FACEValue: Shipyard welder fatally burned

NIOSH’s Fatality Assessment and Control Evaluation Reports
#2003-22-1

Date of incident: Feb. 18, 2003

A 48-year-old shipyard welder was injured and later died from burns she sustained when her wire-fed welder ignited atomized hydraulic oil. Company records indicate safety training was performed and Material Safety Data Sheets were available to employees; however, the MSDS for hydraulic oil did not mention the risk of fire when the oil is atomized. At the time of the incident, the victim was using a high lift to weld above her head on an ocean-going barge that was placed in dry dock for renovations. The victim and other workers had previously complained that the lift ran rough, occasionally dropping unexpectedly. In spite of these complaints, the equipment was not taken out of service. Hydraulic lines were exposed beneath the floor grate of the work platform. Fire investigators speculate that a pinhead leak developed in the lines as the victim was welding, allowing pressurized atomic oil to escape and atomize in the work area. Although no one witnessed the actual event, it is believed the victim was exposed to flames for 2-4 minutes before falling to the floor of the platform. The victim eventually was extricated from the cage and airlifted to the burn unit of a local hospital. She died 62 days after the incident.

To prevent future occurrences:

• Employers and employees should ensure equipment is properly maintained and appropriate for the task at hand. The lift used in this incident was built in 1977, had a poor repair record and had multiple reports of malfunction. Employers should conduct a hazard assessment for each job and ensure all equipment is maintained according to the manufacturer’s recommendations. Additionally, the foreman requested the job be performed from staging rather than a high lift because of the lift’s stability issues. However, the supervisor ordered the high lift to be used, due to cost, portability and other issues.
• Daily checks of all hydraulic equipment should include inspections of hoses and connections. Hydraulic lines should be checked daily for signs of wear, age or damage. Even a small crack or leak could cause hose failure. Softened hoses and cracking or damaged lines need to be replaced. Maintain a detailed maintenance record on all equipment.
• Hydraulic lines should be relocated and protected from physical damage. Hydraulic lines should be routed in a way that protects them from the work process and physical damage. In this case, the lines were routed through the open grate floor of the lift cage. The grates did not prevent the lines from coming into contact with hot slag, which fire officials believe caused the fatal leak.