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Epidemiologic Notes and Reports Acute Occupational Fatalities in a Foundry -- Indiana, 1974-1986

On April 5, 1986, a 34-year-old worker at an iron foundry in Indiana died after acute overexposure to solvent fumes. Investigation of the episode revealed that five other acute work-related deaths attributable to other causes had occurred in the same foundry (average workforce, 250 persons) during the preceding 12 years. Based on an estimated total of 3250 person-years at risk for the workforce at the foundry from 1974-1986, the six fatalities correspond to a mortality rate of approximately 185 per 100,000 workers per year. In contrast, the fatal injury rate during 1980-1984 for the most hazardous U.S. industry, mining, is estimated to be 30.1 per 100,000 workers per year (Table 1) (1).

The event prompting this investigation was the death of a maintenance employee who was spraying a mixture of chlorinated solvents (primary constituent, 1,1,1- trichloroethane) to remove excess grease from machinery. The work was performed in an open-top pit measuring 28 feet long, 14 feet wide, and approximately 5 feet deep; one ladder was used for both entry and exit. Area ventilation, although available, was not in operation because of cold weather. The solvent was dispensed by a hand-held nozzle with two manual valves--one for the gravity-fed solvent, the other for the forced-air flow. Compressed air was mixed with the solvent in a nozzle at the end of the hose. The worker was spraying solvent through this nozzle immediately before death. The nozzle, which had no automatic cutoff, was still releasing solvent when the worker's body was discovered. Although CDC's National Institute for Occupational Safety and Health (NIOSH) recommends that workers wear a self-contained breathing apparatus or a supplied-air breathing apparatus when working in the presence of 1,1,1-trichloroethane, the worker was wearing a less protective chemical-cartridge, air-purifying respirator. The apparent cause of death, as recorded on the death certificate, was "acute over-exposure to solvents."

Follow-up investigation by NIOSH as part of its Fatal Accident Circumstances and Epidemiology program revealed that the Occupational Safety and Health Administration (OSHA) had cited this foundry in 1976 and 1979 for violations of OSHA regulations relating to respirators (NIOSH, unpublished data, 1986) and in 1983 for dispensing flammable solvents through valves without automatic cutoffs. Furthermore, this foundry did not appear to have followed the American Foundrymen's Society guidelines emphasizing the dangers of using organic solvents in confined spaces and of using chemical-cartridge, air-purifying respirators in oxygen-deficient atmospheres (such as below-ground pits) (2). The investigators concluded that the worker was wearing a respirator that was inappropriate for use with 1,1,1- trichloroethane in this setting. The victims of the five other acute occupational fatalities occurring at this foundry since 1974 were males ranging in age from 19 to 46 years (age information is unavailable for one victim) (Table 2). These events are briefly summarized: 1) In October 1974, a casting fell through an internal roof from an overhead conveyor line, striking a 30-year-old worker and causing fatal head injuries. 2) In April 1976, a grinding wheel shattered and fatally injured a 32-year-old worker. 3) In September 1978, a 19-year-old maintenance worker was fatally injured when he was caught in machinery he was greasing. 4) In May 1979, a 46-year-old maintenance supervisor was electrocuted when he touched an energized 440-volt line. 5) In 1979, a worker suffered a fatal cardiac event after working for a short period inside an electric furnace from which molten metal had been drained 6-8 hours earlier; although the temperature of the furnace at the time the worker entered could not be reliably estimated, the normal operating temperature in this furnace is 2800 F.

The investigators made specific recommendations to address the safety problems at this foundry (NIOSH, unpublished data, 1986). No further fatal injuries have been reported. Reported by: JS Morawetz, MSc, International Molders and Allied Workers Union, AFL/CIO CLC, Cincinnati, Ohio. PJ Landrigan, MD, Div of Environmental and Occupational Medicine, Dept of Community Medicine, Mount Sinai School of Medicine, New York. Div of Safety Research, National Institute for Occupational Safety and Health, CDC.

Editorial Note

Editorial Note: Acute trauma is a major cause of occupational death and disability. NIOSH has listed "severe acute traumatic injuries" as one of the 10 leading work-related diseases and injuries (3). Based on the National Traumatic Occupational Fatality database recently established by NIOSH to gather complete information about work-related traumatic deaths, acute occupational trauma accounts for at least 7000 deaths per year in the United States (1).

According to the safety records of the International Molders and Allied Workers Union, the union representing the workers at this foundry, at least 132 fatalities have occurred since 1972 at worksites (primarily foundries and smelters) where its members are employed; 84 of these resulted from injuries, and the others were caused by myocardial infarctions and strokes. One fatality occurred at each of 47 sites, two fatalities at each of 10 sites, and four deaths at each of three sites. Only the foundry described had five or more fatalities reported.

