Case Ditails

Scenario
Case Name In the box girder of the steel Lohse bridge which take over 3 spans, 4 painters suffered organic solvent poisoning.
Pictograph
Date July 1, 1999
Place The Otsu stationary of the Oita prefecture Oita City
Location The bridge erection field of the motorway
Overview * When 3 painters carried out a last inspection and repair of the painting in the arch rib and the steel box girder without the regulated equipment of the regulation, they suffered organic solvent poisoning in the box girder inside and could not escape by themselves.
* The person in charge of the coating operation rushed in to rescue them but he also suffered poisoning and he could not move out of the way.
* 4 persons were saved by the rescue team after the 4 hour half and invaded by slight toxipathy.
Incident On July first, 1999, 4 painters suffered organic solvent poisoning near the middle bridge pier while carrying out a last inspection and repair of the painted surface in box girder of the steel Lohse bridge which take over 3 spans (260m). At around 14 o'clock4 painters were invaded by slight toxipathy at 68m from the bridge edge.
Sequence * The accident also occurred during the last inspection and the repair work of the painted surface.
* During the morning from near top of the arch rib to the middle bridge pier, 3 painters advanced to inspect and do repair work of the painting.
* In order to have lunch at 13 o' clock, the 3 painters put the coating material near the middle bridge pier in the box girder and came outside.
* They came in to the middle bridge pier at around 14 o'clock and resumed the work in the box girder, and they suffered organic solvent poisoning soon.
* At around 16:30, one of the painter crawled out by himself and reported the situation to the person in charge of the coating operation.
* The operator came to box girder for the rescue alone, and confirmed two moving people.
* While the operator asked the foreman to rescue in the box girder by portable telephone, he tried to carry two persons out, but he suffered the poisoning because of not having the protection equipment.
* Foreman who received telephone communications also tried the rescue, but he judged that people in the field could not be rescued, so he asked the rescue team.
* Rescue work by the rescue team began from around 18:30, and it ended at 19:30.
Cause * They worked painting (using the organic solvent) without wearing gas masks and forced ventilation.
* They were too thoughtless to think the inspection and the repair painting as the easy work and to work without the use of a ventilator and gas masks. (Ventilation and the gas mask were used in the main body painting)
* In the atempted rescue, the operator did not wear a gas mask.
* The painters remained the organic solvent in the box girder without the lid in the lunch.
Response Foreman who received telephone communications also tried the rescue, but he judged the persons in the field could not be rescued, so he asked the rescue team.
Countermeasures * They should use the gas mask and forced ventilator on coating operation in box girder, even if it is the easy work. The inspection of equipment should be carried out for the completeness before the opening with the presence of foreman.
* The watchman was placed under work at the both sides of the girder, and curried out regular communication for monitoring of the ventilator and the painter.
Knowledge Comment * Certainly ventilation must be taken, since the organic solvent evaporates and stays in the box girder.
* Everyone must use the ventilator and the gas mask when he enters a box girder for a coating operation.
* It is necessary that the person in charge of coating operation directs the use of the ventilation and the gas mask in work meeting and KYK, and that he watches the condition in the work.
Background * They considered he last inspection and repair coating operation thoughtlessly, and neglected the use of ventilator and gas masks which were the necessary equipment.
* The use of the gas mask and the ventilation was not directed in the work instruction based on the prior work's previous arrangement, pre-meeting, and KYK.
* The person in charge of painting did not play his full part to direct and watch over the use of the gas mask and the ventilator.
* Many diaphragms were placed inside the box girder near the middle bridge pier, so it became the structure in which gas was easy to be accumulated.
Sequel * 4 foremen and 11 floor workers were in the field and each of them tried to rescue after receiving the request, but they returned because of not wearing the gas mask.
* There were 6 manholes and a lot of handholes in a box girder under erection of the girder. But the countermeasures for organic solvents such as the ventilation were insufficient for the installation of concrete.
Incidental Discussion Because the danger consciousness for organic solvent of the foreman man is insufficient, the paintmaker educated the workers later and it was taught that there was an explosion hazard from using portable telephones in the place which was charged with organic solvent.
Account of Concerned Parties * The painters had a high tolerance for organic solvent (thinner), so he judged that it was not necessary to use ventilator and the gas mask on inspection and repair painting.
* The foreman directed staff to use the gas mask and the ventilator when painting the main body, but he also thoughtlessly considered inspection and repair coating.
Reason for Adding to DB During the work in sealed place, they should use adequate facilities and the protectors such as ventilators and gas masks, etc. even if it is an easy work.
Scenario
Primary Scenario Carelessness, Insufficient Precaution, Ignorance of Procedure, Disregard of Procedure, Poor Response to Change in Environment, Change in Environment, Poor Value Perception, Poor Safety Awareness, Poor Value Perception, Poor Safety Awareness, Regular Operation, Nonobservance of Procedure, Regular Movement, Dangerous Movement, Malicious Act, Rule Violation, Bodily Harm, Sickness, Possible Damage, Potential Hazard
Sources Failure knowledge DB promotion committee construction field research council, (Corp.) Japan Bridge construction association presentation material
Number of Deaths 0
Number of Injuries 4
Field Civil Engineering
Author NABESHIMA, Hajime (Japan Bridge Association)
Scenario