|Massachusetts Case Report: 04-MA-032
Release Date: January
On September 2, 2004, two 35-year-old floor sanders (victims) were fatally
injured and two other floor sanders were burned, one seriously, when the
three-family house they were working in caught fire. The victims were
refinishing the wood floors in the third floor unit and the stairs leading
up to the third floor unit of the multifamily house. The incident occurred
when the flammable lacquer floor sealer that they were applying ignited,
causing the house to catch fire. Calls were placed to emergency medical
services (EMS) and the fire department. Within minutes, EMS and fire department
personnel arrived at the site to attend to the victims and control the
fire. One of the victims was pronounced dead at the scene. The other three
workers were transported to a local hospital where a second worker died
of his burns the following day.
The Massachusetts FACE Program concluded that to prevent similar occurrences
in the future, employers should:
- Use wood floor finishing products that are less flammable (products
with flash points greater than 100°F) for indoor applications
- Ensure that ignition sources including gas pilot lights are extinguished
prior to beginning work
- Ensure that work areas are adequately ventilated during indoor application
of wood floor finishing products
- Conduct job hazard analyses and implement and enforce a safety checklist
to be completed prior to beginning work
- Develop, implement, and enforce a written hazard communication program
that includes training employees about the chemicals they work with
and the associated hazards and controls of these chemicals.
The wood floor finishing industry and other stakeholders, such as contractors,
insurance companies, and government agencies should:
- Educate consumers about the hazards associated with finishing wood
floors and actions that can be taken to minimize these hazards, such
as the use of less flammable floor finishing products.
Homeowners finishing wood floors themselves or through hired contractors
- Ensure that only less flammable floor finishing products (products
with flash points greater than 100° F) are used inside their homes.
In addition, policymakers should:
- Consider developing regulatory approaches to minimize the risk of
fires and explosions during wood floor finishing.
Wood floor sanding and finishing can expose workers, building occupants,
and homeowners to a variety of health and safety hazards. In Massachusetts,
three workers have died within a ten month period (September 2004 –
July 2005) in fires resulting from wood floor finishing when the flammable
lacquer floor sealer they were applying ignited. All three of these fatally
injured workers were Vietnamese immigrants. According to a Safety Bulletin
released by the Boston Fire Department, between 1995 and September 2004,
Boston, Massachusetts has experienced more than 25 fires directly attributed
to hardwood floor installation and refinishing, resulting in a property
loss value of over 1.5 million dollars. This Safety Bulletin has been
included at the end of this Massachusetts FACE report.
Nationally from 1992-2002, 52 fatal injuries were sustained by workers
in the floor laying/other floor work business (Bureau of Labor Statistic,
Census of Fatal Occupational Injuries data, using Standard Industrial
Code 1752, not necessarily wood floors). Of these injuries, 21% (11/52)
resulted from fires and explosions. Five of the workers who died due to
fire or explosion were employed specifically in wood floor sanding.
In 2004, the Massachusetts Floor Finishing Safety Task Force was formed
with members from community, health, safety, academic, and economic development
organizations. A report has been released by this task force and is referenced
at the end of this Massachusetts FACE report.
On September 3, 2004, the Massachusetts FACE Program was alerted by local
media that on September 2, 2004, one floor sander was fatally injured
and three others were seriously burned when the house they were working
in caught fire. An investigation was initiated. On September 6, 2004,
the Massachusetts FACE Program was again alerted by local media that a
second worker had died of the injuries he sustained during the September
2, 2004 incident. On October 10, 2004 the Massachusetts FACE Director
interviewed a representative of the victims’ company. The fire report,
death certificates, corporate information, and Occupational Safety and
Health Administration (OSHA) information were reviewed during the course
of the investigation.
The employer, a wood floor company, had been in business for 21 years
at the time of the incident. The company employed approximately eight
workers that were split into two work crews comprised of two to four workers
per crew, depending on the job size. The victims each had between two
and five years of experience.
The company did not have a written comprehensive hazard communication
program. Although the victims did receive on-the-job training, the training
did not address the hazards associated with this incident. The company
provided workers with respirators, but did not have safety procedures
for respirator use. The employees did not have union representation. Both
of the fatally injured workers were Vietnamese immigrants. The company
owner is also Vietnamese.
