Inspection Detail

Inspection: 307163444 - California Institute Of Technology

Inspection Information - Office: Long Beach District Office

Investigation Summary

At 9:20 a.m. on December 11, 2009, Employee #1, a manager of the nuclear magnetic (NMR) liquids department at the California Institute of Technology, was working with a coworker in the NMR department attempting to remove a screw driver from a Varian NMR spectrophotometer. The NMR device is used to analyze chemical sample and consists of a core which houses a powerful toroidal electromagnet, shim coils to adjust the magnetic field for consistency, and radio receiving sensors. Outside of the core are blankets of liquid nitrogen and helium which afford superconductivity to the electromagnet coils. At the time of the incident, a glass sample tube had been dropped into the device and had broken inside the core. In order to remove the tube, Employee #1 removed the shim coils and was attempting to use a screwdriver to push the tube out of the core from the bottom. When the screwdriver came close to the core opening however it was pulled up into the machine and suspended in the exact center of the magnetic field with the shaft pointing up. To retrieve the screwdriver, Employee #1 obtained a 33.5 in. hollow aluminum rod to push it out of the bottom of the device. With W1 positioned at the bottom of the machine, Employee #1 pushed the rod over the shaft of the screwdriver pushing them both down so that his coworker could grab the screwdriver from below. Because the inner diameter of the rod was very close in size to the shaft of the screwdriver, the coworker could not remove the screwdriver from the rod. Employee #1 decided that he would have to remove the screwdriver from the top of the device. Employee #1 and his coworker began allowing the screwdriver and aluminum rod to slip upwards. When the screwdriver came to the bottom opening of the NMR device, the coworker could no longer grasp it securely. The coworker released the screwdriver causing it to move back to the center of the magnetic field. As it did so, the aluminum rod moved upwards protruding from the top of the NMR device penetrating Employee #1's left nostril and continuing into the right frontal lobe of his brain. Employee #1 was hospitalized due to his injuries.

Keywords: MAGNET, NOSE, LOCKOUT, PIPE, BRAIN, PUNCTURE