Incident - Skin grafts from chemical burns

Context 

• A plastics recycling facility included a wash plant to clean incoming material. 
• Caustic soda – sodium hydroxide – was pumped from a bulk container into a vat within the wash plant. 
• The area was surrounded by a bund to contain liquid. 
• C was a labour hire worker on placement at the facility. 
• C had not been briefed on what the liquid in the bund was or what PPE should have been worn while walking in the bund, ie: gumboots. 
• He was not wearing footwear that would have protected against alkaline burns. 

 Detail 

• C started his shift at 7.30am and went to the wash plant to see if a bag holding plastic waste need to be changed. 
• C entered the bund and found a new bag was needed. C detached the full bag and lowered it onto a trolley. 
• C was exposed to liquid in the bund for about three minutes. 
• Soon afterwards C felt discomfort in his toes. When the pain worsened he went home. 
• C noticed bad blisters on his feet and went to the hospital, which measured a very high alkaline level present. 
• C suffered caustic soda burns to the toes on both feet, requiring five skin grafts and eight days in hospital.
• C lost part of the tops of both his little toes.
• A metal grille was later laid over the bund to provide a safe walkway. 

 Background 

• In the hours before C arrived another worker noticed the bulk container was empty and that and that liquid within the bund was white, which was unusual. 
• The main hose above the pump had split. The pump was shut down to stop the flow of caustic soda. 
• Water was hosed into the bund to dilute the solution that had accumulated. 
• The supervisor on the new shift was told about the spill and not to let C change the bags because the bund solution might have been unsafe. 
• However, this instruction was not passed on to C. 
• The solution in the bund would normally be 2% strength; the solution which caused C’s burns was found to be much higher. 
• The design of the bund meant any liquids didn’t drain into a sump but had to be manually pumped out. 

 Lessons 

• Caustic soda causes severe skin burns and eye damage. PPE required includes gloves, protective clothing, eye and face protection, and rubber boots. 
• All workers – including labour-hire staff – need to be inducted into their work areas and supplied with appropriate PPE and training. 
• Problems encountered in one shift need to be clearly transmitted to the next shift. 
• PPE is a last resort. Explore going up the hierarchy of risk controls to minimise or eliminate exposure.