Employee #1, the lead operator of a sewage treatment plant, noticed
that the residual levels had dropped in the tanks, and he decided to add
more ammonium hydroxide to increase the residual levels. Employee #1
removed the camlock fitting and line from an empty 335 gallon tote and
installed it to a full 335 gallon tote containing ammonium hydroxide
solution. While installing the camlock fitting and line onto the full
tote, he failed to secure the camlock fitting latches into the valve
coupling grooves.
As Employee #1 turned the valve to
the open position, the camlock fitting and line sprung off the coupling
and sprayed ammonium hydroxide onto his upper legs and groin area.
Employee #1 immediately turned off the valve and secured the camlock
fitting latches into the coupling grooves. He then went to the emergency
eyewash/shower, approximately 120 feet away, to rinse off the ammonium
hydroxide. Employee #1 rinsed for approximately 15 minutes, but did not
take off his clothing.
He then drove a golf cart to the
administrative building, to notify management of the accident.
Management summoned emergency medical services at approximately 9:45
a.m. and rinsed Employee #1 with an emergency eyewash/shower, located in
the administrative building, until the ambulance arrived. Employee #1
was transferred to the hospital via ambulance at approximately 10:00
a.m. He was hospitalized for two days for treatment of chemical burns to
his upper legs and groin areas.
The use of ammonium hydroxide to
control residual levels in tanks was a new process at the facility. No
written procedures or hazard assessments were completed for the assigned
task. Employee #1 was wearing safety glasses but no other form of PPE
during the accident. Employee #1 said he was in a hurry and normally
would have worn rubber gloves and a respirator while transferring the
camlock and line from one tote to another.
Source: Fire Analysis and Research Division,National Fire Protection Association
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Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"
