Document BydR7vj7pbnD2vB01eomjaX2X

/ 9? X. 7~Y/e* H. Waltemate 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 mMihead collar- It is believed that he was-overcome, bv a combination of VC1 and No fumes. An acting lead technician sUafesfl into the autoclave gjys assistance and he too was overcom^. The acting lead technician recovered upon being removed from the reactor. The technician trainee was admitted to Salem hfemorial Hospital, intensive care unit. He was released on Tuesday, November 14 and returned to work on his regular shift November \ , 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: Lab Technician H. Evans Industrial Relations Manager Resin Technician ( J. Gressler Acting Lead Technician Safety Engineer W. Reed %/ Resin Lead Technician Mass Resin Manager Computer Console Technician A. Webber Plant Manager Latex Technician Trainee Facts Before the Incident 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 plugs from 8100. A/0 0**.+Jr`* *- --jj c * * fc -e f / Je/ ^ a, ^ C-/-- /y < J >*** V I' NGC 15770 Redacted mm. a? tw LOST TIME ACCIDENT - REPETITIVE #6 "CHEMICAL EXPOSURE" MASS RESIN, PEDRICKTOWN 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 p.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 prepoly 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 VCl charge line was not blanked, the keys were still in the agitator drive and the evacuation hose had not 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 colla had his back tc and was working on the manhead approximately twofeet away from j.. heard ~ yell for help, he turned around saw thatwas in the vessel and struggling to get out. then climbedj^into the reactor to help " Facts at the Time of the Incident V C , t' CL K /4 ( Lew__ , 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 Mass Resin, but received no response. .. resin lead technician, was in the computer room, asked ... Co remain in the computer room while he went to Mass Resin to investi gate . Upon entering the building heard the vessel alarm but did not see the warning light. He went to the port end of the vessels, looked in 8100 and noticed two men on the bottom of the. vessel. He ran to the second floor office and called ' in the computer room for help then inserted an evacua tion hose in 8100. called the lab and contacted the poly building for kelp. , resin technician, reported to the computer building to man the computer. r then reported to Mass Resin. Upon J arrival decided to pull the fire alarm for additional help. , resin technician, heard the first emergency call and reported to Mass Resin. ____ _ooked for emergency rescue equipment. They found an air line respirator but did not know where to make the mection. By this time 5 arrived. ,.tcr instructed to call an ambulance. NGC 15771 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 C _______by the collar. It should be noted that the autoclave is horizontal and 5'9M deep. " grabbed ~ and handed him out to .' then grabbed and handed him out to Both men were then taken out to fresh air. Gressler arrived shortly after the men had been taken.to fresh air. _____ revived almost immediately. I 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 All 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 tha> - were overcome by a combination of VC1 and N* 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 Poulson 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. was released on November 14 and returned to work on his regular shift November 16, 1972. NGC 15772 LOST TIME ACCIDENT - REPETITIVE #6 "CHEMICAL EXPOSURE" MASS RESIN, PEDRICKTOWN Page 4 Additional Facts returned to the plant Saturday evening. The incident was then reviewed with He could not add anything to what we had already learned. Since back was to________ he was not sure how got into the vessel, but thought that, he might have fallen. C reason for going in after ' was that he thought he would be able to jump into the vessel, help 1 out, and jump ^ back out himself. However, the last thing half-way out of the vessel. remembers is having , mags resin technician, was not in the building at the time of the incident. He was in the catalyst building weighing