1. Case Study and Briefing
ENV 205:
Occupational Health
Case Study and Briefing
Instructions
Grading
Sample Presentation
These homework note sheets contain a series of questions that will be addressed
during the classroom presentation. For your homework assignment, complete your
reading assignment first, then answer all questions on the note sheets. Record your
answers for future reference.

2. Instructions Step 1- Research and select a workplace hazard
Step 2- Provide subject to instructor NLT Class 2.
Step 3- Research potential cases involving a workplace fatality or severe injury (article, report or investigation).
Step 4- Review OSHA 29 CFR and OSHA website for standard.
Step 5- Prepare 15 minute PowerPoint presentation with narration to be ready NLT 2/25/15. Include the following subjects (20 slides or less):
Overview
Key Stakeholders
Hazard(s)
Risk Assessment
Lessons Learned
CFR Standards and Work Cited
Step 6- Respond to peer and instructor questions.

3. Grading Briefing is worth 17% (17 points) of your overall course grade
Grading criteria includes:
Student understood the work presented points
Main ideas are clearly presented points
Ideas are presented in the prescribe order points
Ideas are supported by information and logic points
Effective use of models, diagrams, charts, and graphs- 2 points
Proper OSHA 29 CFR standards were identified- 2 points
Includes Narration points
Briefing stayed within the 15 minute timeframe 2 point_ points

4. How to Record Narration In PowerPoint
Narration Instructions

5. Research Key References–
Workplace Hazard(s)– Confined Space Entry/ Hazardous Material Lower Explosive Limit (LEL)
Accident Fatality/ Injury– XCEL Energy Hydroelectric Plant Penstock Fire, October 2, 2007
OSHA 29 CFR Standard(s)–
OSHA General Industry Standards (29 CFR 1910)
Electrical Power Generation (29 CFR )
Permit-Required Confined Spaces (29 CFR )
Key References–

6. XCEL Energy Hydroelectric Plant Penstock Fire
ENMG 6200
XCEL Energy Hydroelectric Plant Penstock Fire
These homework note sheets contain a series of questions that will be addressed
during the classroom presentation. For your homework assignment, complete your
reading assignment first, then answer all questions on the note sheets. Record your
answers for future reference.
Sample Case Brief
ENVIRONMENTAL RISK MANAGEMENT

7. Agenda Overview Key Stakeholders Hazard(s) Risk Assessment
Lessons Learned
OSHA CFR 29 Standard(s)
Work Cited

8. ENMG 6200
Overview
On October 2, 2007, a chemical fire inside a permit-required confined space at Xcel Energy‘s hydroelectric plant in a remote mountain location 45 miles (72 kilometers) west of Denver, Colorado, killed five and injured three workers.
Industrial painting contractors were in the initial stages of recoating the 1,530-foot (466-meter) steel portion of a 4,300-foot (1,311-meter) enclosed penstock tunnel with an epoxy coating product when a flash fire occurred.
ENVIRONMENTAL RISK MANAGEMENT

9. ENMG 6200
Overview (2)
ENVIRONMENTAL RISK MANAGEMENT

10. ENMG 6200
Overview (3)
Flammable solvent (MEK) being used (16 gallons) to clean the epoxy application equipment in the open penstock atmosphere ignited, likely from a static spark.
The initial fire quickly grew as it ignited additional buckets of solvent and substantial amounts of combustible epoxy material, trapping and preventing five of the 11 workers from exiting the single point of egress within the penstock.
ENVIRONMENTAL RISK MANAGEMENT

11. ENMG 6200
Overview (4)
ENVIRONMENTAL RISK MANAGEMENT

12. ENMG 6200
Overview (5)
There were ten workers in the tunnel and one at the entrance at the time of the fire.
No fire extinguishers were staged near the sprayer where the initial fire started.
Five were unable to get around the fire on the painting platform to get to the only available exit – the improvised tunnel entrance.
Five workers on the other side of the platform made it to safety, although three of those workers sustained injuries.
ENVIRONMENTAL RISK MANAGEMENT

13. ENMG 6200
Overview (6)
After the initial flash, the fire died down enough for those trapped behind the sprayer to communicate with the survivors on the other side.
Fourteen community emergency response teams responded to the incident.
The closest confined space technical rescue unit – equipped and trained to enter the smoke-filled tunnel – was approximately one hour and 15 minutes away.
The five trapped workers communicated using handheld radios with co-workers and emergency responders for approximately 45 minutes before succumbing to smoke inhalation.
ENVIRONMENTAL RISK MANAGEMENT

14. Key Stakeholders Xcel Energy Inc.- Power Plant Owner
ENMG 6200
Key Stakeholders
Xcel Energy Inc.- Power Plant Owner
RPI Coating, Inc.- Painting Contractor
RPI Workers- Trapped and Injured
Local Fire Departments- Initial 911 Responders
West Metro (Denver) Confined Space Technical Rescue Unit
ENVIRONMENTAL RISK MANAGEMENT

15. Risk Management Process

16. Hazards Confined Space
ENMG 6200
Hazards Confined Space
Limited Access/ Egress
Low Oxygen Atmosphere
Hazardous Materials- Methyl Ethyl Ketone (MEK)
Fire/Explosion
ENVIRONMENTAL RISK MANAGEMENT

