Inspection Detail

Inspection: 105711949 - Automata, Inc.

Inspection Information - Office: Va-E-Manassas (Regional Office)- Safety 0355114

Investigation Summary

At approximately 6:40 a.m. on May 23, 1988, Employee #1, having been instructed by Employee #2, was changing the sulfuric acid (HL68 copper cleaner) solution in a model 650 pre-cleaner system. He purged the system of the spent solution and emptied a partial container of HL68 into the pre-cleaner. Meanwhile, Employee #3 went into the warehouse area and returned with what he thought was a new container of HL68. In fact, Employee #3, who had not been trained in hazardous materials, brought back a 55 gallon drum of sodium chlorite (in black 150-A). Employee #4 placed the pump into the new chemical and turned it on while Employee #1 held the hose. The sodium chlorite caused an adverse reaction when it was mixed with the sulfuric acid (HL68). Employee #1 realized immediately that Employee #3 had brought the wrong chemical and began to complain to Employee #2. Employee #4, sensing that something was wrong, immediately shut off the pump. Employee #2 had started to walk over to the pre-cleaner while telling Employee #4 that the wrong chemical would have to be pumped out when, without warning, the pump exploded. Employee #1 died of multiple injuries, including chemical inhalation, 48 hours after the explosion; Employee #2 sustained cuts, bruises, and chemical inhalation injuries; Employee #3 sustained a fractured right arm, cuts, and bruises, and possible chemical inhalation; and Employee #4 sustained minor cuts and bruises. In addition, Employee #5, working at an adjacent machine, sustained cuts and bruises and possible chemical inhalation; Employee #6 sustained a cut to the forehead and possible chemical inhalation injuries; Employees #7, #8, #9 and #10 were monitored for possible chemical inhalation injuries.

Keywords: FRACTURE, WORK RULES, INHALATION, EXPLOSION, CHEMICAL REACTION, TOXIC FUMES, SULFURIC ACID, UNTRAINED, CONTUSION, INATTENTION