Document 3Qgx164o4gnZJD0qj8xYK6NKJ

TO: W. T. Gunning LOCATION: Avon Lake General Chemical BATE: September 27, 1967 FROM: Safety Department SUBJECT: Inhalation of Vinyl Chloride Vapors - Lost Time Accident On September 23, 1967, at approximately 1430 hours, chemical operator, was cleaning Poly 17 in Bldg. 451 when he was overcome by vinyl chloride vapors. The poly had contained a Geon 120 x 127 charge that had to be dropped after two to three hours of reaction time because of instrument failure. had been in the poly about 25 minutes and had cleaned the poly walls from the top down, including part of the agitator shaft. He then filled the bucket with poly scrapings, climbed out~of the poly and took it to the trash hopper. (At this time made some remark to the charge operator, about there being vinyl present in the poly. Dick reported he told J to put the evacuation hose back in the poly and let it go because the poly had to be held down for a maintenance check so it could not be charged. He also said he did not know if heard him as made no reply but kept walking back to the poly.) Because of the large amount of scrap in the poly, a four inch heel, obtained a second basket and went back into the poly. At this point started to break up the heel left in the bottom of the poly, which was a mixture of hard and spongy material, He filled one of the buckets with scrap which he passed to another helper. , to empty, emptied the bucket, went down to the second floor to close the bottom valve on his own poly, number 20, and then returned to the third floor. Before entering P-20, looked in P-17 and saw Leaning against the agitator shaft with his knees buckled beneath him. ran to and told him what had happened. went to the poly rescue cabinet, sounded the alarm and then went to Bldg. 46l for help. entered Poly 17 to attempt the rescue. Because he did hot have an air mask on, was forced to leave the poly, had returned to Poly 17 and he (without a mask) entered the poly to place the rescue rope about j ankles. realized that he was being overcome by vinyl vapors and left the poly. _ now had the air mask on and re-entered the poly, put the chain fall hook on the rescue rope and . was removed from the poly to the fire escape for fresh air. At this point apparently was not breathing and applied mouth to mouth resuscitation until " started to breath. The ambulance arrived and took to the hospital emergency room for treatment. Dr. Newman was notified and was in communication with the hospital.. At 1630 hours the foreman. Bob Mick, and r returned to the plant. changed clothes and was taken home. reported off from work Sunday because of nerves and nausea. Dr. New man was notified of this and he called and talked with him. redacted NGC 15587 Lost Time Accident 2- - September 27> 19^7 Dr* Newman examined C on Monday morning, September 25? 19&7 and returned him to his regular job, Tn the doctor's opinion, because of the medication received at the hospital, ... could not have worked on Sunday, A Board of Review was held on Monday, September 25? 19&? at 0815 hours. Present-were R. N, Rylands, D. E, Fisk, W. T. Gunning, R. M. Sandfry, A. J. Gula, J. C, Meek, L. Linder, J. Abrahamowicz, and R. F. Gascoigne. related his experience as far as he could remember. 5 also re ported to the board his part in the incident and Robert Mick read his report of investigation. A. J. Gula reported on the conditions of the vessel and equipment. Conclusions: 1. The so called heel in the poly was unreacted vinyl, water which formed ice and a small amount of Geon. As the heel was broken, VC1 vapors were liberated faster than the evacuation hose could carry them away. 2. At the time that < mentioned to Shindler that vinyl was present in the poly, . was already under the intoxicating effects of vinyl, which lead to his error of judgement in re-entering the vessel. 3. Poly 17 was not a normal charge and should have been in spected by the foreman with an explosimeter. Because of inexperience, the foreman was not notified. 