17. Risk Assessment MEK- Health Effects
ENMG 6200
Risk Assessment MEK- Health Effects
Exposure
Methyl ethyl ketone is used as a solvent.
Inhalation/ Dermal routes of exposure.
Concentration higher in confined space.
Toxicity
Acute (short-term) inhalation exposure to methyl ethyl ketone in humans results in irritation to the eyes, nose, and throat. Limited information is available on the chronic (long-term) effects of methyl ethyl ketone in humans.
Chronic inhalation studies in animals have reported slight neurological, liver, kidney, and respiratory effects.
Initial Risk Level
EPA has not classified MEK as to human carcinogenicity.
ENVIRONMENTAL RISK MANAGEMENT

18. Risk Assessment Fire- Safety Effect
ENMG 6200
Risk Assessment Fire- Safety Effect
Probability
Methyl ethyl ketone was used as a solvent in a confined space.
High concentration of MEK vapors were present during paint sprayer cleaning operations.
Contractor stored multiple 5-gallon containers near the paint sprayer within the confined space.
Effect
Highly flammable in presence of open flames, sparks, and heat.
Vapors can travel to a source of ignition and flash back.
During a fire, irritating and highly toxic gases may be generated by thermal decomposition or combustion.
Can release vapors that form explosive mixtures at temperatures above the flashpoint.
Initial Risk Level
High
ENVIRONMENTAL RISK MANAGEMENT

19. Risk Assessment Low O2 Atmosphere- Health Effect
ENMG 6200
Risk Assessment Low O2 Atmosphere- Health Effect
Exposure
Existing ventilation is insufficient to remove dangerous air contamination and/or oxygen deficiency which may exist or develop.
Toxicity
Oxygen deficiency is an atmosphere containing oxygen at a concentration of less than nineteen and one half percent (19.5%) by volume.
Initial Risk Level
Extremely High
ENVIRONMENTAL RISK MANAGEMENT

20. Risk Assessment Limited Access/ Egress
ENMG 6200
Risk Assessment Limited Access/ Egress
Probability
A single access/ egress point was created in the penstock tunnel near the lower section above the turbine.
Coating operations were conducted over 1500 feet from the single opening.
Mixing and sprayer equipment operations was conducted between the opening and where the coatings were being applied.
Effect
Ready access or egress for the removal of a suddenly disabled employee is difficult due to the location from the coating operations and/or size of the opening.
Published safety guidance addressing penstock inspections advises on the importance of alternative escape routes in the event of an emergency.
Initial Risk Level
Due to the single access/ egress point and the distance to the coating operation, rescue operations were severely limited.
Fire inhibited worker egress.
ENVIRONMENTAL RISK MANAGEMENT

21. Level of Risk EH Hazard Exposure Toxicity Initial Risk Probability
ENMG 6200
Level of Risk
Hazard
Exposure
Toxicity
Initial Risk
Probability
Severity
Access/ Egress A II EH
Fire I
HM- MEK
III H
Low O2 B
Risk Rating
Extremely High EH
ENVIRONMENTAL RISK MANAGEMENT

22. ENMG 6200
Lessons Learned
Ensure requests for proposals selection processes include criteria and procedures for prequalifying or disqualifying contractors.
Verify contractor safety and past performance records.
Look to reduce risk by choosing less hazardous materials.
Train workers in confined space safety, safe handling of flammables, emergency response and rescue, and fire prevention.
Conduct periodic safety audits of worksite.
ENVIRONMENTAL RISK MANAGEMENT

23. Lessons Learned Manage Penstocks as a permit-required confined space.
ENMG 6200
Lessons Learned
Manage Penstocks as a permit-required confined space.
Require continuous monitoring for flammable atmospheres at appropriate locations and elevations within a confined space.
Prohibit entry or require evacuation of a confined space if the atmospheric concentration of flammable vapors is 10 percent of the LEL or higher.
Ensure that evacuation plans for penstocks that have only one egress point provide for alternative escape routes and/or refuge chambers.
ENVIRONMENTAL RISK MANAGEMENT

24. Standards and References
ENMG 6200
Standards and References
29 CFR Standards:
OSHA General Industry Standards (29 CFR 1910)
Electrical Power Generation (29 CFR )
Permit-Required Confined Spaces (29 CFR )
References:
Frosch Dan, "Investigators Trace Fatal Colorado Fire to Sealant Device", The New York Times, 10/4/07, 9/12/08
Chemical Safety Board (CSB), Xcel Energy Company Fire Investigation Report, 10/12
CSB, No Escape: Dangers of Confined Spaces Video, 10/12
ENVIRONMENTAL RISK MANAGEMENT

25. ENMG 6200
Questions
ENVIRONMENTAL RISK MANAGEMENT

26. This document is 100% funded by a $2. 2 million grant from the U. S
This document is 100% funded by a $2.2 million grant from the U.S. Department of Labor, Employment and Training Administration (TAACCCT). The product was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership.
This work is licensed under a Creative Commons Attribution 4.0 International License.