Inspection Detail

Inspection: 315282897 - R.R. Donnelley

Inspection Information - Office: Nv-E-Reno 0953210

Investigation Summary

On April 25, 2011, Employee #1 and a coworker, had begun bringing a firetube boiler back online after performing an annual inspection. The boiler was filled with preheated feed water supplied by a deaerator tank. The boiler had not been started up at the time of the accident. Employee #1 was a trainee working under the direct supervision of a coworker, an experienced boiler technician. The coworker noticed one of six handhole covers leaking on the boiler. Employee #1 was instructed to tighten the handhole to stop the leak. Employee #1 used an eight inch crescent wrench to tighten the nut on the stud bolt on the handhole cover. After the leak stopped, Employee #1 was instructed to tighten the other handhole covers a small amount. Employee #1 was tightening the last handhole cover when the stud bolt failed. The cover plate slid down on the inside of the boiler which allowed the hot water to flow out of the opening and into the face of Employee #1. Employee #1 was transported to a local Medical Center and later transported by air to the regional burn center. Employee #1 suffered second and third degree burns on his face, chest, and shoulders.

Keywords: BURN, WRENCH, BOILER, FACE, WATER