4. There was a breakdown in communications for first aid services from the laboratory. Also there was a complete breakdown of our poly rescue procedure. Recommendations: 1. All polys, other than normal charges, shall be called to the foreman's attention so that he may check the contents with an explosimeter. This is to include all polys with a large accumulation on the walls and/or bottom. The Safety Department shall be consulted on these polys before entry is made. Our safety procedures must be followed. 2. We must follow the poly rescue procedure when a person is to be rescued. Much time was lost in this rescue attempt because masks., were not used at the onset. 3. Poly rescue procedure and poly cleaning specs will be a repeated topic for the ten minute safety meetings for all FVC and Latex polymerization employees. This is already being done by the General Foreman. NGC 15588 I ) Lost Time Accident -3- September 27, 19^7 4. More emphasis will be placed, by all management personnel, on the poly check sheet to be assured that it is properly filled out and complied with. Our poly cleaner training program will be evaluated and improved as needed. 5. More emphasis is to be put upon the charge operator's respon sibility over the poly cleaners job operations. 6. The buddy system will be stressed in all meetings because it is a must in our type of operations. R. F. Gascoigne Safety Inspector RFG/gac cc: A.Vittone-R.D.Scott J.L.Nelson G.Pow D.L.Dowell W.Brodine W.Cato R.N.Rylands D.E.Fisk R.M.Sandfry J.C.Meck R.E.Mick A.J.Gula NGC 15589 redacted SUPERVISOR'S REPORT OF ACCIDENT INVESTIGATION PLANT d ^ 1. NAME OF INJUI S. JOB CLAftSlKlC ... c \ cp1 3. EXACT LOCATION OR ACCIDENT n_nti hfJ.aeJr {BE SPECIFIC! DEPT. AND P.H. NO. ACE ^.........._ APPROXIMATE EXPERIENCE IN THIS CLASSIFICATION /- ui- r \t Hi ''-V, 4 J. DATE OF ACCLIDinEPNNTT * & /7 Side, t/s"/ ^17 HHQOUR 11 d - 3- 3 - ? 3. DESCRIBE THE INJURY DAMAGE OR LOSS nmw pm" C* V d >- dr- rV\ 1~ fa i-C? / 6. OESCRIBE THE ACCIDENT (BE SPECIFIC. GIVE COMPLETE DETAILS) WEATHER CONDITION 44;V______________________. LOST TIME 1 1 YES j 1 NO vft >(j /j i f)\ hp <2. / f/4>i fVc, Pc iy/_2_________ 'fVjfrPjJl Ijc fyft HA __Zjjjt pc f\/ S p Juej^r-i s /y^ i;y f-r -----"]!] *<?__ /; ? f&l.-- / 4 f 1 u ?7l vl. PcJcf.___7^ AL-^TVr __r *" *w~>7 ___//<4----.rh^r)--------Cfj 7~4'rr--p^~ //---------- .7 7 /- 77!>~- hrTfo ivu /) /J A<? 7 cf pc Jy_ id___ p<-'4 'nvi*- ' /vre Krf ------fr** 7>r i^r/.--Tc,--~t A r3 /fy{/-- 1'Tty* >-J) ur fit^T u? 1 t)} v7.>e1MP|.oVee`S ACKNOl*/> cor-r. ----r 1 Gcr ftp, i/j hid ft " LU&i'#-- Jlfiud^A CuT ZZl*?.Si if, Jh * 1i?i A/4 -r UNSAFE CONDITION j SPECIFICALLY. WHAT UNSAFE ABOUT THE VEHICLE. MACHINE. TOOL EQUIPMENT OR PREMISES? (IF ANSWERED. SEE BELOW) tJK _ hp>/ ft* A-< //t> t/Cft/ ft f f / iti . /"Z /^ / / //- J J r-j c _v>* f /_ /l-/i -l` " X/tfrry* ___ ON EXIST? (CHECK ITEM OR USE LINE ~C") t^Li/3 ______ {/Of - -ii A' cj -- NOT RECOGNIZED AS UNSAFE CONDITION HIDDEN DEFECTS . 9. UNSAFE ACT SPECIFICALLY. WHAT DID ANYONE DO. OR FAIL TO DO. THAT LED TO THIS ACCIDENT? |IF ANSWERED, SEE ITEM NO. lO BELOW] Y-* Te >> /i-tgj pc /y 4? f' w______ ^^ p'/itHQ f/C L- /s\0 REASON FOR UNSAFE ACT WHAT SPECIFICALLY. IN YOUR OPINION. WAS REASON FOR UNSAFE ACT? (CHECK ITEM OR USE LINE **1" DISREGARD OF INSTRUCTIONS , FAILURE TO UNDERSTAND INSTRUCTIONS 1 I NOT CONVINCED ABOVE ACT UNSAFE INATTENTION C. DID NOT KNOW THE NEEDED METHOD GL INDIFFERENCE (LACK OF INTEREST) D.K UNSKILLED ( Ai-1 Tf-PF M>2F>J I-----1 MENTAL OR PHYSICAL CONDITION (EXPLAIN) it. CORRECTIVE ACTION 1. 63 ' h* b* }*>H ____ hi 5 jWff*Uri.7~~-^ by V'r'7/ . sjhl\r.h h* h*u4 ht'*>ahfa'*><1 ~ 6/r\ fijrfy wtfAT SPECIFIC ACTION HAVE YOU TAKEN TO CONTROL THE ABOVE UNSAFE ACT. UNSAFE CONDITION. AND RITasGn 1 /%/</ ^ olh^ /nau<p -/-/w ft-rt c. hftC A: A-f{ tOft /vs , ttc<z<?iTT nnrvnfi-/ ft ^ Tu^T/'n^ Ts>____ cJeftD____ ! ) 12. IS JOB METHOD ADEQUATE? DATE OF THIS REPORT !> YP F &VI^JYVED ANC^PPROVE D BY L <4X DISTRIBUTION: WHItIe-SAFETY DEPT. YELLOW-DEPARTMENT MGR. 1 } NO IF "NO" ATTACH EXPLANATORY MEMO ^ ----------------------- NGC 15590 BLUE-GENERAL FOREMAN