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Occupational Safety and Health Administration OSHA

Inspection Detail

Inspection: 124062381 - Muscatutuck State Development Center

Inspection Information - Office: Indiana

Nr: 124062381Report ID: 0551800Open Date: 12/30/1993

Muscatutuck State Development Center
Us Highway 50 East
Butlerville, IN 47223
Union Status: Union
SIC: 8051/Skilled Nursing Care Facilities
Mailing: P.O. Box 77, Butlerville, IN 47223

Inspection Type:Accident
Scope:Partial Advanced Notice:N
Safety/Health:Safety Close Conference:01/12/1994
Close Case:03/04/1994

Related Activity:TypeIDSafetyHealth

Violation Summary
Serious Willful Repeat Other Unclass Total
Initial Violations 5 5
Current Violations 4 1 5
Initial Penalty $0 $0 $0 $0 $0 $0
Current Penalty $0 $0 $0 $0 $0 $0
FTA Amount $0 $0 $0 $0 $0 $0

Violation Items
# ID Type Standard Issuance Abate Curr$ Init$ Fta$ Contest LastEvent
  1. 01001 Other 19100146 D02 02/08/1994 02/26/1994 $0 $0 $0 I - Informal Settlement
  2. 01002 Serious 19100146 D03 I 02/08/1994 02/26/1994 $0 $0 $0 I - Informal Settlement
  3. 01003 Serious 19100146 E01 02/08/1994 02/26/1994 $0 $0 $0 -
  4. 01004 Serious 19100146 G03 02/08/1994 02/26/1994 $0 $0 $0 -
  5. 01005 Serious 19100146 J01 02/08/1994 02/26/1994 $0 $0 $0 I - Informal Settlement

Accident Investigation Summary
Summary Nr: 170389795Event: 12/30/1993Employee Dies When Coal Surface Collapses, Burying Him
At approximately 9:30 a.m. on December 30, 1993, 60-year-old Employee #1 and a coworker entered the interior of a coal storage silo to find out why there was no coal supply down through the main chute leading to the power plant below. Outdoor temperatures had not exceeded the mid-20s for at least 5 days. Employee #1 and the coworker climbed 8 feet up an interior fixed industrial ladder to the silo's outer circumference and walked on top of the frozen coal. Employee #1 carried a 1-inch diameter steel hollow pipe. Employee #1 began to bang and chop away on the frozen coal. In an instant, the entire surface collapsed under Employee #1. He disappeared from total view within 2 to 3 seconds. Instinctively, the coworker held onto Employee #1's coveralls for those few seconds, but as he realized that he was sinking, he let go of Employee #1. The coal stopped collapsing and the coworker crawled back to the interior ladder, ascended the flight elevator, and sounded an emergency alarm buzzer and horn in the power plant below. The rescue and retrieval of Employee #1's body took 3 hours 10 minutes. His body was finally found at the head of the main gravity chute. Lack of an existing confined space entry program, adequate and effective employee training on confined space entry procedures, and an effective work permit program, as well as the excessively cold temperatures, all contributed to this fatality.
Keywords: asphyxiated, collapse, confined space, work rules, coal silo, coal, inexperience, unstable surface, frozen, untrained
Inspection Degree Nature Occupation
1 124062381 Fatality Asphyxia Power plant operators

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