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Occupational Safety and Health Administration OSHA

Accident Report Detail

Accident: 170702013 - Employee Injured By Leaking Ethylene Oxide

Accident: 170702013 -- Report ID: 0950614 -- Event Date: 09/24/1992
InspectionOpen DateSICEstablishment Name
11181518910/19/19928062Alta Bates Summit Medical Center
Approximately one-half hour after Employee #1, a central processing attendant, loaded a gas sterilizer, he heard bubbling noises and noticed frothing around the door. He stayed in the area for approximately 10 to 15 seconds, then alarms went off. The alarms are set for 20 ppm (low) and 50 ppm (high); it is not known if both alarms went off. Employee #1 re-entered the area approximately 30 minutes later to disengage the door alarm, holding his breath for this operation. The ethylene oxide (EtO) alarm stayed on for approximately two hours. The EtO leak was attributed to a faulty humidification control valve that continued to inject steam into the sterilization chamber. This resulted in overpressure on the door gaskets that allowed steam, water, and ethylene oxide gas to escape. One accident-related violation was observed.
Keywords: leak, vapor, gasket, ethylene oxide, work rules, inhalation, equipment failure, gas, valve, toxic fumes
Employee # Inspection Age Sex Degree Nature Occupation
1 111815189 Non Hospitalized injury Other Occupation not reported

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