Inspection Detail

Inspection: 307398578 - Koffler Electrical Mechanical Apparatus Repair Inc

Inspection Information - Office: San Francisco District Office

Investigation Summary

At 12:36 p.m. on August 6, 2007, Employees #1 and #2, a foreman and an electrician, respectively, for Koffler Electrical Mechanical Apparatus Repair, Inc., were dispatched to a hotel boiler room to replace the broken motor of a pump for the hotel's hot water piping system. There were four sets of motor and pump units in the boiler room. Two months prior to this job, Employee #1 had replaced one of these set. On the day of the accident, they were replacing another motor and pump unit. All the valves were shut and the motor and pump unit had been removed from the 12 in. hot water pipe when a motor from one of the other three units automatically restarted. Employee #1 heard a whooshing sound coming from the open water pipe, and 120 degress F water started to spray out. Employee #1 attempted to cap off the pipe; Employee #2 went to notify the hotel engineer and then returned to help Employee #1. The hotel engineer was checking the valves and tightening some nuts and bolts on the couplings when Employees #1 and #2 were suddenly sprayed with hot water. Paramedics responded and both employees were taken to St. Francis Hospital. Employee #1 was treated for first- and second-degree burns to his abdomen. Employee #2 was treated for first- and second-degree burns to the back of his legs. The employer was cited for two general accident-related violations. The hotel had only one check valve for the 12 in. hot water pipe that served the entire 42-story building. There were no other intermediate check valves throughout the piping system. California Code of Regulations T8 3329(d) states: "When dismantling or opening closed pressurized or gravity fed systems, internal pressure shall be relieved or other methods utilized to prevent sudden release of pressure or spraying of liquid." One of the functions of the check valve would have been to prevent backflow. It was discovered after the incident that the check valve was not working properly. As a result, it did not have the capacity to stop the water from flowing back into the boiler room. The other general accident-related violations are from T8 GISO section 3314(c) and (g), which require a lockout/de-energizing of electrical equipment. Prior to the removal of the motor and pump unit, the other 3 units were not de-energized to prevent them from building-up water pressure of a minimum of 20 psi. The boiler was also not shut down to prevent build-up of water temperature. A hazard control procedure was not developed by the employer. A reference was also made to T8 3314(i), which required on-site lockout procedures to be followed by outside servicing personnel.

Keywords: BURN, ABDOMEN, CHECK VALVE, WORK RULES, CONSTRUCTION, LOCKOUT, ELEC CIRC PART--MISC, SPILL, ACCIDENTAL DISCHARGE, HOT WATER