1. 5 WORKERS DIE IN YEAST BREW VAT
ACCIDENT CASE STUDY
5 WORKERS DIE
IN YEAST BREW VAT

2. ACCIDENT CAUSATION
Domino Theory.
Multiple Causation Theory.

3. 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.

4. 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

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

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

7. 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

8. 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?

9. 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