Document 1Qxy86bDdVxYmpE468z21e9QK

/ 9? K *0 J.-t H. Walteraate J, W. Gressler Cleveland Pedricktown 11-18-72 LOST TIME ACCIDENT - REPETITIVE #6 "CHEMICAL EXPOSURE*' MASS RESIN, PEDRICKTOWN On Saturday, November 11, 1972, at approximately 5:00 p.m. a lost time Repetitive Accident #6 "Chemical Exposure" was experienced in the Mass Resin Building (512) A technician -trainee fell into Reactor 8100 while cleaning the manhead collar. It is believed that he was overcome bv a combination of VC1 and No fumes- An acting lead tachnician climbed into the autoclave to give assistance and he_too was overcome,, The acting lead technician recovered upon being removed from the reactor* The technician trainee was admitted to Salem Memorial Hospital, intensive care unit* He was released on Tuesday, November 14 and returned to work on his regular shift November 16, 1972* The incident was reviewed with the personnel involved following the incident* A Board of Inquiry was held on Monday, November 13, at 3:00 p.m* with the following in attendance: H. Evans J-. Gressler W. Reed A. Webber Facts Before the Incident Lab Technician Industrial Relations Manager Resin Technician Acting Lead Technician Safety Engineer Resin Lead Technician Mass Resin Manager Computer Console Technician Plant Manager Latex Technician Trainee On Friday, November 10, 1972 Cesco, Inc*, a high-pressure-water-blasting company, was in the plant to clean the reflux condensers on Reactors #8100 and #8300* A small amount of Rock Drill Oil (Texaco Product) was added, by Cesco, to the water as a lubricant* An oily residue with a diesel odor was left in the reactors following the high pressure water cleaning* Cesco finished cleaning reactor 8300 at approximately 3:00 p*m, November 10, 1972* The cleaning equipment was moved to reactor 8100 where the cleaning was finished at approximately 4:45 p.m., November 10, 1972. Cesco could not remove all of the nlues from 810Q. redacted NOC 15764 NOV 27 LOST TIME ACCIDENT - REPETITIVE #6 "CHEMICAL EXPOSURE" MASS RESIN, PEDRICKTOVJN Page 2 Facts Before the Incident (Continued) On Friday, November 10, the 4-12 shift put a vinyl chloride rinse in 8300, recovered the vinyl, pulled a vacuum,broke the vacuum with nitrogen, pulled a second vacuum and again broke it with nitrogen* The Saturday 12-8 shift opened the vessel, prepared it for entry and evacuated for approximately one hour before entry was permitted. The vessel was cleaned without incident. The 12-8 shift then went to reactor 8100 and worked on removing more of the plugs. The Saturday, 8-4 shift charged a vinyl rinse to 8100 at 12:54 o.m. The reactor was recovered, a vacuum was pulled and broken with nitrogen, a second vacuum pulled and it too was broken with nitrogen. The last nitrogen break was at 3:48 p.m. From 3:48 p.m. thru 4:51 p.m. other work in the building was performed and 8100 was left idle. Sometime after 4:51 p.m. 8100 was partially prepared for entry. The prepolv hamer blind was turned and put in the blank position. The air transfer hamer blind was turned and put in the blank position. The emptine port was opened and the manhead removed. It should be noted that the VC1 charge line wasnot blanked, the keys were still in the agitator drive and the evacuation hose TjajTjaot been installed. acting lead technician, removed the manhead and activated the mechanical standby. The mechanical standby was activated for light, so the autoclave could be inspected. technician trainee, obtained a wire brush and started to clean the manhead collar.had his back to_ and was working on the manhead approximately twofeet awav from heard yell for help, he turned around saw that ' was in the vessel and struggling to get out. then climbedjinto the reactor to help ^-- ______ Facts at the Time of the Incident f"'** '* '+ {Y at f* *- ^ *=- * /c4 *< ( 01 ^ computer console technician, received an alarm in the computer room indicating that one of the vessel alarm systems had activated. He called Mass Resin, via the terryphone system, to determine the problem. After approximately 15 seconds there was no response. He again called Hass Resin, but received no response. resin lead technician, was in the computer room, asked to remain in the computer room while he went to Mass Resin to investi gate . Upon entering the building T heard the vessel alarm but did not see the warning light. He went to the port end of the vessels, looked in SlOQ.and noticed twq men on the..bottom..of the vessel- He ran to the second floor office find called . the computer room for help. then inserted an evacua tion hogg in 8100. ... called the lab and contacted the poly building for hlp - , resin technician, reported to the computer building to man the computer. then reported to Mass Resin. Upon arrival decided to pull the fire alarm for additional help. A Garlic, resin technician, heard the first emergency call and reported to Mass Resin. looked for emergency rescue equipment. They found an air line respirator but did not know where to make the connection. By this time arrived. instructed to call an ambulance. NGC 15765 LOST TIME ACCIDENT - REPETITIVE #6 ''CHEMICAL EXPOSURE" MASS RESIN, PEDRICKTOWN Page 3 Facts at the Time of the Incident (Continued) decided that too much time had been wasted and told the group that he was going in the vessel. held by the collar. It should be noted that the autoclave is horizontal and 5*9" deep. grabbed and handed him out t< then grabbed and handed him out t . Both men were then taken out to fresh air. Gressler arrived shortly after the men had been taken to fresh air.revived almost immediately. Poulson was un conscious but breathing. The Pedricktown First-Aid Squad arrived at 5:10 p.m, was put into the ambulance, along with ' and sent to Salem Memorial Hospital, Salem, New Jersey. Facts Following the Incident Al-1 of the personnel involved, except ~ were interviewed but could not add any information. An air content reading was taken on the vessel with a J & W combination meter. At the port end of the vessel the reading was 21% oxygen and 0% explosive mixture. At the manhead the reading was 16%> oxygen and 0% explosive mixture. When the readings were taken the evacuation hose had been in the vessel approximately 20 minutes, so they were not true readings. It is believed that were overcome by a combination of VC1 and N2 As recovered his reactions were different than what might be ex pected from VC1 asphyxiation, (he was very excited and hyperactive). At first Dr. Charles Norton, Plant Physician, indicated that there were signs of either xylene or benzene poisoning. As a result of Dr. Norton's thinking we thought that there-might be contamination in one of our raw materials or that the Rock Drill Oil might have a toxic ingredient. Cesco was contacted to determine if any product they might have used would cause such a reaction. Cesco referred us to Texaco, because the only ingredient used other than water was Texaco's Rock Drill Oil. Texaco's Eagle Point Plant in Westville, New Jersey, was contacted for information about Rock Drill Oil, however, they could not help us. They said that somebody would be in contact with us shortly. Within 15 minutes Mr. Ron Richards, Head of Toxicology for Texaco, New York Office, contacted us with some basic information about Rock Drill Oil. Mr. Richards called a second time with the complete formula With the information from Texaco Dr. Norton was convinced that there was no connec tion between the incident and the oil. We took samples of our nitrogen, fresh vinyl chloride, recovered vinyl chloride, an air sample of the vessel, an expired breath sample from l___ and an oxygen sample from our resusitator. The samples were sent out to be analyzed. The results can be found in "Exhibit 1". was released Saturday evening. was admitted for treatment and observation. i was released on November 14 and returned to work on his regular shift November 16, 1972. 157 LOST TIME ACCIDENT - REPETITIVE #6 "CHEMICAL EXPOSURE" MASS RESIN, PEDRICKTOWN Page 4 Additional Facts L returned to the plant Saturday evening. The incident was then reviewed with He could not add anything to vihat we had already learned. Since back was to he was not sure how got into the vessel, but thought that he might have fallen. _s reason for going in after was that ^ ha though^ he would be able to jump into the vessel, help . out. and jump- back out himself., However, the last thing remembers is having 1 n half-way out of the vessel. mass resin technician, was not in the building at the time of the incident. He was in the catalyst building weighing catalyst. Allied serviceman assigned to mass resin, was not in the building. He had taken a sample to the lab. W. A. Reed, J. W. Gressler, and \ , lead technician of the shift involved, went to Salem Hospital Sunday afternoon to talk to 1 was interviewed, however, he has no recollection of the Saturday incident.. With all, the information, as it is. we must presume, that.3 * and fell into the vessel. Corrective Action The vessel entry and vessel rescue procedures have been reviewed with all employees. A vessel rescue station will be provided in each of the polymerization buildings. (3) All air line respirator connections will be identified. We have started rescue crosstraining between areas. If it should be necessary to high pressure clean the condensers again, following the vinyl rinse, the manhead will be raised approximately 6 inches and the evacuation hose installed for 30 minutes before any work is done on the vessel. 6. Letters of commendation have been sent to the personnel involved in the rescue, the Pedricktown First-Aid Squad and to the guard that was on duty. NOC 1J767 LOST TIME ACCIDENT - REPETITIVE #6 "CHEMICAL EXPOSURE" MASS RESIN, PEDRICKTOWN Corrective Action (Continued) 7. The incident was reviewed with all personnel in the plant. Page 5 JWG:rp J. W. Gressler Attached cci D* L. Dowell - 0. F Beckmeyer J. L. Nelson - R. D. Scott P. D. Terry E. W. Harrington W. E. Brodine G. Pow *' j R. A. Kelley (Akron) Area Managers File o **'? A & /i u e a c *' i to & a c$ f~ . ' /^3 t? -- V <? / ` " / j For {3 *-T <3 /=> * )b a s r / Pec e ts-<* rj-<? f -t-a ^ft/C &< e 'x a e ~-y p Cf Cr *- ^ AA ie? Ls- * e. P * V. / t* * r Ai G- *-t . Pet Pea. ft " 'P t *'? -r , / **. P An. d a h ^e ~7 ^ *-c * C <t A e icP ^ Y r<r/^ Lv ^^ ^ ^ C/ 4.* C . J' "C'--t ex ex x ^ c k^n. at y tf Pet JS j/ /f - a r - ?>- NGC 15768 EXHIBIT 1 Nitrogen 99+% N2 Less than 4 ppm 02 No argon No C02 .35% VC1 Fresh VCl 99+% VCl Less than .1% N2 Less than .001% 02 Less than .001% argon No hydrogen Recovered VCl 99+% VCl .30% N2 .030% 02 .0030% argon Less than 10 ppm 02 No hydrogen Air Sample of Vessel 80+% N2 19.0% 02 .93% Argon .050% C02 .0024% VCl Expired Breath 75% N2 23.5% 02 ,9% argon .070% C02 Oxygen Pure breathing 02, no contaminates All samples were tested using a mass spectrometer. They were scanned from mass 2 thru mass 150. NGC 15769