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DATE: August 24,1999

INCIDENT TYPE: Injury Caused by Emulsion Tank Suction Line Cap

LOCATION: District 2

TYPE OF WORK ACTIVITY: Filling Container with Emulsion

THE ACCIDENT: On July 8, 1999, a Maintenance Supervisor was attempting to fill a portable container with emulsion from a 6,000-gallon bulk storage tank. Being unfamiliar with the pumping procedures, the employee moved the suction handle to the fill position with the recirculate handle in the discharge position. This pressurized the suction line and within about 30 seconds it had built up enough pressure to split the connector ring from the line to the cap in half. The 3-inch fill cap on the suction line blew off striking the employee on the jaw and side of the face breaking the employee’s jaw. A review of the pumping instructions revealed no warning that this could happen. This had the potential of being a much more serious injury.

CONCLUSIONS: The employee was unfamiliar with the proper operation of the equipment and had not been trained in its use. The Pumping Instructions should be clarified, warnings included, and posted where visible to the operator. A chain with lock should be placed on the suction handle holding it in place (suction position) and/or a locked fence should be placed around the controls with only qualified operators having a key. A sign stating "DO NOT OPERATE WITHOUT PROPER TRAINING" should be posted where visible to the operator.

RECOMMENDATIONS: All employees who operate any equipment or machinery must be properly trained. Any equipment or machinery that can be accessed by untrained personnel should be locked out to prevent accidents such as this from happening. Supervisors must make sure that their employees are properly trained in the use of their equipment or machinery. Supervisors that are unfamiliar with the operation of equipment or machinery should contact the manufacturer or supplier for specific operating instructions.

Caltrans received a citation from Cal/OSHA for failure to train the injured supervisor. The violation was classified as serious-accident related, and after January 1, 2000, would have a proposed penalty of $18,000.00. Remember: Fines for Cal/OSHA citations will be paid by the unit receiving the citation (effective January 1, 2000).


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