UNITED STATES
DEPARTMENT OF LABOR

Inspection Detail

Note: The following inspection has not been indicated as closed. Please be aware that the information shown may change, e.g. violations may be added or deleted. For open cases, in which a citation has been issued, the citation information may not be available for 5 days following receipt by the employer for Federal inspections or for 30 days following receipt by the employer for State inspections.

Inspection: 1537100.015 - Chromalloy San Diego

Inspection Information - Office: Ca San Diego

Investigation Summary

At 7:15 a.m. on June 18, 2021, an employee was working as a maintenance technici an for a firm that provided maintenance and repair services for land-based and a irborne gas turbine engines for civilian and military clients. He and other work ers in the maintenance department were replacing metal bars at the bottom of a p it furnace, the "H2 furnace," located in an outdoor area of the facility. Using a stepladder, the employee entered the pit furnace to remove the old metal bars. He was working alone, as his partner/supervisor was working in the production a rea. A worker from the metal preparation department went down to the furnace are a to see if there were any completed parts. He noticed the ladder sticking out o f the furnace. He went over and saw the employee at the bottom of the furnace, u nresponsive. He saw that the switch on the furnace control panel for argon gas w as in the ON position. He shut it off and went to look for help. In the shop nex t door, he found the maintenance supervisor, who immediately ran over to the fur nace and began rescue procedures to remove the employee from the furnace with an overhead crane. The employee had been in the space for ten to fifteen minutes. The employee was retrieved and transported to the hospital. He died from asphyxi ation as a result of exposure to the argon. The San Diego fire department report ed the serious injury accident to DOSH San Diego at approximately 9:00 a.m. The firm reported the fatality at approximately 10:00 a.m. Both reports were made wi thin the 8-hour requirement. Investigators from DOSH San Diego arrived at the si te at approximately 11:00 a.m. The H2 furnace was identified as a permit require d confined space. Maintenance department employees did not obtain a confined spa ce permit and did not follow lockout/tagout procedures for the argon gas system prior to entering the furnace. The employer was cited for a Serious Accident-Rel ated violation of 8 CCR 5157(d) for unauthorized entry into a confined space.

Keywords:argon, asphyxiated, cardiovasc system, confined space, entry permit, furnace, lockout, lockout/tagout, maintenance, respiratory, unauthorized