Microsoft Word - OR-FACE-3-29-19_Fatality investigation report_Farm mechanic hot work_2017-07-1

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FATALITYINVESTIGATIONREPORT

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DATE:

March21,2017

TIME:

8:00a.m.

VICTIM:

46‐year‐oldHispanicfarm

mechanic

INDUSTRY/NAICSCODE:

Agriculture/11

EMPLOYER:

Multi‐cropfamilyfarm

SAFETY&TRAINING:

Safetymeetings&training

facilitatedbyanoutside

organization

SCENE:

Farmmechanicshop

building

LOCATION:

Oregon

EVENTTYPE:

Explosion

INCIDENTHIGHLIGHTS

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



Farmmechanicdiedaftertorchcuttingexplosion–

Oregon

REPORT#:2017‐07‐1 REPORTDATE:March2019

________________________________________________________

SUMMARY

OnMarch21,2017,a46‐year‐oldHispanicfarmmechanicusedaplasma

torchtoremovethelidfromanold55‐gallondrumthatformerly

containedflammablebrakewashfluid.The drumwasemptybutnot

cleaned.Thefirstcutwiththetorchcausedaflashandexplosionthat

blew

thebottomoffofthedrumandknockedthemechanicun conscious. He 

diedinthehospitalthreemonthslater.(Fullreportbeginsonp.3

)

________________________________________________________

CONTRIBUTINGFACTORS

Keycontributingfactorsidentifiedinthisinvestigationinclude:

 Usingahotworkmethodtoremovethelidfromadrumthatformerly

containedaflammableliquid

 Notcleaningortestingtheuseddrumbeforehotworkwasperformed

 Inadequateknowledgeof,oraccessto,alternate,safermethod(s)for

removingthelid



Inadequatetraining andcommunicationregardingspecificjobhazards

(Contributingfactorscontinuedonp.6

)

______________________________________________________

RECOMMENDATIONS

OregonFatalityAss essmentandControlEvaluation(OR‐FACE)

investigatorsconcludedthattohelppreventsimilaroccurrences,

employersshould

:

 Neverweld,cut,orperformotherhotworkonadrumorothermetal

containerunlessithasbeencleanedandventedthoroughly.

 Tofurtherreducetheriskofignitionorexplosion,useanon‐sparking,

manualtoolwhenremovingalidfromametaldru morbarrel.



Routinelyassessjobhazards,provideregular,periodictrainingand

communicationsonsite‐specifichazardsandsafeworkpractices,and

takecorrectiveactionwhenneeded.





Checkandmonitoremployees’knowledgeofjobhazardsand

implementationofsafepracticestocontrolthosehazards.





Provideappropriate,adequatepersonalprotectiveequipmentand

ensureitsappropriateuse.(Recommendationssectionstartsonp.

7

)





Page2

OR‐FACEsupportstheprioritizationofsafetyinterventionsusingahierarchyofsafetycontrols,

wheretopprioritiesarehazardeliminationorsubstitution,followedbyengineeringcontrols,

administrativecontrols(includingtrainingandworkpractices),andpersonalprotectiveequipment.

OregonFatalityAssessmentandControlEvaluation(FACE)Program

TheOregonFatalityAssessmentandControl

Evaluation(OR‐FACE)ProgramisaprojectoftheOregon

InstituteofOccupationalHealthSciencesatOregonHealth&ScienceUniversity(OHSU).OR‐FACEis

supportedbyacooperativeagreementwiththeNationalInstituteforOccupationalSafetyandHealth

(NIOSH)(grant#U60OH008472)throughtheOccupationalPublicHealthProgram(OPHP)ofthePublic

HealthDivisionoftheOregonHealthAuthority.OR–FACEreportsareforinformation,research,or

occupationalinjurycontrolonly.Safetyandhealthpracticesmayhavechangedsincetheinvestigation

wasconductedandthereportwascompleted.Personsneedingregulatorycomplianceinformation

shouldconsulttheappropriateregulatoryagency.

[email protected]

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REPORT#:2017‐07‐1 Page3

INTRODUCTION

OnMarch21,2017,a46‐year‐oldHispanicfarmshopmechanicwasknockedunconsciousbyanexplosionthatoccurred

whenhewasusingaplasmatorchtoremovethelidfroma55‐gallonmetaldrumthatformerlycontainedaflammable

liquid.OR‐FACEreceivednotificationoftheincident

fromOregonOSHA(OR‐OSHA).Thisinvestigationreportisbasedon

reviewofOR‐OSHAinvestigationdocumentsandfollow‐updiscussionswiththeOR‐OSHAinvestigator;reviewofan

incidentinvestigationreportwrittenbyanoutsidesafetyconsultantandfollow‐updiscussionswiththatconsultant;and

bestpracticesresearch.

