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% 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
- Macro-region
- North America
- Country
- United States
- Date
- Component involved
- reactor / oven / furnace / test chamber
- Failure mode
- erroneous release & ignition
- Initiating cause
- run-away reaction
- 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.- Root causes
- Date entry in HIAD
- 01/01/2020
Facility
- Application
- Electrical, electronics and micro-electronics industry
- Sub-application
- circuit boards production
- Hydrogen supply chain stage
- All components affected
multilayer circuit boards manyfactury, chemicals
- Location type
- Unknown
- Location
- unknown
- Operational condition
Emergency & Consequences
- Number of fatalities
- 0
- Number of injured persons
- 14
- 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.
In-depth data
- Release type
- gas mixture
- Involved substances (% vol)
- H2,
CO - Probable IGNITION SOURCE
References
- Sources categories
- OHSA
- Reference & weblink
OSHA Accident Summary Nr: 170620488 - Fourteen Employees Exposed To Carbon Monoxide And Hydrogen
https://www.osha.gov/ords/imis/accidentsearch.accident_detail?id=170620…
(accessed May 2023)