Inspection Detail

Inspection: 303863930 - Becton Dickinson Microbiology Systems

Inspection Information - Office: Madison Area Office

Investigation Summary

On August 19, 2001, Employees #1, #2 and #3 were handling a failure in the operation of an autoclave. Several bottles within the autoclave started to explode after the autoclaving of 178 tightly capped glass bottles for a 30 min gravity cycle. Coworkers called maintenance to the scene of the autoclave failure. Employees #2 and #3 investigated the situation by observing where the broken glass was while standing directly in front of the autoclave. Only a few of the bottles had exploded up to this point. After investigating for a few minutes, these employees went to another part of the Processing Room, and Employee #1 began to don a thermal suit for removal of the glass in the autoclave, and the rack that was holding the remaining unbroken bottles. Then suddenly, the remaining bottles in the autoclave exploded. The rack holding these bottles was ejected out of the autoclave by several feet, knocking over Employee #1. Glass shards and steam were sent throughout the Processing Room at high velocity. Employee #1 had partially donned the thermal suit, and had not yet put on her face shield, but was wearing safety glasses. She received several first and second degree burns and injuries to her arms and face from the flying glass. Debris from the explosion shattered lights on the opposite side of the room, approximately 25 ft from the autoclave. The other two employees were in or at the entrance of the room when autoclave exploded, but were not seriously injured.

Keywords: BURN, PRESSURE VESSEL, EXPLOSION, LACERATION, FLYING OBJECT