BACKGROUND

Hotworkincludeswelding,brazing,cutting,soldering,grinding,andotherprocessesthatproduceoruseflames,sparks,

orheatthatcouldactasanignitionsource,andcanexposeworkerstoavarietyofsafetyandhealthhazards.Theheat

producedbysuchworkcangenerateaircontaminantsandhazardousdecomposition

products.Workersperforminghot

workareexposedtotheriskoffireandexplosionfromignitionofflammableorcombustiblematerialsinthearea.Other

hazardousexposurescanincludeultraviolet(UV)light,noise,orskininjury.Hotworkiscommoninmanyindustry

sectors.Whilethisincidentoccurredona

farm,hotworkanditsassociatedrisksarefoundinconstruction,

manufacturing,boatbuilding,oilandgas,andrenovationandmaintenanceworkinalmostanysetting.

EMPLOYERS

Thedecedentworkedatafamily‐owned,multi‐cropfarmthatalsoprovidesagri‐tourismeventsforvisitors.Thefarm

hasbeeninbusiness

for40ormoreyears.Thefarmemployedatotalof14employeesatthetimeoftheincident, 

includingfull‐timeandpart‐timeemployees,andfourownerswhomanagefarmoperations.Therewere13employees

workingonsiteonthedayoftheincident.

WRITTENSAFETYPROGRAMSand

TRAINING

Theemployer,alongwithotherareaagriculturalemployers,belongstoanon‐profitorganizationthatprovides

educationalresourcesandotherservicesformembers.Theseservicesincludefacilitationofmonthlysafetymeetings

andquarterlywalk‐throughsonmembers’sites.Theorganizationalsosub‐contractswithoutsidesafetyconsultantsto

helpfacilitate

thesesafety‐relatedservices.Reviewofavailablesafetymeetingminutesrecordedoveraseveral‐month

periodpriortotheincidentsuggestedthatfollow‐uponactionitems,andday‐to‐dayimplementationofsafetytopics

discussedatmeetings,mayhavebeenlimitedorinconsistent.



Basedondocumentreviewanddiscussions

withtheOR‐OSHAcompliance officerandtheoutsidesafetyconsultant,it

appearedthattrainingprovidedbytheemployeratthefarmwasinformal.Itwasreportedthattheemployer’swritten

HazardCommunication(HazCom)Programwasbasedonatemplateprovided bytheirworkers’compensationinsurance

carrier.Reviewofa

copyofavailableportionsofthisdocumentindicatedthatsite‐specific jobhazardswerenot

addressedinanydetail.

WORKERINFORMATION

Thedecedenthad25yearsofexperienceworkingforthisemployer.Hehadworkedhiswayupfromfieldlaborerto

mechanic.Itwasreportedthathewasknowledgeable,experienced,

andproficientinusingtheplasmatorch.Itwasalso

reportedthatoneco‐workerdescribedhimasa“…veryskilled,safe,andresponsibleemployee,”andthathewas

consideredaskilledfabricatorwhotookinitiative.Duringthegrowingseason,heoperated equipmentsuchastractors

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REPORT#:OR2017‐07‐1 Page4

andcombines.Duringthenon‐growingseason(whentheincidentoccurred),hespenttimerepairingandmaintaining

variousfarmequipment.HespokeandreadbothEnglishandSpanishfluently.Hisdirectsupervisorwasalsofluentin

bothlanguages.

INCIDENTSCENE

Theincidentoccurrednearthefrontofthefarm’smechanical

shopbuilding(seephoto1)onanapproximately15‐acre

farm.Thepurposeofremovingthedrumlidswastorepurposethedrumsforuseastrashcontainers.Hehadopened

theshop’sbaydoorpartway,presumablyforventilation,becausesmokewasproducedwhenheusedthetorchto

remove

thelidfromadifferentdrumearlierthatmorning.



