Document bvQ9bo4JOVvNxworRZmp7Dby

ge 2 5. There was one nut that could not be turned by hand and used a l 5/8" open end wrench to turn it. 6. As he pushed the wrench for a third turn (less than one complete revolution of the nut) the nut broke free of the burr on the bolt. 7. knuckle struck a nearby pipe resulting in a sharp pain in his hand for about two minutes. 8. When the pain subsided completed the work at the filter. 9. When the work was completed Dave noticed swelling in his hand and went to the lab for first aid. 10. He was taken to the hospital for x-rays and two broken bones in his left hand were discovered. 11. ' returned to work on Sunday for his scheduled shift. FACTS SURROUNDING THE INCIDENT 1. The filters are routinely changed on a monthly basis by the area operators, with Dave having done them numerous times. 2. The proper tools were being used. 3. Some of the nuts can only be turned one flat of the nut at a time due to other obstructions. 4. Dave was not rushed to finish the job. MANAGEMENT SYSTEMS INVESTIGATION 1. There has been instruction in the proper use of tools at our plant. 2. safety performance is unsatisfactory. CONCLUSION This injury was avoidable by exercising more caution and repositioning himself in order to pull the wrench away from rather than push it towards the pipe. W. Kent NGC 13691 REPORT OF MINOR X NJURY <m4 Ec. SECT IQM 44 1 -?--*<:-- F .OYEE NAME: EMPLOYEES JOB TITLE: _ COMS-QC^ WHEN EMPLOYEE CAME FOR TREATMENT. DATE OF INJURY: 1 | --M. ^ ~2_ TIME: 'Tf^C-WNiU DATE: "7~ 4 0^\TMS ^p'm! Slfc3 DEPT.# TIME: STATE ^JnIATURE GF INJURY AND INCLUDE EMPLOYEE'S STATEMENT. ^ S17VP6^> tfe" IvAS TT/lPFTgyO Uv> /V Piltw "TO Lj\\e*S Vl\ 1 A 0^ St^U^vT 4^l \?^ t y pfve TREATMENT ADMINISTERED: p;K)^Tt ^ t5i" P^V) PAtir - tV>Cf,TM.____ ^nCACTU^ EMPLOYEE SENT: WORK 7* HOME EMPLOYEE SIGNATURE:'' FIRST AIDER SIGNATURE:^ DOCTOR l / tf?) HOSPITAL X X l) 1 (ir SENT TO DOCTOR OR HOSPITAL, MDICATe HAHE.K DATE: 7~ V DATE: CORY TO LEAD CH/ IED SUPERVISOR SECTION 4*3 LEAD T EE CI /Al IED SUPERVISOR LEAD TECH/ALLIED SUPERVISOR REMARKS ?< CORRECTIVE ACTION: (W\!i (X t^JLA^ _VV.X- V3/V-L_ V^L") VvSl^.<^ (VCv-Yjc r ^ ! ' A. _A MANAGER SIGNATURE JSS-063 2--18--88 TURN TO WITH I N-- TWO Y DEPARTMENT WORKING DAYS DATE: NGC 13692 DATE: August 3, 1992 TO: F. M. Schuler FROM: D. C. Hicks RE: VCM EXPOSURE IN EXCESS OF PEL LOUISVILLE PLANT Summary Two pipefitters were exposed to VCM in excess of the PEL while connecting/disconnecting VCM tankcars. Respiratory protection was not worn. Board of Review A Board of Inquiry was conducted on June 23, 1992, in the Engineering Conference Room to discuss the incident. Those in attendance were: S. Deetsch D. Hicks B. Kinslow H. Kletke R. Mueller F. Schuler A. Simpson - Engineering Supervisor-LPA - Engineering Supervisor-Utilities - Tank Farm Foreman - Plant Manager - Manufacturing Manager-LPA - Pipefitter Pipefitter - Plant Engineer - Manager, Health, Safety & Environmental Corrective Action 1. Communicate and enforce respiratory requirements during tankcar work. (Hicks/Barnes by 5-15-92 - Complete) 2. Review VCM training requirements with all pipefitters. (Bames by 8-15-92) 3. Post a warning sign at the VCM unloading area indicating mandatory use of respirators. (Kinslow by 8-1-92) 4. Reroute breathing air lines/hoses at the VCM unloading stations to make it less cumbersome to perform work with respiratory protection. (Camm/Kinslow by 6-15-92 -- Complete) 5. Investigate engineering controls to minimize/eliminate VCM exposures. (Dcctsch by 9-192) REDACTED NGC 13693 2- - Narrative Personnel monitoring for VCM exposure indicated that pipefitter ( was exposed to a Time Weighted Average (TWA) of 1.08 ppm on April 20 and 1.20 ppm on May 4 while performing the VCM tank farm job. y another pipefitter performing the same job, was exposed to a TWA of 1.23 ppm on May 11. Neither ' were wearing respirators during the connecting and disconnecting of VCM tankcar unloading nipples and hoses. Facts Surrounding the Incident 1. Respirators have not been worn consistently during VCM tankcar hook-ups. 2. Respiratory protection was not re-established as an actively enforced requirement until May 15, 1992. Management Systems Investigation 1. Management failed to enforce the requirement of wearing respiratory protection. 2. Poor communication of personnel monitoring results over the last several years promoted deterioration of enforcement. Conclusion Two pipefitters were exposed to levels of VCM that exceeded the permissible limits for an 8hour TWA because they were not wearing proper respiratory protection. D. C. Hicks sjm NGC 13694