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Inspection Detail
Inspection: 103378832 - Mcgraw/Kokosing Inc.
Inspection Information - Office: Cincinnati Area Office
Site Address:
Mcgraw/Kokosing Inc.
1801 Crawford St.
Middletown, OH 45043
Mailing Address:
4701 E. Oxford State Rd., Middletown, OH 45042
Union Status: Union
SIC:1541
NAICS: 0
Inspection Type: Accident
Scope: Partial
Advanced Notice: N
Ownership: Private
Safety/Health: Safety
Close Conference: 09/29/1994
Emphasis:
Case Closed: 01/27/1998
| Type | Activity Nr | Safety | Health |
|---|---|---|---|
| Accident | 360169841 |
| Violations/Penalties | Serious | Willful | Repeat | Other | Unclass | Total |
|---|---|---|---|---|---|---|
| Initial Violations | 26 | 4 | 30 | |||
| Current Violations | 8 | 4 | 12 | |||
| Initial Penalty | $182,000 | $280,000 | $0 | $0 | $0 | $462,000 |
| Current Penalty | $29,000 | $0 | $0 | $0 | $196,000 | $225,000 |
| FTA Penalty | $0 | $0 | $0 | $0 | $0 | $0 |
| # | Citation ID | Citaton Type | Standard Cited | Issuance Date | Abatement Due Date | Current Penalty | Initial Penalty | FTA Penalty | Contest | Latest Event | Note |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. | 01001 | Serious | 19100146 D03 | 10/19/1994 | 10/20/1994 | $3,625 | $7,000 | $0 | I - Informal Settlement | ||
| 2. | 01002 | Serious | 19100146 D03 II | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 3. | 01003 | Serious | 19100146 D03 III | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 4. | 01004 | Serious | 19100146 D03 IV | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 5. | 01005 | Serious | 19100146 D03 V | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 6. | 01006 | Serious | 19100146 D04 I | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 7. | 01007 | Serious | 19100146 D04 II | 10/19/1994 | 10/20/1994 | $3,625 | $7,000 | $0 | I - Informal Settlement | ||
| 8. | 01008 | Serious | 19100146 D05 I | 10/19/1994 | 11/20/1994 | $3,625 | $7,000 | $0 | I - Informal Settlement | ||
| 9. | 01009 | Serious | 19100146 D05 II | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 10. | 01010 | Serious | 19100146 D06 | 10/19/1994 | 10/20/1994 | $3,625 | $7,000 | $0 | I - Informal Settlement | ||
| 11. | 01011 | Serious | 19100146 E02 | 10/19/1994 | 10/20/1994 | $3,625 | $7,000 | $0 | I - Informal Settlement | ||
| 12. | 01012 | Serious | 19100146 E03 | 10/19/1994 | 10/23/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 13. | 01013 | Serious | 19100146 F01 | 10/19/1994 | 10/20/1994 | $3,625 | $7,000 | $0 | I - Informal Settlement | ||
| 14. | 01014 | Serious | 19100146 F02 | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 15. | 01015 | Serious | 19100146 F03 | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 16. | 01016 | Serious | 19100146 F04 | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 17. | 01017 | Serious | 19100146 F05 | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 18. | 01018 | Serious | 19100146 F06 | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 19. | 01019 | Serious | 19100146 F07 | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 20. | 01020 | Serious | 19100146 F08 | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 21. | 01021 | Serious | 19100146 F09 | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 22. | 01022 | Serious | 19100146 F10 | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 23. | 01023 | Serious | 19100146 F11 | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 24. | 01024 | Serious | 19100146 F13 | 08/13/1994 | 08/17/1994 | $7,000 | $7,000 | $0 | I - Informal Settlement | Citation has been deleted. | |
| 25. | 01025 | Serious | 19100146 G03 | 08/13/1994 | 10/20/1994 | $3,625 | $7,000 | $0 | I - Informal Settlement | ||
| 26. | 01026 | Serious | 19100146 K03 | 08/13/1994 | 10/20/1994 | $3,625 | $7,000 | $0 | I - Informal Settlement | ||
| 27. | 02001 | Unclass | 19100146 D02 | 10/19/1994 | 10/20/1994 | $49,000 | $70,000 | $0 | I - Informal Settlement | ||
| 28. | 02002 | Unclass | 19100146 D08 | 10/19/1994 | 10/20/1994 | $49,000 | $70,000 | $0 | I - Informal Settlement | ||
| 29. | 02003 | Unclass | 19100146 E01 | 10/19/1994 | 10/20/1994 | $49,000 | $70,000 | $0 | I - Informal Settlement | ||
| 30. | 02004 | Unclass | 19100146 J02 | 10/19/1994 | 10/20/1994 | $49,000 | $70,000 | $0 | I - Informal Settlement |
Investigation Summary
At approximately 10:15 a.m. on April 20, 1994, Employees #1, #3, and #4 had entered the #1 ammonia scrubber (a confined space) to reinstall serviced piping pieces. Employee #2 was acting as attendant. Flammable gas leaked undetected into the vessel and was ignited by any of several possible ignition sources. When the gas flashed, the pressure created by the rapid fire impacted on Employee #2, killing him. Employees #1, #3, and #4 received internal burns. In addition, the pressure front dislodged the trays upon which they were standing, causing Employees #1 and #3 to fall approximately 50 ft to the bottom of the vessel and Employee #4 to be thrown onto and suspended by some of the piping already installed. Employees #1, #3, and #4 were also killed.
Keywords: LEAK, FLAMMABLE VAPORS, EXPLOSION, PIPE, BURN, FIRE, WORK RULES, INSTALLING, CONFINED SPACE, CONSTRUCTION
| # | Inspection | Age | Sex | Degree of Injury | Nature of Injury | Occupation |
|---|---|---|---|---|---|---|
| 1 | 103378832 | Fatality | Burn/Scald(Heat) | Plumbers, pipefitters and steamfitters | ||
| 2 | 103378832 | Fatality | Burn/Scald(Heat) | Plumbers, pipefitters and steamfitters | ||
| 3 | 103378832 | Fatality | Burn/Scald(Heat) | Plumbers, pipefitters and steamfitters | ||
| 4 | 103378832 | Fatality | Concussion | Carpenter apprentices |