Pouring molten metal into molds to produce castings is the basic process of foundry work and is inherently hazardous. Foundry work (along with work in shipyards, sawmills, logging, and petroleum extraction) ranks among job categories with the highest rates of nonfatal injuries (4,5). Because of the relatively small number of foundry workers, no reliable fatal injury rates are available for the category "foundry work" within the manufacturing industry. Estimated industry-specific fatality rates for traumatic deaths per 100,000 full-time workers per year in the United States vary widely by occupational group (from 1.1 for wholesale trade to 30.1 for mining) (Table 1) (1). The fatality rate in general manufacturing is 4.2 deaths per 100,000 workers per year. The annual fatality rate for traumatic injury calculated for this foundry, approximately 185 per 100,000 workers per year, is over five times as high as the fatality rate for mining (30.1 per 100,000), the most hazardous occupation (p=0.002, Poisson).

A traumatic death in the workplace is a "sentinel health event (occupational)" (6) and strongly suggests that the existing safety system has failed and preventive action is warranted. Investigation of an occupational fatality can identify causative factors and lead to the implementation of intervention strategies to reduce the risk of injury. To protect against illness, injury, and death, the workplace should be systematically explored to determine any consistent pattern of risk and opportunity for improved prevention. This reported foundry investigation uncovered a series of fatal events and revealed deficiencies in management of the safety program in the workplace. The specific causes of these six fatalities varied, but the cluster of fatal events in so small a workforce indicates a need for intervention and preventive action.

These occupational deaths in a foundry also illustrate several well-known occupational risks: working in confined spaces (7), electrocution, improperly guarded machinery, heavy falling objects, and acute cardiovascular stress due to heat. NIOSH (8-10), OSHA (11), the American National Standards Institute (12-14), and the American Foundrymen's Society (2) each have published standards and/or recommendations for controlling these hazards.


1.CDC. Traumatic occupational fatalities--United States, 1980-1984. MMWR 1987;36: 461-4,469-70. 2.American Foundrymen's Society. Health and safety guides. Des Plaines, Illinois: American Foundrymen's Society, 1985. 3.CDC. Leading work-related diseases and injuries--United States: severe occupational traumatic injuries. MMWR 1984;33:213-5. 4.Bureau of Labor Statistics. Occupational injuries and illnesses in the United States by industry, 1985. Washington, DC: US Department of Labor, Bureau of Labor Statistics, 1987. (Bulletin no. 2278). 5.California Department of Industrial Relations. California work injuries and illnesses, 1985. San Francisco: California Department of Industrial Relations, Division of Labor Statistics and Research, 1986. 6.Rutstein DD, Mullan RJ, Frazier TM, Halperin WE, Melius JM, Sestito JP. Sentinel health events (occupational): a basis for physician recognition and public health surveillance. Am J Public Health 1983;73:1054-62. 7.NIOSH. Criteria for a recommended standard . . . working in confined spaces. Cincinnati: US Department of Health, Education, and Welfare, Public Health Service, 1979; DHEW publication no. (NIOSH)80-106. 8.NIOSH. An evaluation of occupational health hazard control technology for the foundry industry. Cincinnati: US Department of Health, Education, and Welfare, Public Health Service, 1978; DHEW publication no. (NIOSH)79-114. 9.NIOSH. Proceedings of the Symposium on Occupational Health Hazard Control Technology in the Foundry and Secondary Non-Ferrous Smelting Industries. Cincinnati: US Department of Health and Human Services, Public Health Service, 1981; DHHS publication no. (NIOSH)81-114. 10.NIOSH. Recommendations for control of occupational safety and health hazards . . . foundries. Cincinnati: US Department of Health and Human Services, Public Health Service, 1985; DHHS publication no. (NIOSH)85-116. 11.Occupational Safety and Health Administration. Training requirements in OSHA standards and training guidelines. Washington, DC: US Department of Labor, Occupational Safety and Health Administration, 1987; OSHA publication no. 2254 (revised). 12.American National Standards Institute. American national standard safety requirements for sand preparation, molding, and coremaking in the sand foundry industry. New York: American National Standards Institute, 1981. (ANSI Z241.1-1981). 13.American National Standards Institute. American national standard safety requirements for melting and pouring of metals in the metalcasting industry. New York: American National Standards Institute, 1981. (ANSI Z241.2-1981). 14.American National Standards Institute. American national standard safety requirements for cleaning and finishing of castings. New York: American National Standards Institute, 1981. (ANSI Z241.3-1981).

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