Fatal Accident Circumstances and Epidemiology (FACE) Report: Worker Dies While Cleaning Freon 113 Degreasing Tank in Virginia, November 21, 1986

摘要

A worker died while assisting three workers who were cleaning out a Freon-113 (76131) vapor degreaser at a chemical fuel plant. During this procedure solvent was drained off and the residue on the bottom of the degreaser was cleaned out. The company had written instructions for cleaning out the degreasing tank. All but about 1 gallon of the solvent had been drained off. After taking a break for lunch, the three men returned, picking up the fourth worker who was experienced in the cleaning operation. Using removable wooden stairs two men, including the experienced worker, climbed into the tank. Shortly thereafter both men had trouble breathing and exited the tank. The experienced worker collapsed to the floor and died shortly The other worker experienced no ill effects. The men were using air purifying respirators designed for limited use with organic solvents. The cause of death had not been determined. Recommendations arising from the accident include the performance of a preliminary hazard analysis by the employer to determine hazardous areas within the company and design a more detailed task specific job hazard analysis, initiation of comprehensive policies and procedures for confined space entry, the development and implementation of a more comprehensive respirator program including either quantitative or qualitative fit testing and training in the use and limitations of this equipment.