Event
- Event ID
- 726
- Quality
- Description
- The event occurred at the factory producing multilayer circuit boards by a multistep dip operation. An employee inadvertently mixed 55 gal of 50 percent hydrogen peroxide into 110 gal of 30 percent formaldehyde. This resulted in a carbon monoxide and hydrogen release. The facility was evacuated and the local fire department and ambulance responded. 14 workers, out of whom three were from temporary employment agencies, were treated for inhalation and released.
The employee did not look carefully at the label on the hydrogen peroxide drum. Both hydrogen peroxide and formaldehyde are in similar black 55 gal poly drums with labels on one side. - Event Initiating system
- Classification of the physical effects
- Unignited Hydrogen Release
- Nature of the consequences
- Leak No Ignition (No additional details provided)
- Macro-region
- North America
- Country
- United States
- Date
- Root causes
- Root CAUSE analysis
- The INITIATING cause was that staff advertently mixed two chemicals which produced and released of carbon monoxide and hydrogen.
The fact that the two products containers were not easily distinguishable hints at a management and/or job factor.
Facility
- Application
- Electronics And Micro-Electronics
- Sub-application
- reactor
- Hydrogen supply chain stage
- All components affected
- multilayer circuit boards manyfactury, chemicals
- Location type
- Unknown
- Operational condition
Emergency & Consequences
- Number of injured persons
- 14
- Number of fatalities
- 0
- Post-event summary
- 14 employees were treated for inhalation and released.
Lesson Learnt
- Lesson Learnt
It is unknown if the operator adopted corrective actions.
In general, it appears clear that the procedures should be made more effective. The risk of confusing containers with different chemicals should be reduced. At the same time, staff should be better trained and follow operating instructions more carefully.
Event Nature
- Release type
- gas mixture
- Involved substances (% vol)
- H2,
CO - Presumed ignition source
- No ignition
References
- Reference & weblink
OSHA Accident Summary Nr: 170620488 - Fourteen Employees Exposed To Carbon Monoxide And Hydrogen<br />
https://www.osha.gov/ords/imis/accidentsearch.accident_detail?id=170620… />
(accessed May 2023)
JRC assessment
- Sources categories
- OHSA