Inspection Detail

Inspection: 103796819 - Stct Doc Northern Correctional Institution

Inspection Information - Office: Connecticut Department Of Labor, Division Of Occupational Safety & Health

Investigation Summary

On June 7, 1990, Employee #1 was removing paints and other finishes from furniture by dipping the furniture in a methylene chloride dip tank that measured 4 feet wide by 7 feet long by 42 inches high and contained 8 3/4 inches (approximately 160 gallons) of methylene chloride. There are two 11 inch working platforms located on both long sides of the tank. Two types of ventilation systems were in use at the dip tank: a push-pull type and a slotted-type. Both systems were operating at the time of the incident. Employee #1 was stripping the finish from church pews by pouring methylene chloride over the furniture with a 1 gallon can with an attached 51 inch handle. The furniture would then be scrubbed with a hard-bristled brush with a similar length handle. At approximately 9:00 a.m., Employee #1 complained to a coworker that he was not feeling well and that the methylene chloride was making him dizzy. Another worker saw Employee #1 bent over into the tank with one leg up on the side; he appeared to be retrieving something. Employee #1 was not seen between 9:30 and approximately 9:50 a.m. when a supervisor found him inside the methylene chloride dip tank. Attempts to revive him failed. Employee #1 was pronounced dead by a physician at the site. The medical examiner determined the cause of death to be acute methyl chloride toxicity from inhalation of high levels of methylene chloride. Causal factors included the following: 1) A standard guardrail was not provided to protect personnel from the hazards of the dip tank. 2) Subsequent air samples collected inside the dip tank, which simulated approximately the levels that Employee #1 could bend to, were in excess of both the OSHA ceiling limit and acceptable maximum peak limits for methylene chloride. 3) There was a lack of employee training for employees working in and around open surface tank operations. 4) Personnel protective equipment as required by applicable OSHA standards was not being worn. 5) The facility did not have an effective Hazard Communication Program.

Keywords: GUARDRAIL, PPE, METHYLENE CHLORIDE, WORK RULES, TOXIC ATMOSPHERE, INHALATION, DIP TANK, TOXIC FUMES, OVEREXPOSURE, UNTRAINED