5 WORKERS DIE IN YEAST BREW VAT

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

2. Domino Theory. Multiple Causation Theory. ACCIDENT CAUSATION

3. 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 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 SIDE VIEW EVENRISE YEAST BREW VAT 10ft Deep FLUSH PORT

6. ACCIDENT CASE STUDY TOP VIEW X X X FLUSH PORT X X 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