Inspection Detail

Inspection: 111815189 - Alta Bates Summit Medical Center

Inspection Information - Office: Oakland District Office

Inspection Nr: 111815189

Report ID: 0950614

Date Opened: 10/19/1992

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

Related Activity
Type	Activity Nr	Safety	Health
Accident	361040645

Violation Summary
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

Violation Items
#	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

Investigation Nr: 170702013

Event: 09/24/1992

Employee injured by leaking ethylene oxide

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

Investigated Inspection
#	Inspection	Age	Sex	Degree of Injury	Nature of Injury	Occupation
1	111815189			Non Hospitalized injury	Other	Occupation not reported

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