WEATHER

Theweatherwasnotconsideredtobeafactorintheincident.AccordingtoWeatherUnderground–HistoricalWeather,

theaveragetemperatureonthedayoftheincidentwas54degreesFahrenheit(F);thetemperatureatthetimeofthe

incidentwasapproximately46degreesF.Light rainwasfalling(<0.1inch).Windspeedwasreportedascalmjustprior

tothetimeoftheincidentandaneasterlywindupto13milesperhour(mph)wasreportedshortlyafterthetimeofthe

incident.

INVESTIGATION

Itwasreportedthatthefarmusedempty55‐gallonsteeldrumsastrashcontainersinthefieldsbecausetheywere

heavyand

didn’tblowover.Thetaskofremovingdrumlidstomakethemintotrashcanswastypicallyperformedevery

coupleofyears,eitherbyasupervisororbythemechanic(decedent).Typicallythistaskwasperformingusingthe

plasmatorch,andtheworktypicallywasdoneinthefarm’smechanicalshop.

Thetorchwaspurchasednewthreetofive

yearsbeforetheincident.Itwasreportedtherewerenomechanical,non‐sparkingtoolstoremovedrumlidsavailable

onsite.

Photo1.Shopexterior;baydoorreportedlyhad

beenpartwayopenattimeofincident,presumably

forventilation(PhotocourtesyofOR‐OSHA).

Photo1.Shopexterior;baydoorreportedlyhad

beenpartwayopenattimeofincident,presumably

forventilation(PhotocourtesyofOR‐OSHA).



REPORT#:OR2017‐07‐1 Page5

Onthedaybeforetheincident,themechanicusedtheplasmatorchtoremovelidsfromthreeotherdrums.Justpriorto

theincidentthenextmorning,themechanicremovedthelidfromafirstdrum.OR‐OSHAreportedobservingasmall

amountofresidualproductinthefirstdrum;OR

‐OSHAalsoreportedobservingalabelindicatingthefirstdrum’soriginal

contenttobeantifreeze,andalsoapictogramindicatingnottoapplyheat.Reviewofinterviewremarksindicatedthat

themechanicreported tohissupervisorthatthecuttingperformedonthefirstdrumthatmorningproducedsmoke.

Evidenceindicated

thatthemechanicpartiallyopenedtheshopbaydoorpriortoremovingthelidofaseconddrum(the

drumthatexploded),presumablyforventilation.Securitycamerafootagefromtheshopindicatedthatjustpriorto

workingontheseconddrum,themechanictiltedthedrumonanangleandthen

rolledittowardthefrontoftheshop

nearthepartiallyopeneddoor.Hewasworkingaloneatthetimeoftheincident.

Areviewofavailablesafetytrainingrecordsandthefarm’swrittenHazComprogramsuggestedthatinternaltrainingat

thefarmwasinformalanddidnotaddresssite‐

specificjobhazardsinanydetail.Therewerenoproceduresforsafe

removalofdrumlidsinthefarm’swrittensafetyprogramrecords.Thesupervisorindicatedhehadadvisedthe

mechanictocleanthedrumspriortocuttingthem.Itisnotknownwhatspecificcleaningtechniquewasexpected,or

whether

anycleaningpracticewasfollowedeitheronthedayoftheincidentorduringprior,similarwork.Itwas

reportedthatsupervisorypersonnelprovided“informaltrainings,”suchasadvisingthemechanicnottocutnear

flammablematerialsandto“checktoensureitwassafetocut.”Itwasalso

reportedthatonthedaybeforetheincident,

thesupervisorprovidedageneralremindertocheckdrumcontentspriortoperforminghot work,butnospecific

instructionsweregiven.Evidencedidnotindicatethelevelofknowledgethemechanichadregardingflammable

hazards,buthewasconsideredtobegenerallyfamiliar

withthehazardsandwithflammablelabels.Recordsindicated

thatapproximatelyamonthpriortotheincident,themechanicattendedasafetytrainingwhereafarmshopsafety

videowasshown.Thevideoprovidesanoverviewofcommonsafetyconcernsinatypicalfarmshop.Itisnotknown

whether

thesafetyvideoaddressedflammablehazards.Onthewhole,evidencesuggeststhattypicalsafetysupervision

andsafetyprogramprocessesatthefarmdidnotregularlyaddressspecificsafepracticesforworkingaroundflammable

materials.

