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Occupational Safety and Health Administration OSHA

Accident Report Detail

Accident: 170180483 - Nine Employees Exposed To Ethylene Oxide In Sterilizer Leak

Accident: 170180483 -- Report ID: 0950642 -- Event Date: 03/27/1991
InspectionOpen DateSICEstablishment Name
11215746604/12/19916324Glendale Memorial Hospital
At 3:45 p.m. on March 17, 1991, the ethylene oxide alarm sounded for a Vernitron sterilizer, model VMPB3G48, serial #85548-85-3. The sterilizer was in the preparation room in the central supply department. The engineering and security departments responded, but did not detect any ethylene oxide leaks. Employees #2 through #4 were also present. It was not likely that there was ethylene oxide exposure because the sterilization cycle started at 5:50 p.m. with a mixture of 12 percent ethylene oxide and 88 percent freon. The ethylene oxide alarm went off several times, but was not considered urgent because the alarm had been triggered in the past by the presence of alcohol and steam. Between 7:00 p.m. and 8:00 p.m., engineering and security employees entered the area. Employee #6 used a detector to locate a leak behind the service door. He did not make repairs because the unit was going to shut down, and he left the area. Employee #7 located the leak with a detector and observed vapors and steam coming out of the front of the ethylene oxide unit. Employees # 5, #7, #8, and #9 evacuated the area. At 1:00 a.m. on March 28, 1991, Employee #1 entered the area from an unsecured entrance, experienced headaches, and left. The contract repair company told the employer that the leak was due to a nonfunctioning exhaust fan. There were no known permanent injuries and no employees were hospitalized.
Keywords: leak, fan, vapor, inadequate maint, ethylene oxide, headache, alarm, air contamination, exhaust fumes, chemical
Employee # Inspection Age Sex Degree Nature Occupation
1 112157466 Non Hospitalized injury Other Guards and police, excluding public service
2 112157466 Non Hospitalized injury Other Health aides, except nursing
3 112157466 Non Hospitalized injury Other Managers, medicine and health
4 112157466 Non Hospitalized injury Other Guards and police, excluding public service
5 112157466 Non Hospitalized injury Other Health technologists and technicians, n.e.c.
6 112157466 Non Hospitalized injury Other Health aides, except nursing
7 112157466 Non Hospitalized injury Other Mechanical engineering technicians
8 112157466 Non Hospitalized injury Other Health aides, except nursing
9 112157466 Non Hospitalized injury Other Health aides, except nursing

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