Document DDb0N1aj8eQo7KoN3xG6X8vL5

R. E, Jones 20 April 1976 W. J Stueben \ Unusual Occurrence Report - Lost-Time Injury On 5 April 1976 at: 2:10 p.ra., a Hays iron stop (plug cock valve), Model 7450 on a 10,000 gallon tank car, SRPX 14962, broke while 60% Dimethylamines was being off loaded to a truck, spraying a loading operator, Tom Clyatt, with the amines. The operator was taken to the hospital where he is currently being treated for burns to the skin, lungs, trachea, and eyes. The prognosis is good. Investigation of the incident revealed the following: The operator had the required protective equipment on and had followed normal procedures when the accident occurred. * He went to a safety shower immediately after the incident. The degree of injury was increased because the wind blew the escaping vapors towards the operator while he was in the safety v shower, causing him to breath additional vapors. f - Two other valves, identical to the one that broke, were found near the loading area broken the esme way, indicating previous problems with this type of valve. These problems ware not reported to Amines management. The operators were having the valves rep -replaced without notifying their supervisors. ----- - The valve broke while the operator, was standing next to it, indicating that it had bean broken previously, either when starting to load or at another time. 1 _ - Thera is no automatic shut off available in the plant that would prevent Amines from being discharged if a valve broke or a line ruptured while loading with natural ga3 pressure. In this case, the natural gas had' been shut off because the truck was almost full and the Amines was discharged from fche^car by the remaining pressure. * Laboratory analysis by our insurance carrier will determine why the /i valve broke. \ 4 AP00054496 R* E* Jones -2- 20 April 1976 Conclusiong Lack of communication from the operators to their supervisors enabled the problem of inadequate and breaking valves to go unrecognized, The wearing of goggles by the operator prevented any severe corneal damage. Action to Prevent Recurrence ^|J^ q Amines solutions will no longer be loaded into any tank car without first replacing any plug cock type valves with Wooster ball valves. A project to load solutions by metering in order to reduce product losses will be reemphasized in that it will also reduce operator exposure to possible loading accidents, - Escape-type respirators will be required while loading as soon as /they are certified by NIOSH. ^---- (m _ Additional Actions 4uid=>. Wo,^ #J<noT Loading procedures across the plant will be reviewed by the Safety Dept, and the Loading Supv. and findings and recommendations will be reported to the Central Safety Committee for action. The incident will be publicised so that everyone is aware of what happened and why it happened. Goggle areas around loading platforms will be reemphasized and expanded in recognition of the potential for exposure and the value of goggles. .. UJSsjsr * -W. j* Stueben * ./ AP00054497 BIOGRAPHICAL HIGHLIGHTS Brian-A. Gebbia Plant .Superintendent Education: Bachelor of Science in Chemical Engineering University of Southwestern Louisiana , 1971 Master of Science in Chemical Engineering West Virginia College of Graduate Studies, 1976 Radiology Training: Basic principles and practices of radiation in. General Chemistry and Basic Engineering courses oresented in BSChE curriculum. Radiology Experience: Ohmart density gauges (nitric acid use) . Radioactive source is Cesium-137. Duration of exDerience was 4 months. AP00054446 and C6e*nica&- tSCAMBlA PLANT BIOGRAPHICAL HIGHLIGHTS WILLIAM V. HENRY - SAFETY ENGINEER Education: Bachelor of Science in Safety Engineering Louisiana State University, 1973 Radiological Courses Taken: 1) Nuclear Science 2051, ''Contemporary Radiological Science" Introduction to radioactivity in nature, synthetic radionuclides and radiation sources; radiological applications in chemistry, industry, biomedical sciences, engineering, energy production; radiological safety. 2) Nuclear Science 4331, "Radiation Hazards and Control" Consequences of human exposure to high energy radiation; control of radiation hazards, including exposure limits, detection techniques, shielding, laboratory design, emergency action, and federal and state regulations. Professional Training: NIOSH course, "Recognition of Occupational Health Hazards" A portion of this course was devoted to radiation aspects. 2/5/81 AP00054447