Inspection Detail

Occupational Safety and Health Administration OSHA

Inspection: 111920112 - Ca. State Dept. Of Correction Sierra Conservation

Inspection Information - Office: Ca Modesto

Nr: 111920112	Report ID: 0950624	Open Date: 01/30/1992

Ca. State Dept. Of Correction Sierra Conservation
5100 O' Byrnes Ferry Road Jamestown, CA 95327		Union Status: Union
SIC: 4952/Sewerage Systems
Mailing: P.O. Box 497, Jamestown, CA 95327

Inspection Type:	Accident
Scope:	Partial	Advanced Notice:	N
Ownership:	StateGovt
Safety/Health:	Safety	Close Conference:	01/30/1992
		Close Case:	02/26/1992

Related Activity:	Type	ID	Safety	Health
	Accident	361375942

	Inspection		Degree	Nature	Occupation
Accident Investigation Summary
Summary Nr: 958959		Event: 12/23/1991	Employee'S Wrist Burned By Chlorine Flash
At approximately 11:00 a.m. on December 23, 1991, at the Sierra Conservation Center, a medium security prison, Employee #1, an experienced water/sewage plant supervisor, preparing to change a 1 ton chlorine cylinder, disconnected a vacuum line from the nearly empty cylinder. The cylinder valve was in the OFF position and the vacuum had been allowed to purge the regulator for several minutes. Because an electric regulator heater had never been installed, according to an in-house investigation, entrained water vapor apparently froze in the drip trap, isolating recondensed chlorine. When the regulator was removed from the tank, the chlorine flashed to vapor and caused a chemical burn to Employee #1's right wrist. Employee #1 also suffered a delayed reaction to chlorine inhalation. He was hospitalized for 24 hours for observation and treatment. A regulator heater was installed immediately. Note that December 23 was an extremely cold day. No chlorine release had ever been experienced at this location during cylinder changes before this accident. An approved SCBA had been moved up to within 50 ft of the cylinder before the cylinder change.
Keywords: vapor, work rules, inhalation, gas, chlorine, chemical burn, wrist
1	111920112		Hospitalized injury	Other	Water and sewage treatment plant operators

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Occupational Safety and Health Administration OSHA