On January 19, 2023, less than five pounds of hot water and pulp were accidentally released, seriously injuring one employee at a paper mill in Georgia, a facility that produces paper products.
The employee had been tasked with inspecting and cleaning a pulp screen. The pulp screen equipment’s drain system had plugged (an abnormal condition), causing water and pulp to remain inside the equipment. With the plugged drain, the process conditions allowed the typically warm water to become hot.
When the employee started unbolting the equipment flange to access the screen, hot water and pulp sprayed out of the flange, contacting the employee. The employee received thermal burns requiring hospitalization. Miscommunication and ineffective training allowed the worker to open this equipment before it was effectively isolated and de-energized.
After the incident, the company added safety interlocks to shut down this equipment automatically during certain abnormal conditions.
Probable Cause
Based on the company's investigation, the CSB determined that the probable cause of the incident was opening equipment that contained pressurized hot water and pulp. Contributing to the incident was ineffective communication and training on the site’s procedure to control hazardous energy.
Source: CSB