Inspection Detail

Inspection: 306118555 - Basic Food Flavors, Inc.

Inspection Information - Office: Nv-E-Las Vegas 0953220

Investigation Summary

At approximately 10:30 p.m. on January 21, 2003, Employee #1 and a coworker were assigned to dismantle portions of a structure that enclosed the front part of a "small" liquid filter press. The two workers also had to cap off and remove air lines, steam lines, and to disconnect the electrical power. The "small" press was located 10 feet above the concrete floor and was accessed by a metal stairway located off to the left. While also performing other maintenance and repairs throughout the rest of the facilities, the two workers removed the guardrails, catwalk/work platform and front beam, and "busted" loose the press itself from the concrete floor. The removal of these materials was accomplished using ladders, fork lifts, oxygen acetylene torches and hand tools. Another coworker began cleaning the "large" press plates, which had been located behind the "small" press. The coworker saw Employee #1 walk up the stairway, open the wall electrical panel, "do something", and then go back down the stairway and out of the area. Approximately 10 minutes later, the same coworker saw Employee #1 come back up the stairway. Again, Employee #1 opened the wall electrical panel and "did something" for approximately three minutes. Employee #1 then closed the panel. The coworker lost sight of Employee #1 when he went to the back of the "large" press. Within a few minutes, the coworker came back around the "large" press and saw Employee #1 lying on the concrete floor several feet from the bottom of the staircase. The coworker yelled to another coworker, who was working off to the right side of the "small" press, and both of them went to help Employee #1. Upon arriving, Employee #1 was unconscious and bleeding from the back of his head. Employee #1 was transported to University Medical Center by ambulance where he was diagnosed with subdural hematoma, intraparenchymal bleed and aortic aneurysm (later found not ruptured). A CT scan revealed degenerative disc disease and fractures to the 12th thorax and third lumbar. He also had a closed head injury (later also a fractured skull), a contusion to his left thigh and an abrasion on the right hand. There were no electrical burns or blisters. On January 26, 2003 at 9:20 a.m., Employee #1 was removed from life support and was pronounced dead.

Keywords: STAIR, FALL