catalysts Robert Synder, 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 William West, lead technician of the shift involved, went to Salem Hospital Sunday afternoon to talk to I was interviewed, however, he has no recollection of_hhe Saturday incident. With all the information, as it is. we must presume that ` Tjge 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 bui ldin'gs. All air line respirator connections will be identified. We have started rescue crosstraining between areas. ^5) 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. NGC 15773 PUSl DON - * r - // /* 9->* 9 -r cS A v *-*< '*]'**/ Vr-o, y. ^ * S: ' 9 9^? *#y /Mfl ? 9^ ~s> V t-4- ^ p W '"V ^ -J jOV /T? ^ * ?*? 3--f 9 -^y * J* Ps ^ - *J O --tj y v <p* V *" * ~t * ^To-y c,J &*&~4 c/ -* s/>a * r> X P yt ^ p 3 Wpj-9^ y 9j*j &v *. y ** *y- ' y*J19Cf * * cS S> * 0 v/- V" a 7?J >/ /~ ^-_r * vl -Jt :f * P yV- ^ ? <? rA 0 caf* A *" V9"'*'5> 7 r-'%X 1700S -laXsaj^osg 9IT1 saoS'pu'ew BS-iV (uoa^v) ^1133 `V "8 oa *o auipoaa `a *tt UO^SUXJJBH 'tt *a AaaX 'a '& a *U - uos-[3N -1 T *a 'o - ii9oa *t 'a : do 33X98323 *ft p3tlD333V d3t3Hf g sSea ^uxd stX^ ux x9^uosaed xi pswexAaa spw ^uspxoux sqi (_ (panux^uoo) ucTnov"SAxlpsaaoo MrtoxxDiaaaa. `nissh ssvw ..aansoaxa TvoiHaHD,, 9# aAixiiaaaa - XNaaiDDv awix xsoa EXHIBIT 1 Nitrogen 99+% N2 Less than 4 ppm 02 No argon No C02 .35% VC1 Fresh VC1 99+% VCt Less than .1% N2 Less than .001% 02 Less than .001% argon -No hydrogen Recovered VC1 99+% VC1 .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% VC1 Expired Breath . 75% N2 23.5% 02 .9% argon .070% C02 Oxygen Pure breathing 02a no contaminates All samples were tested using a mass spectrometer. They were scanned from mass 2 thru mass 150. NGC 15775 T* 7r /*?>*. ( H. Waleemate J. IT. Gressler Cleveland Pedricktown 11-20-72 HEAR ilISS - R^ETITIVE#7^nE)gL0DDJG^B00B^TRAPn - PEDRICKTOWN On Tuesday, October 10, 1972, at approximately 3:30 p.m* a Repetitive Accident Type #7 "Exploding Booby Trap" was experienced at the Pearl-Paste Polymerization Building (513), An explosion occurred within paste reactor #26. No injuries resulted! however, two roof panels and a roof ventilatpr_abov_-J:he reactor were.. dislodged and a wall panel on the pearl side of the building was separated sUghtlY.- A Board of Inquiry was held following the near miss, with the following in attendance: ,. - Lead Technician H. T. Evans - Industrial Relations Manager J, W. Goetsch - Resin Manager G. E. Higby - Sr. Electrical Engineer - Technician - Technician - Technician J. M. Smith - Plant Engineer A. R. Webber - Plant Manager Facts Before the Incident Paste Polymerizer #26 had gone through the normal sequence of gvents without incident. The reactor was put on transfer at 3:00 p.m. and had finished the transfer and recovery phases by 3:20 p.m. paste technician, opened the* mknhead and .inserted a Crouse-iJinds type EyH 106 drop, light into the reactor. He then started flushing the reactor with a P.M. water ho sg. He had been flushing the reactor for approximately 5 minutes when he noticed water and some small chips setting on the bottom-of-the reactor.. He called _to the computer console technician via the two-way radio, to find out if the sewer valve had been opened. The console technician replied that it had been opened. then went to the first floor to double-check the_position of the.Yarwav valve. While Yarway the explosion took place. _was_checking the Facts at the Time of the Incident .i, lead technician, a technician trainee, the explosion occurred. , technicians, and r were on the Pearl side of the building when was inside poly #3, cleaning the reactor. AIL five employees heard the explosion but were not sure of the source. and stood by while got out of poly #3. Cawman had the computer technician put the building to "hold." REDACTED NGC 15776 NOV 21 1978 KEAR MISS - REPETITIVE #7 "EXPLODING BOOBY TRAP" - PEDRICKTOWN Page 2 Facta at the Time of the Incident (Continued) ran from the first floor to the second floor, noticed an acrid odor, sounded the gas alarm and put on a Scott Air-Pak. __ went to their gas alarm stations. ... complaining of a ringing sensation in his ears was sent to the Dispensary. put on a Scott