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^ 7 CT*H '"W2 -J- c* // B.F.GOODRICH CHEMICAL COMPANY Avon Lake General Chemical Plant - TO: V,r. T. Gunning FROMi J. R. Shellenberger DEPT: Safety DEPT: Geon DATE: November 16, 1972 SUBJECT: Near-Miss Accident - Overcome with Vinyl Chloride Vapors Inside Poly Repetitive Accident Type #6 Cei/ SUMMARY: On November 13, 1972 at 0835, ' , Chemical Operator 2nd Class, was ' 46overcome, with Vinvl Chloride vapors while cleaning inside _a pearl reactor in B/ I in the.Geon Resin area. He was removed bv the normal rescue operation and taken to idle outside catwalk where he was revived by Dr. Newman and the nurse. He was then taken to St. Josephs Hospital where he was kept for observation overnight. He was released on November 14-th without any further complications. BOARD OF REVIEW: A Board of Review was held at 0930 on November 13, 1972 with the following people in attendance: R.N.Bylands W.T. Gunning R.S, Mather W.K.Pember R.F.Gascoigne J\ R. Shellenberger - Chemical Operator Helper - Chemical Operator 2/c - Chemical Operator Helper Glen Evans - Foreman - Charge Operator - Charge Operator NARRATIVE OF EVENTS: On the 12^8 shift at about 0400, poly 109 had been recovered and opened for cleaning. The evacuation hose was inserted into the poly at this time. The man on 12-8 did not carry the poly cleaning procedure any further as he was reassigned to the Catalyst Bldg, at 04-00. The poly remained in this condition until the start of the 8-4 shift at 0800. The poly evacuation system was working well during this period of time. shift was scheduled to work on the day shift. had come in at 0400 on the 12-8 shift for overtime, so he knew that poly 109 had already been partially prepared for cleaning. working 12 midnight to 12 noon, started working on poly 111 next to poly. 109. At about 08l opened the manhead on poly 111 and inserted an evacuation hose into the poly - the same hose that had been in poly 109 since 0400. then washed the residual resin out of poly 111. Simultaneously, Tippie finished washing down poly 109. then cleaned the top blades with a special tool while working outside of the reactor and then started working on the bottom blades. Be was having difficulty getting the botton blades clean. During this same time _____ reached__in through the manhead with both hands to chip off the build-up on the top_ baffle hanger - using a hammer_and screwdriver. REDACTED NOC 15761 MOV 20 Near Miss Accident - Overcome with Vinyl Chloride Page 2 At about 0825 . having finished nolv 131 - flaked if h&^waTlted the. bottom inspection plateremoved/polv 109 am indicated that he did. went to the second floor and removed the bottom inspection plate on poly 109 for i ______and on polv 111 for himself. Neither bottom valve was closed because i assumed that both polys would be HRG cleaned - not knowing the difficulty was having in removing lumps stuck to the poly 109 agitator. returned from the second floor and was prepared to insert the HRC Unit into poly 111. told"Hey watch out". _______. at_the time_did not know what he meant and resumed his work on poly 111. indicated that just prior to this conversation he observed __ lock out polv 109. insert the ladder, into poly 109 and go get his bucket and cleaning -bnnla. He recalls seeing _, t out of the corner of his eye enter the poly assuming that " had performed the proper vessel entry preparations. also recalls hearing . __ hammering inside poly 109. After 2-5 minutes says he turned from his work on poly 111 and noticed that the evacuation hose was not in poly 109. He looked into the poly and sawsitting on the bottom in a slumped position with his arms wrapped around the agitator shaft. _ . summoned help an. was removed from the poly by the normal rescue methods. He was revived on the catwalk and subsequently taken to St. Joseph HospitaJVwhere he remained overnight for observation. Oi-. lli + f A x c_ p<x^*y 0 + . returned to the plant the following day for an interview concerning the accident. ADDITIONAL INFORMATION: 1 storv agreed perfectly with _____ story up to the point he decided he had to enter poly 109. Beyond this point in time he remembers 2Sfeig- ou*s.J* 2. While was chipping off the lumps 'from the bottom blade his face was fairly close to the manhead. but not inside it. 3. While using the screwdriver and hammer for baffle cleaning, his face probably was somewhat inside the manhead. 4. had 7-8 hours sleep the night before even though he worked over time. He stated he was not overtired at the time of the incident. OTHER BELATED FACTS Kc jje/ While . was in polv 109. the bottom valve on the poly was open, the <? //o P-: evacuation hose was not in the poly, the top inspection plates were still in place and a poly safety check sheet for poly entry had not been filled he. out. These are all violations of the standard polv entry procedure. Jt 2. At the time the rescuer went into polv 109 he "felt" the presence of VC1 on his legs. The concentration, therefore, was apparently very high in the poly at the time of rescue. NGC 15762 Near Miss Accident - Overcome with Vinyl Chloride Page 3 3. The VC1 entered the poly through a defective Saunders valve on the Blowdown tank and through the onen bottom valve on oolv 109. 4. At the time removed the bottom inspection plate there was no VC1 coming out the opening. says he is very sensitive to VC1 and-he feels he would "have noticed VC1 if it were present at this time. The inspection port was not plugged because i flushed it out. 5. VC1 was profusely coming out this inspection plate opening when the source of VC1 was found during the rescue operation. 'Why it was coming out at one time and not another is an unanswered question. DISCUSSION: Since has no memory from the time he decided that he must enter the poly, there is the possibility that he was being overcome with VC1 from the manhead as he was cleaning the t>olv externally. The concentration of VG1 in the poly was very high when was pulled from the poly. However, there was no VC1 coming from the bottom opening when the inspection plate was removed and most of the cleaning from the outside did occur before this time. VCl was freely flowing out this inspection port at the time of the rescue. If _ was partially overcome with VCl through the manhead this could explain why he did not follow some of the safety procedures, since VCl does have an intoxicating effect. However, it is inconsistent that he would not follow the normal entry safety procedures, but that he would be able to lock out poly, insert the ladder, get his tools, speak to _ , enter poly and start hammering. BECOMMSNPATIONS and ACTION TAKEN? Based upon Hie facts available was suspended for ten working days. The accident is being reviewed with the rest of the department. It is being stressed very strongly that violation of standard safety practices in the future could lead to termination whether an accident is involved or not. The use of hand tools for cleaning 1100 gallon polys from the outside will be discontinued immediately. The use of a separate HRC cleaning safety check sheet will be abandoned. The poly preparation for HRC cleaning will be more identifiable to the vessel entry procedure so that when an entry is required, only a few more steps will be needed. Q) When Hie poly alarm cart is not being used it has been the practice to have another employee working in the immediate area to make frequent manr. head checks. This practice will be discontinued and the standby will be required to continuously monitor -the poIt entry. The five minute alarm interval on the poly alarm carts will be changed t-n three minute intervals. The use of an alarm cart at five minute intervals would have given a longer VCl exposure in the poly than was experienced with the use of as a standby in Hie immediate area. JHS/hu H-X g - . R. Shellenberger DON