Itwasreportedthatemptydrumswereperiodicallyobtainedinbulkfromanoutsidevendorthatdelivered

thedrumsto

thefarm.Evidencesuggeststhatthedrumthatexplodedmayhavebeenonsiteforatleast15yearspriortothe

incident.Product‐specificsafetydatasheets(SDS)werenotavailable,anditisnotknowniftheyaccompaniedthedrums 

whenoriginallyobtained.Labelson

thedrumthatexplodedindicateditsformercontentwasaflammable“brakewash

blend”(seephotos2,3,and4onthenextpage).TheOR‐OSHAinvestigatorobtainedaSDSforasimilarbrakewash

blendproduct,whichstated,“Classifiedasflammablematerial.Avoidheat,sparks,orflames.”

Evidenceindicated

thatthemechanic’sfirstcutwiththetorchonthedrumlidcausedaflashandanexplosionthatblew

thebottomoffthedrumandknockedthemechanictotheground.Hissupervisorwasapproximately100yardsaway

whentheexplosionoccurred.Twootherworkersandaneighborreported

hearingaloudexplosion.Co‐workersranto

theshopwheretheyfoundthemechani clyingontheconcreteflooroftheshop,unconsciousbutbreathing,withthe

operatingplasmatorchstil linhishand.Itwasreportedhehadbeenwearingshadedsafetyglasses,weldinggloves,and

workcoveralls.Co

‐workerscalled911;emergencyrespondersarrivedshortlythereafterandlife‐flightedthemechanic

toahospitalburncenter.Heneverregainedconsciousnessanddied atthehospitalthreemonthslater.

Thecauseofdeathwasreportedastraumaticheadinjury.Evidencesuggestedthattheexplosionblewthebottomoff

the

drumandpropelledthedrumagainsthisfaceandhead,knockinghimtotheground.DiscussionwiththeOR‐OSHA

investigatorindicatedthathisinjuriesappearedtoinvolveacombinationofbeingstruckbythetopofthedrumasit



REPORT#:OR2017‐07‐1 Page6

propelledintohishead,thenbeingthro wnbackwardsandlanding ontheconcreteflooroftheshop.Mostoftheflames

fromtheignitioneventwerecontainedinthedrum,butitispossibletheworkersufferedminorflashburnsinaddition

tohistraumaticheadinjuries.



CAUSEOFDEATH

AccordingtoOregonVitalRecordsdata,thecauseofdeathwastraumaticheadinjury.



Photo4.Viewofdamageddrum

followingexplosion;bottomof

drumwasblownoff.

(PhotocourtesyofOR‐OSHA)

Photo2.Labelononesideofdamaged

drum,stating“Caution‐Flammable”

(PhotocourtesyofOR‐OSHA)

Photo3.Flammablelabelon

anothersideofdamageddrum

(PhotocourtesyofOR‐OSHA)

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REPORT#:OR2017‐07‐1 Page7

CONTRIBUTINGFACTORS

Occupationalinjuriesandfatalitiesareoftentheresultofoneormorecontributingfactorsorkeyeventsinalarger

sequenceofeventsthatultimatelyresultintheinjuryorfatality.OR‐FACEinvestigatorsidentifiedthefollowingfactors

thatmayhavecontributedtothisincident:

 Usingahot

workmethodtoremovethelidfromadrumthatformerlycontainedaflammableliquid

 Notcleaningortestingtheuseddrumbeforehotworkwasperformed

 Inadequateknowledgeof,oraccessto,alternate,safermethod(s)forremovingthelid

 Inadequatetrainingandcommunicationregardingspecificjob

hazardknowledgeandassociatedsafeworkpractices

RECOMMENDATIONS/DISCUSSION

 Recommendation#1:Neverweld,cut,orperformotherhotworkonadrumorothermetalcontainerunlessithas

beencleanedandventedthoroughly.

Discussion:Avoidhotworkondrumsoranymetalcontainersthatcontainorpreviouslycontainedflammable

or

toxicsubstances,orifyoudonotknowthenatureofits contents.Thisincludescontainersthatappeartobeempty

becauseresiduesinsidethecontainermaypresentexplosionorfirehazards,ortoxicexposures.