The company was hired to refinish the wood floor in a third floor unit
and two sets of wood stairs leading up to the third floor in a multifamily
house (Figure 1). One stairway connected
the first floor to the second floor and the other stairway connected the
second floor to the third floor. At the time of the incident, the third
floor unit was vacant and the bottom two units were occupied. The owners
of the multifamily house lived in the first unit, which comprised the
entire first floor and a section of the second floor. The remaining area
on the second floor comprised the second unit and the entire third floor
was one unit. The owners of the house were home at the time of the incident
and the second unit occupants were not home.
During the interview, the company representative described their usual
floor finishing procedure, which included but was not limited to the following:
- Opening windows and extinguishing pilot lights
and other possible ignition sources, prior to beginning the sanding
- Sanding wood areas to be refinished using electric
sanding equipment, such as drum sanders and edge sanders. The company
representative stated that the majority of their sanding equipment has
dust collecting systems, but that these systems do not collect 100%
of the dust. Manual hand sanding is often performed as well.
- Vacuuming the sanded area to remove the remaining
- Applying floor primer to the sanded area. The
company representative reported that the floor primer typically used
was a lacquer sealer, which takes approximately 30 - 45 minutes to dry.
- Applying two coats of polyurethane once the lacquer
sealer is dry. Typically an hour is allowed between applications of
the first and second coats. The second coat of polyurethane takes approximately
one day to completely dry.
The day of the incident was the company's first day on site. Four floor
sanders were assigned to the job, with one of the floor sanders also acting
as a field supervisor. Two of the workers arrived at the house at 8:45
a.m. and started sanding the stairway that led from the first floor to
the second floor. These workers then moved to sanding the stairway that
led from the second floor to the third floor and the wood floors in the
third floor unit. Once finished with the sanding task, the two workers
vacuumed the remaining wood dust within the third floor unit and the stairs
that connected the second floor to the third floor. At approximately 11:00
a.m. the workers stopped vacuuming and started to apply the lacquer sealer
to the wood floors in the third floor unit.
According to the manufacturer’s material safety data sheet (MSDS),
the lacquer sealer being used contained, but was not limited to, acetone,
toluene, xylene, and keytones and had the following physical characteristics:
- Hazardous Material Identification System (HMIS)
ratings of: health (2), flammability (3), and instability (0). HMIS
is a numerical rating system ranging from zero to four: minimal hazard
(0), slight hazard (1), moderate hazard (2), serious hazard (3), and
severe hazard (4) (Figure 2).
- Vapor density rating greater than one (this lacquer
sealer is heavier than air).
- Percent volatile (the percentage of a liquid or
solid that will evaporate at an ambient temperature of 70° Fahrenheit
(F)) rating of 72% - 84%.
- Flash point (lowest temperature at which a chemical’s
vapors are concentrated enough to ignite) rating of 9° F.
- Flammability classification rating of 1B (flash
point below 73° F and boiling point at or above 100° F).
At approximately 11:30 a.m., two more workers arrived at the house to
help apply the wood floor finishing products. Immediately prior to the
incident, at approximately 12:45 p.m., one of the two surviving workers
was vacuuming the second floor stairway landing and the other surviving
worker was in the second floor bathroom. At this same time, the two victims
were up on the third floor of the house applying the lacquer sealer. One
was inside the third floor unit (victim #1) and the other victim (victim
#2) was located in the upper section of the stairway that led up to the
third floor from the second floor.
When the vapors from the lacquer sealer ignited it caused an explosion
and created a fireball that traveled through the two stairways down to
the first floor. The explosion also resulted in a fire that engulfed the
entire third floor of the multifamily house. The two surviving floor sanders
had been the furthest from the explosion and were the first two workers
to exit the burning house. The floor sander who was located in the stairway
that led to the third floor unit (victim #2) exited the house with his
clothes on fire shortly after the two surviving workers exited the house.
The fourth floor sander (victim #1), who was working inside the third
floor unit, did not exit the burning house.
