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Accident Case Study: 5 Workers Die in Yeast Brew Vat
Accident Case Study: 5 Workers Die in Yeast Brew Vat
Accident Case Study: 5 Workers Die in Yeast Brew Vat
5 WORKERS DIE
IN YEAST BREW VAT
ACCIDENT - SLIDE 1 OF 8
ACCIDENT CAUSATION
Domino Theory.
Multiple Causation Theory.
ACCIDENT - SLIDE 2 OF 8
ACCIDENT CASE STUDY
5 WORKERS DIE IN YEAST BREW VAT
OVERVIEW OF THE INCIDENT
You are a member of the safety committee and have been notified
to report to work 3 hours early to assist in an investigation of an
accident. 2 maintenance workers and 3 bakers were found huddled
together at the base of an “Evenrise” yeast vat. All 5 five had
extreme “blueing” of the lips and fingernails. 1 other worker has
been taken to the hospital complaining of extreme headaches,
dizziness, disorientation and nausea. You and your group must
conduct an accident investigation to determine the root cause. The
bakery has been shut down and is losing $288,000 per day in
revenue.
ACCIDENT - SLIDE 3 OF 8
ACCIDENT CASE STUDY
THE VAT TOP VIEW
FLUSH PORT
10ft Deep 6ft
ACCIDENT - SLIDE 4 OF 8
ACCIDENT CASE STUDY
SIDE VIEW
EVENRISE
YEAST BREW VAT
10ft Deep
FLUSH PORT
ACCIDENT - SLIDE 5 OF 8
ACCIDENT CASE STUDY
TOP VIEW
XX
X FLUSH PORT
XX
VICTIMS
SERVICE LADDERS
ACCIDENT - SLIDE 6 OF 8
ACCIDENT CASE CHRONOLOGY
12:02am: Baker 1 attempts to flush (clean) residual product from
vat
12:10am: Baker 1 attempts to flush the vat, vat fails to flush
12:17am: Baker 1 attempts to flush vat for the third time
12:33am: Baker 1 reports the problem to maintenance
12:35am: Baker 1 tries to find supervisor, unable to locate
12:40am: Maint 1 arrives, enters vat through service door
12:44am: Maint 2 arrives and checks service box on rear of vat
12:49am: Maint 2 enters vat through service door
12:55am: Baker 1 hears noises, climbs ladder, looks into vat
12:55am: Baker 1 yells for help, enters vat through service door
12:55am: Baker 2 responds and enters vat through service door
1:25am: Supervisor arrives and enters through service door
2:55am: Baker 3 arrives, and enters vat
2:56am: Baker 3 is disoriented, immediately exits and notifies
911 ACCIDENT - SLIDE 7 OF 8
3:17am: Responders find all 5 workers dead at the scene
QUESTIONS TO BE CONSIDERED
ACCIDENT - SLIDE 9 OF 8