ACCIDENT CASE STUDY. 5 WORKERS DIE IN YEAST BREW VAT. Domino Theory. Multiple Causation Theory. ACCIDENT CAUSATION. ACCIDENT CASE STUDY. 5 WORKERS DIE IN YEAST BREW VAT. OVERVIEW OF THE INCIDENT.
Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.
5 WORKERS DIE
IN YEAST BREW VAT
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.
YEAST BREW VAT
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