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UNITED STATES
DEPARTMENT OF LABOR

Occupational Safety and Health Administration OSHA

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Inspection Detail



Violation Summary
Serious Willful Repeat Other Unclass Total
Initial Violations 4 4
Current Violations 4 4
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. 01001A Serious 19100146 C01 02/07/1996 02/09/1996 $0 $0 $0 -
  2. 01001B Serious 19100146 C02 02/07/1996 02/09/1996 $0 $0 $0 -
  3. 01001C Serious 19100146 C04 02/07/1996 02/09/1996 $0 $0 $0 -
  4. 01002 Serious 19100146 G01 02/07/1996 03/06/1996 $0 $0 $0 -
  5. 01003 Serious 19100147 D04I 02/07/1996 03/06/1996 $0 $0 $0 -
  6. 01004 Serious 19101000 A02 02/07/1996 02/09/1996 $0 $0 $0 -

Accident Investigation Summary
Summary Nr: 171016066 Event: 01/05/1996Employees Killed Or Overcome By Carbon Monoxide
The worksite was a state penitentiary ash silo that received and stored ash from two boilers until it was transported elsewhere. The outside temperature was minus 11 degrees Fahrenheit when inmates began to empty ash out of the silo. Earlier in the week, however, several boiler tubes had ruptured, sending an unusual amount of wet ash and unburnt coal into the silo, freezing and plugging the outlet. Employee #2 decided to enter the silo and ram out the obstruction from the inside. Employee #1 saw Employee #2 collapse, and called for help before entering to rescue him. Employees #3, #4, and #7 then entered the silo to help. None of the employees realized that carbon monoxide had built up in the silo due to smoldering ash and unburnt coal. Employees #9, #10, and #25 through #29, city fire fighters, were also exposed to carbon monoxide while rescuing Employees #1 through #3. The three workers were, by then, unconscious, and they all died. Later that same day, Employees #6, #8, and #11 through #29 were exposed to carbon monoxide when the conveying system for sending ash to the silo was opened up for maintenance. Employees #6, #8, #11, and #12 were hospitalized for overexposure. The system had been in operation for 16 years and was not perceived as a hazard. Employees routinely entered the ash silo to clean it out or to unplug it.
Keywords: work rules, boiler, inhalation, clogged, overexposure, carbon monoxide, ventilation, confined space, chemical vapor, silo
Inspection Degree Nature Occupation
1 125197061 Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
2 125197061 Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
3 125197061 Hospitalized injury Poisoning(Systemic) Firefighting occupations
4 125197061 Hospitalized injury Poisoning(Systemic) Firefighting occupations
5 125197061 Hospitalized injury Poisoning(Systemic) Power plant operators
6 125197061 Hospitalized injury Poisoning(Systemic) Power plant operators
7 125197061 Hospitalized injury Poisoning(Systemic) Power plant operators
8 125197061 Non Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
9 125197061 Hospitalized injury Fracture Supervisors; handlers,equip-cleaners,laborers nec
10 125197061 Fatality Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
11 125197061 Fatality Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
12 125197061 Fatality Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
13 125197061 Non Hospitalized injury Poisoning(Systemic) Firefighting occupations
14 125197061 Non Hospitalized injury Poisoning(Systemic) Firefighting occupations
15 125197061 Non Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
16 125197061 Non Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
17 125197061 Non Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
18 125197061 Non Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
19 125197061 Non Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
20 125197061 Non Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
21 125197061 Non Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
22 125197061 Non Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
23 125197061 Non Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec
24 125197061 Non Hospitalized injury Poisoning(Systemic) Supervisors; handlers,equip-cleaners,laborers nec

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