On a Saturday afternoon this past May, while pumping a two-part “GREEN” soy- based foam into the attic ceiling of a Cape Cod home renovation, a fireball erupted, taking the hose man’s life.
The circumstances of the flashover were investigated by the Falmouth Fire Department, the Commonwealth of Massachusetts Fire Marshall’s Office Investigators, private fire investigators, insurance investigators, and OSHA. To date, only OSHA has released their findings, obtained through a Freedom Of Information request.
As a local resident, an active safety consultant, and an OSHA trainer here on Cape Cod, many clients, associates and others had come to me since the incident for guidance and advice on the continued use of his insulation, generally recognized to be both state-of-the-art and the future for commercial and residential building insulation.
Despite the present incomplete disclosure of all expected findings, it seems clear that the safety community can now go forward with at least preliminary warnings and advisories relating to the continued use of these chemical products and insulating techniques. To wait further can only potentially set up other installers for similar safety risks.
Manufacturer sheets known as MSDS or Material Safety Data Sheets, Urethane Soy Systems industry technical sheets, and OSHA’s own technical information now focus entirely on known chronic toxicological risks to users, with essentially no mention of what was OSHA’s own ultimate conclusion in this instanceâ€”that the physical property of spontaneous combustion was the flashover trigger. Certainly OSHA’s 108-page Final Rule on Methylenedianiline (“MDA”) and 8-page brochure for Construction Safety and Health Outreach Training is devoid of fire, explosion, or spontaneous combustion warnings. Both publications, relied upon by safety personnel and increasingly by the general public with immediate web access, need to be augmented with demonstrative Physical Hazard concerns in light of these conclusions. A web search of product information on SoyTherm 50, SoyTherm 100, and other two-component open-celled, spray-applied polyurethane insulation foams plus OSHA.gov available information on isocyanates and, as mentioned, 4,4’ MDA, provided no Physical Hazard evidence. There was, effectively, no warning information on physical hazards of airborne concentrations of this chemistry during the mixing, blow-in, or cleanout procedures.
The Falmouth tragedy resulted in SERIOUS cited deficiencies in the safety programs of the two companies working there that dateâ€”four for one company, and eleven for the second company.
The final OSHA citations resulted in negotiated penalties of $6,240 for one firm and $8,360 for the second, offered below for greater safety awareness.
Four Serious fines for the “exposing” application contractor included:
1926.20: The accident prevention program did not provide for frequent and regular inspections of the job sites, materials and equipment to be made by competent persons designated by the employer. --- $2,000.00. Negotiated to $1,300.00.
1926.21: The employer did not instruct each employer in the recognition and avoidance of unsafe conditions and the regulations applicable to their work environment to control or eliminate any hazards or exposures to illness and injury. --- $2,800.00. Negotiated to $1,820.00.
1926.21: Employees required to enter into confined or enclosed spaces were not instructed as to the nature of the hazards involved, the necessary precautions to be taken, and in the use of protective and emergency equipment required. --- $2,000.00. Negotiated to $1,300.00.
1926.150: The employer did not develop a fire protection program for all phases of the construction or demolition work. --- $ 2,800.00. Negotiated to $1,820.00.
The controlling firm was cited for the following eleven deficiencies:
1926.150: The employer did not develop a fire protection program for all phases of the construction or demolition work. --- $ 2,800.00 Negotiated to $1,820.00 .
1910.134 : The employer did not provide a medical evaluation to determine the employee’s ability to use a respirator before the employee is fit tested or required to use the respirator in the workplace. --- $2,000.00 Negotiated to $1,000.00
1910.134 : The employer shall insure that employees using tight-fitting respirators pass an appropriate qualitative or quantitative fit test before an employee may be required to use a respirator. --- $2,000. Negotiated to $1,000.00
1910.134: All respirators were not stored to protect them from damage, contamination, dust, sunlight, extreme temperatures, excessive moisture, and damaging chemicals, and were not packed to prevent deformation of the facepiece and exhalation valve. --- $ 2,000.00 Negotiated to $1,000.00
1910.134: The employer did not maintain at the compressor a tag containing the recent filter and/or air purifying sorbent bed change date and signature of the person authorized by the employer to change them. --- $800.00 Negotiated to $400.00
1910.134: Employer did not provide effective training to employees who were required to use respirators. --- $1,000.00 Negotiated to $500.00
1926.151: The vicinity of operations which constituted a fire hazard was not conspicuously posted: “No Smoking or Open Flame.” ---- $1,400.00 Negotiated to $700.00
“Specifically, the foam spraying operation”.
1926.405: Flexible cords were not connected to devices and fittings so that strain relief is provided to prevent pull from being directly transmitted to joints or terminal screws. --- $800.00 Negotiated to $400.00
1926.407: Equipment, wiring methods, and installations of equipment in hazardous (classified) locations were not approved for the hazardous (classified) location or safe for the hazardous (classified) location. ---- $2,000.00 Negotiated to $1,000.00
Specifically, the back of the box truck was not wired for Class 1, Division 2 hazardous location.
1926.407: Equipment which is safe for the location was not of a type and design which the employer demonstrates will provide protection from the hazards arising from the combustibility and flammability of vapors, liquids, gases, dusts, or fibers. --- $2,000.00 Negotiated to $960.00.
