Text For Citation: 01 Item/Group: 001 Hazard: LOCKOUT

Section 5(a)(1) of the Occupational Safety and Health Act of 1970: The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed to: (a) The employer did not establish and enforce a written program, including training for affected managers, supervisors, and workers involved with the maintenance and the operation of the three pressure vessels (autoclaves) at the workplace. The employer operated the unlicensed and uninspected east autoclave used to impregnate metal castings with sodium silicate for more than three months when: a). The locking ring, used to rotate and clamp the locking lugs on the vessel lid and on the vessel, did not fully close. With an operating pressure of 65 psig, there was more than 58 tons of force against the forty-eight inch diameter vessel lid. b). There were two operating modes for the autoclave. The control panel could be set using an "automatic" or "manual" sequencer. The employer took no action to use a combination of locks, operator training, and administrative order to designate the allowed operating mode for supervisors, main- tenance workers, and engineers with detailed knowledge of the features of the machine and the hazards of errored operation. c). The "automatic" operating system for the autoclave operation system properly had the safe closure switch on the lid wired in series. Because the locking ring did not fully close and set the lid safety switch, operators who used the "auto- matic" mode had to manually trip the safety switch. The "manual" operating system, that was also available defeated the safe closure switch on the atuoclave lid. Workers were given no instructions on which mode to use. For an extended period of time, operating the autoclave could only be done by defeating the lid safety switch. d). The build-up of sodium silicate on the lugs of the lid and the vessel was not monitored, and the accumulation pro- gressively made full closure of the locking ring more dif- ficult. e). Workers were routinely required to hammer, by using an aluminum mallet on the lid and locking ring, to cause the locking ring to open and the lid to lift at the end of the silicate impregnation cycle. f). The employer did not provide the operators with training and clear written instructions that described what was normal or abnormal operation of the autoclave and the operator's authority to operate the machine under those situations. g). On Saturday, March 14, 1992, a written repair order with the highest priority was issued. The repair order indicated that the locking ring on the east autoclave would not close. The employer did not take action to lock out the controls and supplying air (gas) pressure to the autoclave. The employer did not issue specific and immediate "do no use" instructions to the operators. An explosive release of the autoclave lid occurred on the morning of Monday, March 16, 1992, with extreme worker injury.