However,ifnoalternativesareavailableanditisnecessarytoperformhotwork

onmetaldrums,thereareseveral

importantstepsthatshouldbetakentohelppreventsimilaroccur r ences:

o Identifywhatwasinsidethedrumandwhetherthesubstanceisflammableortoxic;otherwise,treatevery

containertobetorchcutasifitcontainedaflammablesubstance.

o Followallmanufacturer

precautionsonwarninglabels,pictograms,and/orSDSs;

o Followproductandequipmentmanufacturers’instructions;

o Establishsafeworkproceduresinadvanceofhotworktasks,includinghowtocleanadrumandtestfor

residues.

o Employersshouldtrainworkersonhowtoidentifyhazardsandensurethattheyfollow

safehotwork

proceduresabove.

OregonOSHAregulationsrequirethatcontainersbecleanedbeforeanyhotworkisperformed,suchthat“…there

arenoflammablematerialspresentoranysubstancesthatwhensubjectedtoheat,mightproduceflammableor

toxicvapors.”[OAR437‐004‐2310(5)(a)].Notethatwhilethisruleapplies

toweldingatagriculturalworkplaces,

similarrequirementsareinplaceforgeneralindustry,constru ction , andotherindustrysectorsaswell.Theserules

alsodiscusstesting,venting,andpurgingsuchcontainerstoensurethattheyarefreeandremainfreeofflammable

ortoxicvapors.Inthecurrentincident,theprocedures

useddidnotincludeanyofthesesteps.Inaddition,all

possibleignitionsourcesshouldberemovedfromtheareasuchasflames,sparks,and/orspark‐producing

equipment,andallcapsandstoppersshouldberemovedfromthedrum.

OR‐OSHAincludesadditional,specificrequirementsinthegeneralindustrystandardregarding

cleaningandtesting

containersbeforeperforminghotwork.Forexample,OAR437‐002‐0297doesnotallowhotworktobeperformed

on“…drums,barrels,tanks,orothercontainersuntiltheyhavebeencleanedsothoroughlyastomakeabsolutely

certainthattherearenoflammablematerialspresentorany

substances…orothermaterialswhich,whensubjected

toheat,mightproduceflammableortoxicvapors.”Tomeetthe“absolutelycertain”test,therulefurtherstates

that“…appropriatetestingequipmentistobeusedpriortoandfrequentlyduringthewelding,torch orabrasive

cuttingorotherhotworkoperations”toverifythe

conditionsremainsafethroughouttheprocess.

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REPORT#:OR2017‐07‐1 Page8



Someresourcessuggestpurgingthedrumwithwaterasaneffectivewaytoreducehazardsassociatedwithhot

work.Oneexampleistofillthedrumcompletelywithwater(ortooverflowing)priortoapplyingheat.However,be

awarethatfillingthecontainerwithwatermaynotremoveallresidues

andsolids;itispossiblethatvaporpockets

couldremainandcouldbeignited.Inaddition,simplyrinsingouttheemptycontaineranddryingitdoesnotremove

allresidualproductandvapors.Further,disposalofthewaterusedforcleaningorpurgingmayintroduce

environmentalconcernsthatwouldneedto

beaddressed.Inaddition, manymanufacturersrecomme ndthatdrums

shouldnotbereused,norshouldheatbeappliedtothem,andth attheyshouldbedisposedofproperly.Itwas

learnedfromfollow‐updiscussionwiththeoutsidesafetyspecialistinvolvedintheincidentinvestigation,thatafter

theincidentoccurred,

thefarmimplementedchangesinitssafetyprocedurestoreducetheriskofexplosions,

includingfillingdrumstothebrimwithwaterpriortotorchcutting.Whiletheseimplementedchangesreducethe

riskofanotherincidentoccurring,theydonoteliminatetherisk.



 Recommendation#2:Tofurtherreducethe

riskofignitionorexplosion,useanon‐sparking,manualtoolwhen

removingalidfromametaldrumorbarrel.

Discussion:AsstatedinRecommendati on#1,avoidhotworkondrumsoranymetalcontainersthatcontain, may

contain,orpreviouslycontainedflammableortoxicsubstances,orifyou

donotknowthenatureofthecontents.

Instead,usemethodsthatdonotinvolveheatorsparks.Mechanicaldrumopeningtoolsareavailablethatcan

accomplishthetaskquicklyandefficiently.Oneresourcesuggestedthatevenwhenusinganon‐sparkingtoolto

openadrumthatcontainsormay

havecontainedaflammableliquid,thedrumshouldbefilledwithwaterfirstas

anaddedprecaution.Thesameneedtoaddresssecondaryenvironmentalissueswiththewaterusedforthis

purposewouldstillapply.

