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Occupational Safety and Health Administration OSHA

Accident Report Detail

Accident: 170606891 - Employee Exposed To Ethylene Oxide

Accident: 170606891 -- Report ID: 0950641 -- Event Date: 01/20/1994
InspectionOpen DateSICEstablishment Name
11984372002/14/19948062Century City Hospital
On the afternoon of January 20, 1994, an ethylene oxide leak occurred on the p-1 level of Century City Hospital in the Central Services area. This occurred during the sterilization cycle on the ethylene oxide gas sterilizer (AMSCO model #2027). During the cycle, the equipment emitted a pulsing audible buzzer, signifying a mechanical failure. Employee #1 mistook the sterilizer pulsing buzzer for a solid buzzer that signals the completion of the sterilization cycle. When he opened the sterilizer door to transfer the load to a secondary aerator for a second sterilization cycle, ethylene oxide was released into the immediate area, exposing Employee #1 and sending a high alarm reading on the ethylene oxide monitor. A serious accident related citation was issued (5220(j)(3)(c)(3)).
Keywords: ethylene oxide, work rules, alarm, process safety, overexposure, accidental discharge, inattention
Employee # Inspection Age Sex Degree Nature Occupation
1 119843720 Non Hospitalized injury Cancer Health technologists and technicians, n.e.c.

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