5 WORKERS DIE IN YEAST BREW VAT ACCIDENT CASE STUDY 5 WORKERS DIE IN YEAST BREW VAT

ACCIDENT CAUSATION Domino Theory. Multiple Causation Theory.

OVERVIEW OF THE INCIDENT ACCIDENT CASE STUDY 5 WORKERS DIE IN YEAST BREW VAT OVERVIEW OF THE INCIDENT You are a member of the safety committee and have been notified to report to work 3 hours early to assist in an investigation of an accident. 2 maintenance workers and 3 bakers were found huddled together at the base of an “Evenrise” yeast vat. All 5 five had extreme “blueing” of the lips and fingernails. 1 other worker has been taken to the hospital complaining of extreme headaches, dizziness, disorientation and nausea. You and your group must conduct an accident investigation to determine the root cause. The bakery has been shut down and is losing $288,000 per day in revenue.

ACCIDENT CASE STUDY 7ft 10ft Deep 6ft TOP VIEW THE VAT Oval interior (10ft deep, 7ft wide, 6 feet wide) Interior access is achieved with a fixed metal ladder Rotating mixing arm at bottom of vat A 36” wide service door built into the top of the vessel 12” wide flush portal for cleaning residual product 7ft FLUSH PORT 10ft Deep 6ft

ACCIDENT CASE STUDY 10ft Deep SIDE VIEW EVENRISE YEAST BREW VAT FLUSH PORT

ACCIDENT CASE STUDY X X X X X TOP VIEW FLUSH PORT VICTIMS SERVICE LADDERS

ACCIDENT CASE CHRONOLOGY 12:02am: Baker 1 attempts to flush (clean) residual product from vat 12:10am: Baker 1 attempts to flush the vat, vat fails to flush 12:17am: Baker 1 attempts to flush vat for the third time 12:33am: Baker 1 reports the problem to maintenance 12:35am: Baker 1 tries to find supervisor, unable to locate 12:40am: Maint 1 arrives, enters vat through service door 12:44am: Maint 2 arrives and checks service box on rear of vat 12:49am: Maint 2 enters vat through service door 12:55am: Baker 1 hears noises, climbs ladder, looks into vat 12:55am: Baker 1 yells for help, enters vat through service door 12:55am: Baker 2 responds and enters vat through service door 1:25am: Supervisor arrives and enters through service door 2:55am: Baker 3 arrives, and enters vat 2:56am: Baker 3 is disoriented, immediately exits and notifies 911 3:17am: Responders find all 5 workers dead at the scene

QUESTIONS TO BE CONSIDERED What caused the deaths of these workers? Do you believe there is a single cause to this accident that, if removed would have prevented it? Do you believe there are multiple causes? Are multiple OSHA Standard violations involved? What could upper management have done? What could the supervisor have done? What could the co-workers have done? To what extent is a lack of written policy responsible? What written policies need to be developed To what extent is a lack of training responsible? Were the hazards associated with yeast fully understood?

ACCIDENT CASE FACTS Hazard Communication program non-existent or ineffective Confined space program non-existent or ineffective Lock-Out Tag-Out program non-existent or ineffective Fall Protection program non-existent or ineffective Maintenance department allowed “lone-wolf” situation Bakery department allowed “lone-wolf” situation Written procedures did not address “lone-wolf” situation Supervisor did not have established “rounds” in department Hazards associated with yeast not fully understood