There were multiple ignition sources within the third floor unit, such
as gas appliances and electrical sources. Gas appliances within the third
floor unit included, but were not limited to the gas heating unit located
above the ceiling, and the gas stove located in the kitchen. Electrical
ignition sources included, but were not limited to, the refrigerator located
in the kitchen, and electrical switches located throughout the unit.
The two owners of the house and a friend of theirs were home at the time
of the incident. After hearing the explosion and realizing that the house
was on fire, they called 911 and exited the house. A nearby off-duty firefighter,
who had heard the smoke alarms and noticed the smoke, arrived at the incident
site and attended to the three floor sanders who had exited the house.
Personnel from the local fire department and emergency medical services
(EMS) arrived within minutes of notification. Due to a language barrier
between the floor sanders, who spoke Vietnamese and the fire fighter and
EMS personnel who spoke English, the information that a fourth floor sander
(victim #1) was still inside the burning house was not able to be communicated.
Victim #1 was found by fire fighters inside the first floor stairway
and was pronounced dead at the scene. The three floor sanders who exited
the house were all taken to a local hospital. At the hospital, a second
floor sander (victim #2) died of his severe burns the following day. One
of the two surviving floor sanders was released from the hospital a few
days later, and the other remained in critical condition in the hospital
for an extended period of time with severe burns. A short time after the
incident, the house was torn down due to extensive fire damage.
Investigations conducted by OSHA, the Massachusetts State Fire Marshal,
and the local fire department determined that the ignition source was
most likely the gas stove pilot located in the kitchen of the third floor
unit. In addition, it was concluded that the windows in the third floor
unit were most likely closed at the time of the incident.
Cause of Death
The medical examiner listed the cause of death for victim #1 as severe
charring thermal burns and for victim #2 as complications of severe thermal
Recommendation #1: Employers should use wood floor finishing products
that are less flammable (products with flash points greater than 100°
F) for indoor applications.
Discussion: The flash point of a liquid is the lowest
temperature at which it gives off enough vapors to ignite when a source
of ignition (see recommendation #2) is present. The
lower the flash point of a liquid, the higher the risk of fire or explosion.
Many floor finishing products with flash points greater than 100°
F, which are less flammable, are available. The flash point of a product
can be found on the product label or the manufacturer’s material
safety data sheet (MSDS) or by calling the manufacturer.
In this incident, a highly flammable lacquer sealer (flash point of 9°
F) was being used indoors. When finishing wood floors indoors, less flammable
floor finishing products (products with flash points greater than 100°
F) should always be used. Less flammable products will greatly reduce
the risk of product ignition, explosions, and fires.
Recommendation #2: Employers should ensure that open flames and other
ignition sources including gas pilot lights are extinguished prior to
Discussion: In this case, the third floor unit had a
number of potential ignition sources within 50 feet of where the lacquer
floor sealer was being applied. Investigating agencies concluded that
at least one of these ignition sources, the gas stove pilot, was not extinguished
prior to the beginning of work and was most likely the ignition source.
Open flames and other ignition sources within 50 feet of floor finishing
product application should to be extinguished. Sources of ignition include,
but are not limited to, cigarettes and lighters, pilot lights for gas
appliances (gas stoves, gas hot water heaters, gas heating units, gas
clothes dryers), cycling electrical appliances (refrigerators, air conditioners,
electric heating units, electric hot water heaters), and electrical devices
that could be inadvertently switched on (lights, radios, electrical switches).
Cigarettes should not be smoked or light within the work area, gas pilots
should be extinguished and cycling electrical appliances and other electrical
devices should be turned off and unplugged prior to using flammable products.
It should be ensured that electrical switches, such as light switches,
are not turned on or off during the entire floor finishing process, from
sanding to when the applied floor finishing product is dried. In addition,
when possible the power to the work area should be turned off during floor
Recommendation #3: Employers should ensure that work areas are adequately
ventilated during indoor application of wood floor finishing products.
