NIOSHTIC-2 Publications Search

Pilot plant operator killed in pressure vessel release at a Massachusetts biotechnology company.

Massachusetts Department of Health
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 94MA019, 1994 Dec; :1-7
On May 24, 1994 a 22 year old male pilot plant operator was fatally injured at a Massachusetts biotechnology company when he opened a pressure vessel which was still under pressure. The victim was extracting the compound taxol from yew needles in a near "super critical" fluid process which employed methanol and carbon dioxide, at a pressure of 2,000 pounds per square inch (psi). The victim, who was alone, was at the end of the procedure when the pressure release occurred. Apparently believing the vessel to be depressurized, the victim attempted to remove the heavy steel cover. It appears he removed the four bolts holding the cover in place, and was attempting to remove the retaining flanges when the cover of the vessel blew. The pressure was released, throwing the victim 10 feet across the room. An assistant to the company president noted that the building's alarm and sprinkler systems had been activated, and alerted the president as he was leaving the building. Within 15 seconds the president found the victim, with a slight pulse, entangled in equipment. Paramedics were immediately summoned. The victim was transported to a hospital where he was pronounced dead later than night. In order to prevent future similar occurrences, the MA FACE Program recommends that employers: 1. And equipment manufacturers install safe guards, such as mechanical interlocks, on pressure vessels to ensure that they are completely depressurized prior to being opened. 2. Use a system of "checks and balances" to verify whether residual pressure remains in pressure vessels. 3. Ensure that all operators of pressure vessels are fully trained prior to allowing them to operate a system. 4. Use procedures for minimizing the potential for materials blockage in those supercritical extraction processes prone to blockage. 5. Develop procedures to insure the purity grade of solvents used in supercritical fluid systems. 6. Ensure that process equipment and operations undergo safety reviews before going into service in research, pilot or production capacities. In addition, government agencies should: 7. Consider developing safety standards to protect employees who operate pressure vessels.
Region-1; 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; Protective-measures; Pressure-chambers; Training; Pharmaceutical-industry
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-94MA019; Cooperative-Agreement-Number-U60-CCU-108704
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Massachusetts Department of Health
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division