By Robert Harrison, MD, and Laura Styles, MPH

The headlines a few weeks ago were alarming. The tragic death of a worker in a 270-degree oven three years ago led to a $6 million agreement to settle criminal charges in what Los Angeles District Attorney Jackie Lacey said was the largest payout in a California workplace death (see news report). The California Fatality Assessment and Control Evaluation (FACE) program investigated this case, and the investigation report provides additional details: On Thursday, October 11, 2012, at approximately 5:30 a.m., a 62-year-old Hispanic male machine operator working in a food processing plant died when he was sealed inside a pressure cooker. The victim was assigned the task of loading the steam pressure cooker called a “retort” with carts of canned tuna using a pallet jack. When the victim’s supervisor went to check on the work progress, he noticed the pallet jack and carts loaded with canned tuna in front of the retort. The inlet door was open and the outlet door was closed. The victim was not visible. The supervisor instructed a co-worker to load the retort while he went to look for the victim. The co-worker loaded the retort with the carts containing 12,000 pounds of canned tuna but did not look inside prior to loading. The inlet door to the retort was then closed and sealed by another employee and the steam pressure turned on. After an extensive search for the victim, the supervisor had the retort turned off and the outlet door was unsealed and opened. The victim was found unresponsive inside the retort by the outlet door and pronounced dead at the scene by responding police and fire personnel.

How Could This Happen?

The employer had written procedures for both confined spaces and permit-required confined spaces for other vessels in the plant. However, the company supervisor never identified the retorts as confined spaces and there were no written policies or procedures for loading them. As a consequence, the employees working with the retorts never received confined space or permit-required confined space training. Had the employer conducted and documented periodic safety audits and inspections that identified all hazardous work areas for employees, the retorts would have been classified as a permit-required confined space. If the retorts had been identified as a permit-required confined space, there would have likely been the proper procedures, controls and training to safely load the pallets. The tragedy points to the need for comprehensive safety programs in workplaces where the work process may pose inherent risks of serious job-related injury or death.

How Do We Prevent this from Happening Again?

Confined space deaths continue despite a wealth of information on how to prevent them. The following are guidelines for working in confined spaces.

• Companies should identify all confined spaces in their facility and develop and implement written confined space entry procedures for each confined space.
• Companies should post warning signs at all confined space entry points. The signs should be understandable to workers who cannot speak or read English.
• Companies should identify all workers who are potentially exposed to confined space hazards and provide training to those employees, including engulfment, oxygen deprivation, presence of toxic gases and mechanical and electrical hazards.

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