Air-Pak. ( wearing Scott Air-Paks, went to poly #26, installed an evacua tion hose, disconnected the drop light and checked the area. Both, and a noted the hole in the roof, but saw no other physical damage. Facts Following the Incident r-- .. --i The roof panels immediately above the poly were dislodged and a hole approximately 4* x 12* was opened in the roof. The roof ventilating fan above poly #26 was pushed upward from its base and the electrical conduit pulled loose. No evidence of a fire or explosive force was noted in the vessel; however some charring was present on the roof beams just above the reactor. The rupture disc, rated at 235 psi, was blown. The drop light fixture was blown out the roof and found 10 feet from the S.E. corner of the building. An investigation of the incident and a thorough check of the area was conducted by J. W. Goetsch, G. E. Higby, J. M. Smith, _ and H. T. Evans before the "all clear" was given at 3:45 p.m. The investigation and subsequent board of inquiry drew the following conclusions: fl) Residual vinyl from the previous paste charge was ignited bv an electrical spark. (5) ' The Crouse-Hinds EVH 106 drop light was not equipped with a supporting chain. The light cord was secured at the manhead with the full weight of the light fixture supported bv the cord. 3. The trainee, , was tested and sustained no damage to his ears. 4. Poly #26 remained out of service until a thorough inspection and hydrostatic tests were conducted. 5. The manual vent line on poly #26 was slightly bent but did not require re placing. 6. Normal operations were resumed in the building at approximately 4:15 p.m. 7. All employees responded to the emergency calmly and efficiently. The employees in the building, especially 'e most effective. NGC 15777 NEAR MISS - REPETITIVE #7 "EXPLODING BOOBY TRAP*' - PEDR1CKTOWN Page 3 Additional Facta L. The cause of the explosion is due to one of three possibilities: a. The light separated from the cord causing an arc, and the ensuing explosion. OR b. Water may have been accidentally sprayed on the hot globe causing it to crack thus causing a short and the ensuing explosion. OR c. The drop light may have slipped hitting the bottom of the reactor causing the globe to break, a short and the ensuing explosion. 2. All drop lights were equipped with supporting chains; however, the particular drop light involved did not have a supporting chain. The drop light was a low voltage, explosion-proof type but was not water proof . *-- 4. The transformer did not short out and the breaker did not trip. According to w _ the reason for the transformer not shorting or the breaker not tripping is that the cord was found with the wires separated and not touching. 5. Drop lights are inspected quarterly., however this particular drop light was two weeks past due. 6. Mr. W. E. Brodine was contacted and concurred with the inspection and test of the vessel. The vessel was entered, visually inspected and measured. No variations were apparent. The agitator was removed to protect the oil seal during the hydrostatic test. The reactor was filled with water and pressured to 375 psi. The pressure was held for one hour with no noticeable loss of pressure. The vessel was hydrostatically tested according to ASME code. Corrective Action 1. All drop lights were removed from service immediately. 2. _Explositm-proof hand lanterns have been purchased and are in use. ^3^ Drop lights ordered in the future will be explosion proof and waterproof. The inspection of electrical cords and appliances was re-emphasized. NOC 15778 NEAR MISS - REPETITIVE #7 "EXPLODING BOOBY TRAP" - PEDRICKTOWN Corrective Action (Continued) The Incident was reviewed with aLl employees. Page 4 JWG: rp J. W. Gressler cc: D. L. J. L. P. D. Dowell - O. Nelson - R. Terry F. Beckmeyer D. Scott E* V. Harrington tf* E. Brodine G. Pow R. A. Kelley (Akron) Area Managers File e. A 4V y^ <j. f- AVjO f ' '/**- a <l ct Ijo o^ > "f" * j/o *^o c- F 4^ -r u i> Awt **-* e. /V *- v'i' r ftj'e. <j * /. v /f */ 3C+ a -pO *- !r o ^ a ot e. /`J y jyg e * y / y^e /* e /cr r f-A.t* y y^-e- ^. oy Fot' ^ s`t//a C y ` h Gt , **-t w //, 9 Aot'fr^o ^ &LSO c$ G G/ y o /<- c / C. ?/; //- a <r- ? 2-. NOC 15779