[ Introduction ]
[ Industrial Accident of Confined Space ]
[ Industrial Accident of Chemicals ]


Level 1 Level 1 Level 1





Incautious Use of Chemicals

Summary
    In this incident, a worker sustained injuries while handling chemicals. Chemical substances are selected for use in industry because of some specific properties they possess. These and other properties of chemical substances are nevertheless also known to have caused serious bodily injuries to or ill health in people working with them.
    Sodium cyanide is classified as a toxic substance. It is very toxic if inhaled, swallowed and in contact with skin. It causes severe burns and irritation to eyes and skins. The substance if contact with acids also liberates toxic gas.

    Circumstance and Observations
      A worker's forearms, face and right eye were seriously burnt by caustic soda solution. The accident took place in a bleaching and dyeing factory. The injured worker was at the time pouring a bag of caustic soda flakes into a bucket of warm water. The vigorous exothermic reaction between caustic soda and water caused the liquid to splash out. The worker who was wearing only short plastic gloves and rubber boots thus sustained the aforesaid injuries.


    Accident Causation Model
      We have applied Heinrich's Domino Theory to represent the sequence of events as follows:


      (a) Ancestry and social environment
        -Lack of knowledge of hazards during chemicals in use and safety guidelines
      (b) Fault of person
        - Unsuitable personal protective clothing
      (c) An unsafe act and / or mechanical hazard
        - The vigorous exothermic reaction between caustic soda and water
      (d) The accident
        - Liquid to splash out
      (e) The injury
        - A worker's forearms, face and right eye were seriously burnt.


    Preserving Event Data (5-P's)
      Parts
        - Caustic soda flakes
        - Bucket
      Position
        - Point in time of current and past occurrence: pouring the caustic soda flakes into a bucket of warm water
        - Position of occurrence in relation to overall facility: Bleaching and dyeing factory
      People
        - Operations personnel
        - Management personnel
        - Technical personnel
        - People from other similar sites with similar processes
        - Safety personnel
      Paper
        - Specifications
        - Procedures
        - Training records
        - Employee file information
        - Production histories
        - Safety records information
        - Internal memos / e-mails
      Paradigms
        - We do not need data to support RCA because we know the answer

      Analysis the Data
        We have applied the fault tree analysis to represent the root causes of this case as follows:



      Prevention Recommended
        Prevention of these mishaps is often very simple. The fact that they still occur is more often a result of the user's ignorance of the properties of the chemicals. The accident could have been prevented if the following safety precautions had been taken.
          - Suitable protective clothing and equipment was provided and used while handling chemicals.
          - Workers handling chemicals were properly trained in the risks and the safety precautions relating to the chemicals and properly supervised to adopt the required precautions while at work.
        Legal Action
          Various provisions of the Factories & Industrial Undertakings (Dangerous Substances) Regulations, 1988 were breached in the incidents. These included:
            - Regulation 11, which requires the proprietor to provide safety information, training and arrangements such as arrangements for supervision to prevent dangerous substances from causing bodily injuries to workers.
            Regulation 12, which requires the proprietor to provide protective clothing and equipment.