Discussion: In this case, it was concluded that the
third floor unit's windows were most likely closed at the time of the
incident and that no other means of ventilation was being used in the
work area where the lacquer sealer was being applied. Inadequate ventilation
during indoor application of flammable floor finishing products, such
as lacquer sealers, can lead to a buildup of the product vapors to a concentration
that could easily ignite.
It is recommended that employers ensure work areas are adequately ventilated
for the products being used. Ventilation should draw the air out of the
work area during indoor floor finishing and could include opening windows
and using fans classified as explosion proof that are plugged in outside
of the work area. Work area ventilation should continue until the applied
floor finishing product is dry.
Providing adequate ventilation during indoor use of flammable wood floor
finishing products, including lacquer sealers, can be problematic because
too much air flow can interfere with the quality of the wood floor finish.
The complexity of ensuring indoor work areas are adequately ventilated
while applying flammable floor finishing products without jeopardizing
the quality of the wood floor finish underscores the importance of using
products with flash points above 100°F for indoor use.
Recommendation #4: Employers should conduct job hazard analyses and implement
and enforce safety checklists to be completed prior to beginning work.
Discussion: The surviving employees reported that they
were not the individuals responsible for extinguishing pilot lights and
opening windows, but they thought the windows in the third floor unit
could have been open and that the pilots and other ignition sources were
extinguished prior to the beginning of work.
Before the start of a floor finishing job, a competent person*
should work with the homeowner to gather as much information as possible
on ignition sources within the work area and ventilation options. This
information and the product manufacturer’s safety precautions should
be incorporated into a wood floor finishing safety checklist that is given
to the work crew before going to the work site for the first time. The
employer should ensure that employees perform the tasks on the safety
checklist prior to starting work. This could be accomplished by the employer
routinely performing unscheduled site visits. It should be made clear
by the employer that if employees are not following the checklist prior
to beginning work, they will be reprimanded. In addition, it should also
be made clear to employees that if they feel uncomfortable about a current
work situation because of safety and/or health reasons, work should be
stopped immediately or not begun and the employer should be notified.
*Competent person: a person through training
or knowledge who is capable of identifying existing and predictable hazards
in the surroundings or working conditions which are unsanitary, hazardous,
or dangerous to employees, and who has authorization to take prompt corrective
measures to eliminate them.
Recommendation #5: Employers should develop, implement, and enforce a
written hazard communication program that includes training employees
about the chemicals they work with and the associated hazards and controls
of these chemicals.
Discussion: Employers are required by the Occupational
Safety and Health Administration (OSHA) to instruct employees in the recognition
and avoidance of unsafe conditions, in the regulations applicable to their
work, in this case floor finishing, and to control or eliminate any hazards
or other exposures that could result in serious illness or injury.
Floor finishing companies should develop and implement a hazard communication
program that includes identifying and developing a list of all hazardous
chemicals used and generated in floor finishing, obtaining material safety
data sheets (MSDSs) and labels for each hazardous chemical and informing
employees about these chemicals and the associated hazards through employer
provided training. Hazard communication training should include, but not
be limited to:
- an explanation of material safety data sheets
and the labeling system
- where and how employees can obtain and use the
appropriate hazard information
- safety and health hazards of the chemicals used
and generated in floor finishing
- methods and observations that may be used to detect
a presence (or an elevated level) of hazardous chemicals at the jobsite
- measures for employees to protect themselves from
hazards, such as appropriate work practices, emergency procedures, and
personal protective equipment.
It is required that all trainings be documented. Documentation should
include: who provided the training and their qualifications, the content
of the training, workers who were trained, and any assessments of workers’
comprehension of the training.
Companies that employ workers who do not understand English should identify
the languages spoken by their employees and design, implement, and enforce
a multi-lingual hazard communication program. To the extent feasible,
the hazard communication program should be developed at a literacy level
that corresponds with the literacy level of the company’s workforce.
Companies may need to consider providing special safety training for workers
with low literacy to meet their safety responsibilities.
