Inspection Detail

Inspection: 2902971 - Koch Oil Refining Company

Inspection Information - Office: Minnesota Department Of Labor And Industry

Investigation Summary

AT APPROXIMATELY 9:30 AM ON SEPTEMBER 13, 1986, EMPLOYEE #1 WAS PERFORMING A FLANGE BLINDING OPERATION ON A PIPE CONNECTED TO A COKER FRACTIONATOR TOWER. THE TOWER HAD PREVIOUSLY BEEN PURGED WITH STEAM. THE PIPE WAS LOCATED APPROXIMATELY 47 FEET ABOVE GROUND LEVEL. EMPLOYEE #1 WAS WORKING FROM A LANDING AT THE LEVEL OF THE PIPE. WHEN THE FLANGE WAS OPENED, OIL, STEAM AND GAS ESCAPED FROM THE FLANGE OPENING. EMPLOYEE #1 AND ANOTHER EMPLOYEE CONTINUED TO INSTALL THE BLIND. A WITNESS AT GROUND LEVEL OBSERVED EMPLOYEE #1 STAND UP, SLOWLY WALK APPROXIMATELY 7 FEET TO THE GATE AT THE DESCENDING CAGED LADDER, OPEN THE GATE, STEP OUT TO THE LADDER, TAKE 2 TO 4 STEPS DOWN, STOP, LOOK TO HIS LEFT AND COLLAPSE. AS HE BEGAN TO COLLAPSE, HE FOLDED OVER INSIDE THE CAGE AND THEN FELL APPROXIMATELY 25 FEET THROUGH THE CAGE, LANDING HEAD FIRST ON TOP OF EMPLOYEE #2, WHO WAS STANDING AT THE BASE OF THE LADDER ON A LANDING APPROXIMATELY 17 1/2 FEET ABOVE GROUND LEVEL. EMPLOYEE #1 SUSTAINED A SKULL FRACTURE, FOR WHICH HE WAS HOSPITALIZED. EMPLOYEE #2 SUSTAINED A BRUISED LEFT HIP AND FRACTURED LEFT THUMB. HE WAS TREATED AT THE HOSPITAL EMERGENCY ROOM AND RELEASED.

Keywords: FRACTURE, COLLAPSE, LADDER, THUMB, FIXED LADDER, SKULL, FALL, HIP, CONTUSION