intoxication. Causal factors include equipment design and malfunction, coupled with human error.

Keywords: MAINTENANCE, WORK RULES, FREON, JAMMED, DEGREASER, CONVEYOR, FALL, STRUCK BY, FALLING OBJECT, OVEREXPOSURE