Help for companies is available through the Massachusetts Division of
Occupational Safety (DOS) which offers free consultation services designed
to help small employers recognize and control potential safety and health
hazards at their work sites, improve their safety and health programs,
and assist in training employees
(Link updated 3/21/2013)
In addition, the Massachusetts Department of Industrial Accidents (DIA)
has Occupational Safety and Health Training Grants available for companies
and organizations that are covered by the Massachusetts Workers’
Compensation Law. The grant money must be used to provide and improve
prevention education and training in occupational safety and health to
employers/employees within the Commonwealth
(Link updated 3/21/2013)
The Office of the State Fire Marshal works to preserve life and property
from fire and explosion by prevention, engineering, education, and enforcement
(Link updated 3/21/2013)
Recommendation #6: The wood floor finishing industry and other stakeholders,
such as contractors, insurance companies, and government agencies should
educate consumers about the hazards associated with finishing wood floors
and actions that can be taken to minimize these hazards, such as the use
of less flammable floor finishing products.
Discussion: An educated consumer will be able to make
the best decisions about which floor finishing process to choose and which
contractor to hire based on their knowledge of associated hazards and
available product choices. Consumer education should be a joint effort
involving floor finishing contractors, insurance companies and government
Floor finishing contractors and insurance companies should provide information
to consumers about floor finishing options and the impact of all available
products. Government agencies should consider the implementation of an
outreach program to inform the public about associated hazards and the
availability of less flammable products for floor finishing.
Recommendation #7: Homeowners finishing wood floors themselves or through
a hired contractor should ensure that only less flammable floor finishing
products (products with flash points greater than 100° F) are used
inside their home.
Discussion: Homeowners who ensure that only less flammable
products, products with flash points greater than 100° F, are allowed
to be used inside their home will minimize the risk of fires and/or explosions
that could endanger themselves, their families, and workers (when using
Recommendation #8: Policymakers should consider developing regulatory
approaches to minimize the risk of fires and explosions during wood floor
Discussion: There are a number of regulatory approaches
that may reduce the risk of fires and explosions associated with wood
floor finishing and thereby protect workers and the general public. The
effectiveness and the feasibility of the following approaches should be
- State licensing requirements for wood floor finishers
that would require training, designation of competent persons, and oversight
of business practices.
- Permitting rules that would require contractors
or homeowners to notify local fire departments or other appropriate
local agencies of plans for wood floor finishing jobs involving the
use of flammable products. Information about product selection and safe
work practices would be handed to the person obtaining the permit.
- Disclosure requirements that direct wood floor
refinishers and manufacturers to provide information to consumers about
the flash point and toxicity of the products to be used in their homes.
- Requiring the use of less flammable products (products
with flash points greater than 100° F) when finishing wood floors
The wood floor finishing industry in Massachusetts consists mainly of
small businesses, many of whom are Vietnamese owned and staffed (particularly
in the Boston area). Representatives from the wood floor finishing industry
and the Vietnamese community should play an integral part in exploring
licensing, permitting or disclosure requirements, to ensure that the procedures
are feasible, economical and linguistically appropriate.
- Code of Federal Regulations, 29 CFR 1910.1200 Hazard Communication.
Government Printing Office
- Code of Federal Regulations, 29 CFR 1926.21 Safety training and education.
Government Printing Office
- Code of Federal Regulations, 29 CFR 1926.20 General safety and health
provisions. Government Printing Office
- Code of Federal Regulations, 29 CFR 1926.57 Ventilation. Government
- Boston Fire Department, Press Release, Safety Bulletin Hazards Associated
With Hardwood Floor Refinishing. Accessed October 18, 2004 at http://www.cityofboston.gov/bfd/download/Hardwood%20Floor%20Refinishing%20PR.pdf (Link no longer valid 4/12/2007)
- National Fire Protection Association, Frequently asked questions.
Accessed September 23, 2005 at http://www.nfpa.org/faq.asp?categoryID=920&cookie%5Ftest=1 (Link updated 9/18/2006 - no longer available 5/28/2013)
- Massachusetts Floor Finishing Safety Task Force, Protecting Workers
and Homeowners from Wood Floor-Finishing Hazards in Massachusetts, September
29, 2005. Accessed September 29, 2005 at http://www.masscosh.org/node/57 (Link updated 3/19/2008)
- Green Seal, Choose Green Report, February 2005. Accessed March 2005
at http://www.greenseal.org/resources/reports/CGR_wood_finish.pdf (Link no longer available 10/30/2013)
Safety Bulletin - Hazards Associated With HardWood Floor Refinishing
In light of the recent tragic event in Somerville regarding the death
of two construction
workers, the Boston Fire Department is issuing the following safety bulletin.
bulletin is designed to inform contractors, managers and homeowners to
hazards and dangers associated with hardwood floor installation and finishing/refinishing.
