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A crew leadman and a general foreman die from burns sustained in fire at sanitation plant in California.

Public Health Institute
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 94CA002, 1994 Nov; :1-4
A 38-year-old white, non-Hispanic crew leadman (decedent #1) and a 33-year-old white, non-Hispanic general foreman (decedent #2) died from burns sustained while working in a hydraulic concrete channel ("mixed-liquors channel") at a county sanitation district plant. Both decedents were working for a subcontractor who had been hired by the sanitation district. They were installing a large butterfly valve (gate valve) in a hydraulic channel where oxygen was pumped into sludge. This channel is a confined space as defined in Title 8 of the California Code of Regulations (CCRs). The oxygen content of the air in the channel was elevated because of an operation which took place just prior to the incident. Decedent #1 was using a pneumatic hammer to chip away the sidewall of the channel. The pneumatic hammer struck something in the concrete causing a spark. The decedents' oxygen-enriched clothes caught fire and a second worker (decedent #2) jumped into the channel to help. Decedent #2's clothing also caught on fire and both workers were observed running through the channel on fire. A third co-worker leaned over to look in the channel at his co-workers and his shirt caught on fire. Co-workers at the scene stated that when they saw the victims on fire they yelled at them to roll on the ground. The victims were transported by ambulance to a regional burn center where decedent #1 died two days after the incident, and decedent #2 died three days afterwards. The third victim who was initially hospitalized for his burns was released several days later. The CA/FACE investigator concluded that, in order to prevent similar future occurrences, host employers and employers should: 1. inform contractors of the existence of any confined spaces on the worksite and the hazards presented by the confined space and the host employer's experience with the confined space; 2. inform the contractor of precautions or procedures that the host employer has implemented for the protection of employees in or near permit spaces where contractor's employees will be working; 3. inform employees of the existence and location of confined space hazards by posting signs or by other means; 4. develop a comprehensive rescue plan to be used in the event of a confined space emergency; and 5. provide specific fire safety training for employees so that in the event of a fire, employees know how to extinguish flames from their clothing.
Region-9; Accident-analysis; Accident-prevention; Accidents; Injuries; Injury-prevention; Traumatic-injuries; Work-operations; Work-analysis; Work-areas; Work-performance; Work-practices; Safety-education; Safety-equipment; Safety-measures; Safety-monitoring; Occupational-hazards; Confined-spaces; Chemical-properties; Chemical-reactions; Chemical-synthesis; Fire-hazards; Fire-protection; Fire-safety; Protective-clothing; Protective-measures
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-94CA002; Cooperative-Agreement-Number-U60-CCU-907284
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Public Health Institute
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division