TranslateInspection Detail
Inspection: 308384890 - Domtar Industries, Inc
Inspection Information - Office: Madison
Site Address:
Domtar Industries, Inc
100 Wisconsin River Drive
Port Edwards, WI 54469
Mailing Address:
, , 00000
Union Status: Union
SIC:2621
NAICS: 322121/Paper (except Newsprint) Mills
Inspection Type: Referral
Scope: Partial
Advanced Notice: N
Ownership: Private
Safety/Health: Safety
Close Conference: 07/25/2006
Planning Guide: Safety-Manufacturing
Emphasis:
Case Closed: 09/15/2006
| Type | Activity Nr | Safety | Health |
|---|---|---|---|
| Accident | 100801349 | ||
| Referral | 200804342 | Yes |
| Violations/Penalties | Serious | Willful | Repeat | Other | Unclass | Total |
|---|---|---|---|---|---|---|
| Initial Violations | 2 | 2 | ||||
| Current Violations | 2 | 2 | ||||
| Initial Penalty | $12,000 | $0 | $0 | $0 | $0 | $12,000 |
| Current Penalty | $7,800 | $0 | $0 | $0 | $0 | $7,800 |
| FTA Penalty | $0 | $0 | $0 | $0 | $0 | $0 |
| # | Citation ID | Citaton Type | Standard Cited | Issuance Date | Abatement Due Date | Current Penalty | Initial Penalty | FTA Penalty | Contest | Latest Event | Note |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. | 01001A | Serious | 19100147 D04 I | 08/03/2006 | 08/15/2006 | $4,550 | $7,000 | $0 | I - Informal Settlement | ||
| 2. | 01001B | Serious | 19100147 D06 | 08/03/2006 | 08/15/2006 | $0 | $0 | $0 | I - Informal Settlement | ||
| 3. | 01002 | Serious | 19100133 A01 | 08/03/2006 | 08/15/2006 | $3,250 | $5,000 | $0 | I - Informal Settlement |
Investigation Summary
Between 10:30 and 11:00 a.m. May 30, 2006, Employees #1 and #2, who were maintenance workers, were working in the pump room, removing the pump for the weak black liquor storage tank. This activity required group lockout procedures. Procedures were not developed to identify the specific responsibilities for group lockout. The operators issue the line-breaking permits to the maintenance workers performing the task. The operators are tasked with closing specific valves in this line for this task. Lockout of the main circuit for the weak black liquor pump was done by Employees #1 and #2. The line breaking permit was issued by the operations department, who was at the time of the request working on an evaporator pump. Operations issued the line-break permit without closing the valves because they were "pressed for time." Operations filled out the permit with the intent of coming back in what he thought would be a couple minutes to close the valves for which he was responsible. He did not expect that the maintenance workers would start as soon as they had. The operations department was responsible for closing the valve on the suction side of the pump. This valve was not closed which resulted in the release of the weak black liquor. Employees #1 and #2 checked the bleed off valve for the pump and nothing came out. One employee noticed that the bleed off valve was caked with dried weak liquor. He attempted boring it with a wire brush and still no solvent came out. The gate valves were checked by turning the handles and they did not move which indicated that they were in the 'open' position. One employee stated that the valve on the suction side was not seen, when he checked the other valves. Employees #1 and #2 began removing the bolts from the pump once the coupler was removed. All but four bolts were removed as a matter of practice. The last four bolts were loosened, and Employees #1 and #2 began prying the pump away from the volute, when the weak black liquor was released. Both employees ran out the door to the showers as the release occurred. Employees #1 and #2 sustained chemical burns and were hospitalized.
Keywords:maintenance, work rules, lockout, valve, chemical burn, pump, accidental discharge, chemical
| # | Inspection | Age | Sex | Degree | Nature | Occupation |
|---|---|---|---|---|---|---|
| 1 | 308384890 | Hospitalized injury | Burn(Chemical) | Machinery maintenance occupations | ||
| 2 | 308384890 | Hospitalized injury | Burn(Chemical) | Machinery maintenance occupations |