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Machinist struck and killed by fragments from ruptured steam turbine housing.

Michigan State University
Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 01MI011, 2002 Feb; :1-8
On Saturday, February 24, 2001, a 51-year old journeyman machinist was killed when he was struck by fragments projected from a steam turbine that broke apart during an overspeed trip test. He and several other employees of his company that rebuilt the turbine (Company A), employees of the company that operated the steam turbine (Company B), and employees of the company that owned, maintained and used the wind generated by the turbine (Company C) were observing the test. Three overspeed trip tests were required before the turbine that had recently been sent out for repairs could be brought into production operation. The overspeed trip test consisted of allowing the turbine to accelerate to a particular rpm speed to test a mechanical shutoff valve that would prevent the turbine from accelerating to a dangerous speed. On the second test, the mechanical shutoff valve did not function properly and allowed the turbine to reach an overspeed condition. The turbine buckets overran their safe speed, and the turbine rotor failed. One hundred buckets broke away from one of the twelve rings on the shaft and pierced the two-inch thick turbine housing. Fragments from the broken housing and turbine buckets struck the victim causing his death. Recommendations: 1. Develop, document, and implement a procedure for inspecting, reporting, operating, maintaining, and repairing equipment and replacing defective equipment based on manufacturer's instructions, industry guidelines and consensus standards. A job safety analysis of all routine and non-routine work should be included in the procedures. 2. Train workers to use the procedures developed in accordance with the manufacturer's instructions, industry standards, and consensus guidelines. Use the job safety analyses to improve workers' ability to recognize existing or potential hazardous conditions. 3. Develop a clear description of job responsibilities and accountability for each worker and supervisor. 4. Do not operate equipment with nonfunctioning or malfunctioning parts. 5. Provide guardrails, barriers, signs, floor markings, and signals to warn workers of potential hazards.
Accident-analysis; Accident-potential; Accident-prevention; Accidents; Injuries; Injury-prevention; Safety-education; Safety-equipment; Safety-practices; Safety-measures; Traumatic-injuries; Region-5; Work-practices; Training; Work-analysis; Work-areas; Work-operations; Work-performance; Workplace-monitoring; Personal-protection; Personal-protective-equipment; Signaling-systems; Equipment-operators; Equipment-reliability; Occupational-hazards; Occupational-safety-programs
Publication Date
Document Type
Field Studies; Fatality Assessment and Control Evaluation
Funding Type
Cooperative Agreement
Fiscal Year
NTIS Accession No.
NTIS Price
Identifying No.
FACE-01MI011; Cooperative-Agreement-Number-U60-CCU-521205
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Michigan State University
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division