Inspection Detail

Inspection: 1429466.015 - Black Diamond Blade Company

Inspection Information - Office: Sacramento District Office

Investigation Summary

At 11:30 a.m. on July 15, 2019, an employee (line supervisor) was checking a noisy solenoid on a chrome plating parts tank. A coworker (maintenance) suggested flushing the system to clear it during lunch. The employee thought the coworker was just flushing one line but the coworker began flushing the whole system at 11:00 a.m. and left. Plating was still going on but when the flush began the tank exhaust systems were turned off and locked out for 30 minutes. After approximately 15 minutes a chrome mist travelled out of the chrome room and into the shop's bay. The employee ran in to see what he could do to stop it and began hosing down the parts in the tanks to keep the mist down. After about 10 minutes of inhaling the mist, the employee was coughing and choking uncontrollably and had to leave the room. The employee donned his respirator and returned to the room at which time the exhaust system came back online and removed the mist. Meanwhile other coworkers in the bay reported exposures, donned respirators, shut equipment down and exited the building. Most coworkers reported irritation of the throat and sinuses. Over the next two weeks the employee and fourteen coworkers were sent to clinics to get checked. The doctors that examined the employee and his coworkers were not familiar with the details of the incident, concentrations involved or complications from occupational exposure to chromium and no additional information was made available. The employee's health deteriorated and his blood chrome concentration kept increasing over the next month. On August 16, 2019, he was hospitalized and treated for two days with his final diagnosis still pending.

Keywords: Chemical, Chemical Exposure, Chemical Vapor, Chrome, Cough, Engineering Controls, Head, Inhalation, Lack of Engineering Controls, Lack of Work Procedures, Lockout, Lockout/Tagout, Lung, Maintenance, Malfunction, Material Handling, Mech Malfunction, Metal, Misjudgment, Misjudgment of Hazardous Situation, Non-PEL Overexposure, Overexposure, Tank, Vapor, Ventilation