Since 1995 the City of Boston has experienced more than 25 fires directly
hardwood floor installation and refinishing. This resulted in a property
loss value of over
1.5 million dollars. In the majority of cases the cause of the fire resulted
from failure to
follow the manufacturer’s safety precautions in the handling, use
and storage of the floor
The process of hardwood floor installation and finishing or refinishing
involves the use of
any number of the following kinds of products:
- Adhesives - For gluing wood flooring
to concrete or other surfaces
- Sealers - Chemicals used to seal
the wood surface after sanding
- Surface Finishes - These finishes
remain on the surface of the floor and form
a protective coating
Contractors must be thoroughly familiar with the manufacturer’s
instructions and safety
precautions associated with the products in use. Building managers and
should question their contractor as to the type of finishing chemicals
the contractor is
planning on using. In particular they should request from the contractor
a copy of the
manufacturer’s safety precautions and review those sections pertaining
and health hazards.
Improper handling of these products may present the following
Fire or Explosion - The use of these chemicals in poorly
ventilated or enclosed areas may cause a significant build-up of flammable
vapors. A spark or open flame could ignite the vapors causing a fire or
Health and Environment
Refinishing can create a large amount of dust from sanding. There is
also the potential
for chemical emissions from the sealer or surface finish. These products
solvents and other substances: polyurethane, ureaformaldehyde and various
Workers who improperly handle the products can be exposed to high levels
Prolonged and repeated exposure may produce adverse health effects.
- Always follow all of the manufacturer’s
- All open flames and sources of ignition that may
be present or within the heating or ventilation systems must be eliminated
(example: pilot lights, electrical motors, open flame or smoking).
- Adequate ventilation must be provided per the
- Adequate respiratory protection shall be provided
- Less flammable or non-flammable products should
be used when available.
- Less toxic products should be used when available
to prevent adverse health effects in workers.
Commonwealth of Massachusetts regulations to date:
Flammable Liquids used for Floor Refinishing
527 CMR 14.03 (6) allows recognized tradesmen or artisans to have and
use 5 gallons of
flammable liquids without obtaining a permit, provided it is removed from
the building or
structure upon completion of each working day.
They must have a suitable fire extinguisher of a least 1A-10BC rating
available at all
527 CMR 14.04 (8) in locations where flammable vapors may be present,
shall be taken to prevent ignition by eliminating or controlling sources
Sources of ignition shall include open flames, lightening, smoking, cutting,
hot surfaces, frictional heat, sparks, static (electrical and mechanical),
ignition, physical chemical reactions and radiant heat. The Head of the
shall prohibit the use of devices or order the suspension of an operation
precautionary measures are not taken.
Other sources of ignition: stoves, refrigerators, electric lights and
equipment, fans used for ventilation if not of the proper type.
BFPC 17.02 Permit Required
A permit shall be obtained for application of finishing materials by
spraying, dipping or
other means of which use of more than one gallon of flammable or combustible
fluidized powders in any working day. No permit will be required for small,
spraying operations for domestic or other incidental use unless required
by the Head of
the Fire Department when such operations are a major process of a business.
In closing this information is provided on the Boston Fire Department
web site at
http://www.cityofboston.gov/BFD/index.html. (Link no longer valid 4/12/2007)
Additional questions can be directed to the Fire Marshal at:
Boston Fire Department
1010 Massachusetts Avenue
Boston, MA 02118
To contact Massachusetts
State FACE program personnel regarding State-based FACE reports, please
use information listed on the Contact Sheet on the NIOSH FACE web site
Please contact In-house
FACE program personnel regarding In-house FACE reports and to gain
assistance when State-FACE program personnel cannot be reached.