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Safeguard OSH Solutions - Thomson Reuters

Safeguard OSH Solutions - Thomson Reuters



Safeguard Magazine

Incident investigation—Confined space work can be deadly

Summary

An employee sent to apply a solvent-based primer inside two grain silos was found slumped and unresponsive in a silo towards the end of his day’s work.

CONTEXT

  • • 
    The silos were located on a poultry farm in Hawke’s Bay.
  • • 
    The farm contracted a waterproofing company to work on two silos.
  • • 
    The job was to apply primer to the interior of the silos and then apply a membrane.
  • • 
    The waterproofing company assigned an employee, K, to do the work.
  • • 
    He began the job at 10am on a day in April 2014.

DETAIL

  • • 
    The primer was a bitumen-based product.
  • • 
    Its chief toxic component was toluene, a solvent.
  • • 
    The primer’s label said it should not be used in confined spaces.
  • • 
    K worked in the silo alone. He had no buddy to check on him, and had no rescue harness to assist in his extraction if he lost consciousness.
  • • 
    He wore a respirator with a dust filter because he lacked a solvent filter on site.
  • • 
    He wore disposable gloves.
  • • 
    At 12.30pm the farm director checked on his progress.
  • • 
    At 4.30pm another farm staff member found K sitting on the silo floor, unresponsive. Emergency services were called.
  • • 
    He tried but failed to get K out of the silo.
  • • 
    A colleague joined him and together they got K out of the silo. All three were taken by ambulance to hospital.
  • • 
    Ambulance staff found K to be unconscious, pale, cool, and covered in bitumen product. He had suffered solvent inhalation.
  • • 
    His legs went into spasm in the ambulance.
  • • 
    He had short-term memory loss and could not recall collapsing.
  • • 
    He had pain and grazes consistent with some kind of fall.
  • • 
    K’s rescuers also suffered from the toxic atmosphere in the silo but were assessed and released from hospital later that day.

CONTRIBUTING CAUSES

  • • 
    K’s employer had not assessed the hazards at the farm and had no specific procedures to identify hazards.
  • • 
    The employer relied on the principal’s own hazard assessment when accepting a job.
  • • 
    Employees were not trained in confined space work.
  • • 
    There was no operating procedure for work in confined spaces.
  • • 
    The use of the dust filter exposed the employee to solvent fumes.
  • • 
    Disposable gloves did not protect his skin from solvent absorption.

BROADER LESSONS

  • • 
    Any work carried out in a confined space is potentially lethal.
  • • 
    Confined space work requires a safe operating procedure.
  • • 
    Staff working in confined spaces require specific training.
  • • 
    The company was successfully prosecuted by WorkSafe New Zealand.

Thanks to WorkSafe New Zealand for its assistance with this column.

Thomson Reuters

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