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52-year-old female janitor died as a result of a vapor flashback while using flammable lacquer thinner to remove carpet glue from concrete basement floor.

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 04MI130, 2005 May; :1-7
On September 17, 2004, a 52-year-old female janitor for a public housing commission died from burn injury complications sustained on September 9, 2004. The victim was removing carpet glue from a concrete floor in the basement "den" area of a townhouse unit with a flammable lacquer thinner. See Figure 1 for an example of a townhouse basement unit layout. The victim was assisting a co-worker in preparing the townhouse unit for a new tenant. While her co-worker was cleaning the second story of the townhouse, she proceeded to the basement. The mechanical room contained the gas hot water heater and furnace, plumbing and electrical for a washer and dryer, and a laundry tub. The victim was using the flammable lacquer thinner on the floor to soften the carpet glue so she could remove it. Although both basement rooms had 17" x 11" windows, she did not open them. It is hypothesized that she poured the lacquer thinner on the floor. The vapors from the lacquer thinner migrated into the mechanical room, contacted the open flame of the hot water heater and flashed back and burned her. Her co-worker working upstairs heard the victim scream and came to assist her. The co-worker found the victim at the top of the basement stairs and assisted her outside. The co-worker used her walkie-talkie to contact the housing commission office, and office personnel contacted 911. The victim was transported to a local hospital where she died approximately a week later. Recommendations: 1. Employers should develop and implement a hazard communication (Right-to-Know) program. 2. Employers should investigate if substitution of water-based, non-chlorinated cleaning products in place of flammable materials used for cleaning is possible. 3. Employers should develop and implement a site-specific health and safety program. 4. Michigan Housing Directors Association (MHDA) should establish a Health and Safety (H&S) committee, as should each individual housing commission. 5. Housing commission units should consider replacing older hot water heaters with heaters that are equipped with flammable vapor ignition resistant (FVIR) components. 6. Gas hot water heater manufacturers should place fire hazard warning labels near the pilot light as well as in another observable location on the unit.
Region-5; Accident-prevention; Accident-analysis; Accidents; Injury-prevention; Injuries; Traumatic-injuries; Women; Maintenance-workers; Flammable-gases; Flammable-liquids; Flash-point; Solvent-vapors; Solvents; Ventilation
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-04MI130; 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: June 15, 2021
Content source: National Institute for Occupational Safety and Health Education and Information Division