Severalexamplesofnon‐sparkingmanualdrumopeningtoolsareshownonthefollowingpage.

Pleasenotethat

theseexamplesareprovidedforinformationalpurposesonly.Mentionofany productormanufacturerinthisreport

doesnotconstituteorimplyanendorsementbyNIOSHorOR‐FACE.



REPORT#:OR2017‐07‐1

 Page9



Example1.Mechanicaldrumopening 

tooleliminatestheneedforhotwork

https://worksafe.govt.nz/dmsdocum

ent/353‐hot‐work‐on‐drums‐and‐

tanks

Example2.Non‐sparkingdrumdeheaderwithaluminumblade,

bronzealloy

https://www.newpig.com/non‐sparking‐drum‐dehea der/p/DRM563

Example3.Manualdrumdeheaderwithnon‐sparkblade

https://www.homedepot.com/b/Building‐Materials‐Material‐Handling‐Equipm ent/Vestil/N‐5yc1vZca3dZe3g



REPORT#:OR2017‐07‐1 Page10

 Recommendation#3:Employersshouldroutinelyassessjobhazards,provideregular,periodictrainingand

communicationsonsite‐specifichazardsandsafeworkpractices,andtakecorrectiveactionwhenneeded.



Discussion:Routinehazardassessmentsoftheworksiteshouldbeperformedtoidentifynew,potential,andongoing

hazards.Workplacehazardcommunicationandothersafetyandhealthprogramsandtrainingshould bebasedon

thesesite‐specificjobhazardassessments,todevelopappropriateproceduresandprovideadequatedirectionon

howtosafely

addresstheidentifiedhazards.Forexample,resultsofahazardassessmentmighthaveprompte dthe

farmtodevelopahotworkmanagementprogramtocontroloreliminatehotworkhazards.

Inthiscase,anapplicabletemplatewasusedforthefarm’swrittenHazComprogram,buttheprogramdidnot

adequatelyincorporate

site‐specificjobhazardsandconditionsorincludespecificproceduresandpracticesto

addressandcontrolthem.Theoutsourced,group‐basedtrainingandsafetymeetingsprovidedbasicinformationon

relevantfarmsafetytopics.However,itappearedthatadequatejobhazardassessmentsorfollow‐upwerenot

providedonsiteto

reinforceworkers’knowledgeofspecifichazardsandhowtoimplementsafeworkpractices.

Whilethemechanicwasconsideredknowledgeableandexperiencedinoperatingtheplasmatorchandinotherjob

tasksheperformed,hereceivedonlyinformalandnon‐specificguidanceregardingsafeworkpracticesforcutting

drums.Asmentionedearlier,

afterthemechanicreportedsmokebeingproduc edwhileworkingonthefirstdrumon

thedayoftheincident,asupervisordidnotprovidespecificinstructionsaboutusingdifferent,saferequipmentor

workpracticesbeforeremovingthelidfromthedrumthatexploded.Itisnotknownwhetherjobhazard

assessmentsconductedatthefarmfollowingthisfatalinjuryincludedconsiderationfordiscontinuingthepracticeof

convertinguseddrumsintotrashcans.



 Recommendation#4:Supervisorsshouldcheckandmonitoremployees’knowledgeofjobhazardsand

implementationofsafepracticestocontrolthosehazards.

Discussion:Supervisorsshouldregularlyassessthe

effectivenessofsafetytrainingbyaskingworkersquestions

abouttheirworkplans,observingworkpractices,andprovidingfeedback.Thepurposeofthistypeofassessmentis

fortheemployertoensurethatemployeesareadequatelyknowledgeableofhazards(includingpotentialhazards),

andthattheyunderstandappropriate,safeworkpracticesandhow

toimplementthem.Supervisorsshouldmonitor

andprovidefeedbackaboutemployees’safeworkpractices,includinghowtorecognizeandcontrolhazards.

 Recommendation#5:Employersshouldprovideappropriate,adequatepersonalprotectiveequipmentandensure

theirappropriateuse.

Discussion:Whileitmaynothavepreventedthisfatalincident,weldinghelmetsshould

bewornwhenarcwelding

orcutting.Inthiscase,themechanicwaswearingshadedsafetyglasses,weldinggloves,andworkcoveralls.TheOR‐

OSHAreportindicatedaweldinghelmetwasobservedintheshopnearwheretheincidentoccurred.Itwas

reportedthatthemechani cworethehelmetwhen

performingweldingforfabricationwork,althoughhedidnot

wearthehelmetwhenusingtheplasmatorchtoremovethelidonthedrumthatexploded.



