Inspection Detail

Inspection: 2330058 - Dela-Tek, Inc.

Inspection Information - Office: Region 09; San Francisco

Investigation Summary

AT 10 AM ON MAY 19, 1986, EMPLOYEES #1 THROUGH #3 WERE USING WATER AND ACETONE TO CLEAN A SIMPSON MULLER-MIXER. THE MIXER CONTAINED LESS THAN 10 POUNDS OF RESIDUE FROM A MAGNESIUM-TEFRON-FLUOREL-ACETONE MIXTURE. THEY WERE LOCATED IN THE PROCESS BUILDING AT A REMOTE LOCATION. A FLASH FIRE OCCURRED, APPARENTLY WHEN FLAMMABLE VAPORS WERE IGNITED BY STATIC ELECTRICITY. THE EMPLOYEE'S SHIFT HAD STARTED AT 7 AM. AT 8 AM, IN ACCORDANCE WITH COMPANY POLICY, THEY BEGAN THE SHUT-DOWN PROCESS BECAUSE OF HIGH WINDS AND 20% HUMIDITY. AT 8:30 THEY WERE ORDERED TO STOP THE BATCH PROCESS AND CLEAN UP. THERE WAS NO MONITORING OF FLAMMABLE VAPORS AT THE PROCESS BUILDING. COMBUSTIBLE MATERIAL WAS USED FOR THE CONSTRUCTION OF THE EMPLOYEE'S WORK PLATFORM AND FOR THE WALLS OF THE PROCESS BUILDING. THE EMPLOYEES WERE GIVEN NO FORMAL TRAINING ON THE HAZARDS OF THE CHEMICALS THEY WERE USING. EMPLOYEE #1 DIED 29 DAYS LATER AND EMPLOYEE #2 DIED 5 DAYS LATER. THEY WERE BURNED OVER 88% OF THEIR BODIES, ESPECIALLY THE FACE, UPPER TRUNK, AND EXTREMITIES, AND EXPERIENCED RENAL FAILURE AND EDEMA OF THE LUNGS. EMPLOYEE #3 ALSO EXPERIENCED EXTENSIVE BURNS BUT SURVIVED, AND WAS RELEASED FROM THE HOSPITAL 2 MONTHS LATER ON AN OUTPATIENT BASIS.

Keywords: BURN, LUNG, FLAMMABLE VAPORS, EXPLOSIVE MIXING, CLEANING, FIRE, TORSO, FACE, UNTRAINED