Inspection Detail

Inspection: 314025099 - Magnagro Corporation

Inspection Information - Office: Wichita Area Office

Investigation Summary

"At approximately 2:30 p.m. on April 1, 2010, Employee #1, Employee #2 (leadman) and Employee #3 were preparing product involving the use of fermented molasses as one of the ingredients. The workers were having problems moving the molasses from tank #2 to tank #1. According to the employer, he told Employee #2 via telephone, to add water to the molasses to bring it to a level where the container contents could be transferred to tank #1. Due to the low volume of fermented molasses in tank #2, Employee #1 entered and was descending a rope ladder into the storage tank to attempt to push the molasses through the piping into tank #1. While descending the ladder, Employee #1 fell or slipped off the ladder, falling to the bottom of the tank. Employee #2 heard Employee #1 fall and went on top of the tank to see what happened. Employee #2 called for assistance via 911, and then entered the tank to attempt to rescue Employee #1 when he collapsed, falling into the tank. Employee #3 heard Employee #2 drop into the tank and went to the top of the tank. Employee #3 began to enter the tank through the top, but stopped because he was not sure how he would get Employees #1 and #2 out through the manhole. Employee #3 climbed down off the tank and found an electric saw. Employee #3 cut a hole in the bottom side of the tank and entered the tank. While trying to pull one of the two Employees out, Employee #3 was overcome and passed out, falling to the outside of the tank. Upon arrival, the Lawrence Fire Department and EMS began treatment of Employee #3 and transported him to hospital, where he was treated and released. The Lawrence Fire Department extracted Employee #1 and #2 from the tank and attempted to revive them. Employee #1 was taken to hospital and pronounced dead, and Employee #2 was pronounced dead at the scene. The molasses tanks #1 and #2 measured approximately 14 feet in height, 120 inches in diameter, with domed tops, and single manhole measuring 21 inches in diameter. A rope ladder was used to enter/egress the interior of the tanks and was either attached to the top of the tank or the ceiling bracing of the structure. Access to the tanks from the outside was by ladder to the top of tank #1. The employees would then jump across to tank #2. There is no catwalk and insufficient space to access the top of tank #2 with a ladder. During the investigation, oxygen levels in the molasses storage tank #2 was measured and found to be 9.9 while carbon dioxide levels were found to be between 56,977 and 97,932 parts per million. The employer did not have any equipment or devices to monitor the atmosphere in the tanks, and used a box fan to ventilate for an hour or two before entering into product tanks. MagnaGro Corporation, a manufacturer of organic fertilizers and other related products, has been in business in Lawrence, Kansas since December 1993. attached to the top of the tank or the ceiling bracing of the structure."

Keywords: OXYGEN, OXYGEN DEFICIENCY, ASPHYXIATED, CONFINED SPACE, FERTILIZER MIXING, LADDER, CARBON DIOXIDE, FALL, MANHOLE, TANK