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DISCLAIMER

MentionofanycompanyorproductdoesnotconstituteendorsementbytheNationalInstituteforOccupationalSafety

andHealth(NIOSH)orOR‐FACE.Inaddition,citationstowebsitesexternaltoNIOSHorOR‐FACEdonotconstitute

endorsementofthesponsoringorganizationsortheirprogramsorproducts.Furthermore,neitherNIOSH

norOR‐FACEis

notresponsibleforthecontentofthesewebsites.Allwebaddressesreferencedinthisdocumentwereaccessibleasof

thepublicationdate. 

REFERENCES

Theincidentdescribedinthisreportisnotuniquetoagriculture;firesandexplosionshaveoccurredinmultipleindustry

sectors.Norarethese

hazardslimitedtoworkplacesettings;fatalandnear‐fatalinjuriesinvolvinghotworkperformed

onusedindustrialdrumshavehappenedtoconsumersaswell.Useddrumsliketheoneinvolvedinthisincidentare

readilyavailableontheconsumermarket,forexample,forrecyclingorrepurposingintoconsumerproductssuch as

rain

barrels,barbequegrills,andotherhouseholdorrecreationaluses.Resourcesaddressinghotworkhazardswere

incorporatedintothisreportandareprovided below.



Hazardsofcuttingemptydrums–V1.1–17September2018–NTWorkSafebulletin‐divisionoftheDepartmentof

Attorney‐GeneralandJustice–NorthernTerritory,Australia.

http://www.worksafe.nt.gov.au/PDF%20Conversion/hazards‐of‐cutting‐empty‐drums.pdf

“Hotworkondrumsandtanks”–DeptofLabour,OccupationalSafety&HealthService,Published:March1988‐ISBN0‐

477‐03420‐9https://worksafe.govt.nz/dmsdocument/353‐hot‐work‐on‐drums‐and‐tanks

OregonOSHA,Division2,SubdivisionQ,GeneralOccupationalSafetyandHealthRules,OAR437‐002‐0297Weldingor

CuttingContainers.

https://osha.oregon.gov/OSHARules/div2/div2Q.pdf

OregonOSHA,Division3,SubdivisionJ(29CFR1926;adoptedbyreference),Construction,1926.352(h)(i).

https://osha.oregon.gov/OSHARules/div3/div3J.pdf

OregonOSHA,Division4,SubdivisionQ,Agriculture,OAR004‐2310(5)WeldingorCuttingContainers.

https://osha.oregon.gov/OSHARules/div4/div4Q.pdf

WeatherUnderground.https://www.wunderground.com/history /

“Welding–Hotwork”FactSheet–CanadianCentreforOccupationalHealthandSafety.

https://www.ccohs.ca/oshanswers/safety_haz/welding/hotwork.html

Additionalresources:

“Drumexplodesduringwelding,killingworker”–WorkSafeBC,publishedJune2012

https://www.youtube.com/watch?v=9DP5l9yYt‐g

“Laborerburnedcutting55‐gallondrumwhenleftoverfuelexploded”–WashingtonFACEprogram,report#71‐177‐

2019,publishedJanuary2019http://www.lni.wa.gov/Safety/Research/Face/Files/LaborerBurnedCuttingDrum.pdf 

“TwoVietnamesefloorsandersdiewhenwoodfloorfinishproductignites”–MassachusettsFACEprogram,

Massachusettscasereport#04‐MA‐021,publishedJanuary2006.

https://www.cdc.gov/niosh/face/stateface/ma/04ma032.html



REPORT#:OR2017‐07‐1 Page12

INVESTIGATORINFORMATION

ThisinvestigationwasconductedbyBarbaraL.Epstien,FatalityInvestigator/OutreachSpecialist,OR‐FACEProgram.The

reportwasreviewedandreceivedinputfromRyanOlson,PhD,Director,OR‐FACEProgram,andtheOR‐FACE

PublicationsReviewPanel.

ACKNOWLEDGEMENT

TheOregonFACEProgramwouldliketoacknowledgethecomplianceofficerand

staffofOregonOccupationalSafety

andHealth(OregonOSHA),adivisionoftheOre gonDepartmentofConsumer&BusinessServices,forproviding

assistanceandinformationduringthisinvestigation.