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Inspection Detail
Inspection: 111815189 - Alta Bates Summit Medical Center
Inspection Information - Office: Oakland District Office
Site Address:
Alta Bates Summit Medical Center
350 Hawthorne Ave.
Oakland, CA 94609
Mailing Address:
2450 Ashby Ave., Ste. 2601, Berkeley, CA 94705
Union Status: Union
SIC:8062
NAICS: 0
Inspection Type: Accident
Scope: Partial
Advanced Notice: N
Ownership: Private
Safety/Health: Health
Close Conference: 10/27/1992
Planning Guide: Health-Manufacturing
Emphasis:
Case Closed: 11/02/1992
| Type | Activity Nr | Safety | Health |
|---|---|---|---|
| Accident | 361040645 |
| Violations/Penalties | Serious | Willful | Repeat | Other | Unclass | Total |
|---|---|---|---|---|---|---|
| Initial Violations | 1 | 1 | ||||
| Current Violations | 1 | 1 | ||||
| Initial Penalty | $2,000 | $0 | $0 | $0 | $0 | $2,000 |
| Current Penalty | $2,000 | $0 | $0 | $0 | $0 | $2,000 |
| FTA Penalty | $0 | $0 | $0 | $0 | $0 | $0 |
| # | Citation ID | Citaton Type | Standard Cited | Issuance Date | Abatement Due Date | Current Penalty | Initial Penalty | FTA Penalty | Contest | Latest Event | Note |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. | 01001 | Serious | 5220 D05 | 11/06/1992 | 09/24/1992 | $2,000 | $2,000 | $0 | - |
Investigation Summary
Approximately one-half hour after Employee #1, a central processing attendant, loaded a gas sterilizer, he heard bubbling noises and noticed frothing around the door. He stayed in the area for approximately 10 to 15 seconds, then alarms went off. The alarms are set for 20 ppm (low) and 50 ppm (high); it is not known if both alarms went off. Employee #1 re-entered the area approximately 30 minutes later to disengage the door alarm, holding his breath for this operation. The ethylene oxide (EtO) alarm stayed on for approximately two hours. The EtO leak was attributed to a faulty humidification control valve that continued to inject steam into the sterilization chamber. This resulted in overpressure on the door gaskets that allowed steam, water, and ethylene oxide gas to escape. One accident-related violation was observed.
Keywords: LEAK, VAPOR, GASKET, ETHYLENE OXIDE, WORK RULES, INHALATION, EQUIPMENT FAILURE, GAS, VALVE, TOXIC FUMES
| # | Inspection | Age | Sex | Degree of Injury | Nature of Injury | Occupation |
|---|---|---|---|---|---|---|
| 1 | 111815189 | Non Hospitalized injury | Other | Occupation not reported |