Specifically, on or about 5/19/08, a non-rated, portable halogen light was used in the attic space
Reportedly, the open cell foam used in the attic space and the closed cell (denser – higher R value but less flame spread resistant requiring sheet rock cover to meet building code) used elsewhere in this renovation are not compatible in the same spray equipment requiring a full hose line flush and cleaning before switching product. The degree and effectiveness that this was followed by the applier has not been determined. The physical hazard of failing to follow this directive needs to be studied and communicated to future users of this product.
Similarly, it was determined that the agitator needed to properly mix the two- component product was not working this date. Manufacturer’s warnings talk only of product quality issues due to improper mixing and do not address the potential for heat entrapment, greater off-gassing of product, or other safety/health matters. OSHA concluded that the atmospheric concentration of the blown-in foam in this, effectively, “confined space” was the actual fuel for the fire as the attic’s inside sheathing, joists and foam insulation were heavily charred but not flame engaged when the fire department arrived on scene. Heat and smoke was intense as were foam vapors (actually sickening three firefighters) but the building was never flame involved. Much of the attic from 18” to floor level appeared non-fire damaged after the flashover.
OSHA’s narrative and worksheet state, “The company was spraying expanding foam insulation in the attic of a single-family, two-story house that was undergoing renovations. The spray foam properties were such that it could generate sufficient heat immediately following its application to cause spontaneous combustion. Among the chemicals being used were diisocyanate; flouroethane and lead naphthenate. There was no fire extinguisher in the attic space during the spraying process and no rescue plan in the event of a medical emergency. The employer had not developed or implemented a fire protection or prevention plan. Access to the attic was via a 3’ wide by 6’ long hole in the second floor ceiling. The attic was not ventilated. A flash fire occurred in the attic in which an employee died.” OSHA further notes that, “the products used were SoyTherm 50 and SoyTherm 100 and are diphenylmethane diisocyanate (MDI) based. A technical bulletin issued in Novemeber of 1993 by the Polyurethane Division of the Society of the Plastics Industry, Incorporated located in New York City warns of the spontaneous combustibility of the material. SOYTHERM is known in the industry as an open cell foam insulation.”
For OSHA to cite this obscure source in their findings linking spontaneous combustibility to this tragedy substantiates their own lack of acknowledging it as a potential hazard in its applicable current references. Moreover, it spotlights where such warnings aren’t, but need to be, more than anywhere else, in the manufacturer’s own Material Safety Data Sheets and Technical Training materials.
This writer needed to go back to a NIOSH publication published in 1976, before epoxies were glamorized into isocyanates, to find a small booklet titled Epoxy Wise Is Health Wise that through cartoon characters describes, “Eartha, thinking of her Friday night date, lit a cigarette near epoxy. Boom!” A simple warning that should have survived the revision process.
Discussions with both OSHA and the Deputy Fire Chief on other possible ignition sources appeared to dispel two anecdotal origins that immediately took favor on this New England peninsula that the employee was a smoker and he was using a halogen lamp to improve his illumination in this nearly black building area. The fire department could find no lighter on the body or in the area nor was there any evidence of smoking materials (although conceded that smoking materials could have been destroyed in the fire blast). Further, the two prongs on the halogen lamp were soot covered after the blast, indicating to fire officials that the lamp could not have been plugged into a wall socket at the time. Other employees have maintained that this lamp had burned out days earlier and was not in use on the day of the tragedy.
The origin of the ignition is highly relevant, however, OSHA investigating personnel made clear that the major lesson to be learned is the criticality of mechanical ventilation to a confined space undergoing this type, and maybe all types, of foam insulation. In this case the employee was wearing a hose supplied air respirator for his own respiratory protection and therefore may have been completely unaware of the vapor cloud that his activities were creating in this confined attic space. The ignition source may in truth be less of a safety lesson than the conditions that he was creating making any possible ignition source the trigger for a tragedy.
Chemicals in the residential construction world are a far larger source for concern than we are presently acknowledging in manufacturers, distributors and our own independent safety literature.
Massachusetts has experienced the deaths of three additional workers in recent years caused by the use of highly flammable wood floor finishing products, “lacquer sealers.” Boston alone over the past decade has had more than 25 fires directly attributed to hardwood floor installations and refinishing, resulting in more than $1.5 million in property damage.
In August 2005, 2 workers were critically hurt in Newburyport, Massachusetts, when vapors from a highly flammable waterproofing substance that one of the workers had been spraying exploded in the subbasement of a four-story house. That blast blew out the first floor wall of the house, bowing the side into the shape of a V, while sending a side door over 50 feet into the back yard. A similar waterproofing spray ignited on June 6, 2006, in the Flatlands neighborhood of Brooklyn, New York, killing a 27- year-old workman and severely injuring two others. This area, too, was poorly ventilated, officials said, allowing fumes from the spray to build up, although in this case also the ignition source was not established. Fire officials said that the spray compound was stored and heated in a truck parked outside the house, and was then run through a hose into the basement, where it was being used to waterproof a tubâ€”a dispensing system for the chemicals nearly identical to that of this Cape Cod tragedy, with “Green” –Soy based foam insulation.
Richard Hughes, a safety and health consultant, can be contacted at P. O. Box 3416, Waquoit, MA 02536-3416; 508-548B0866; FAX: 508-548-5657; E-mail: firstname.lastname@example.org ;Web: www.excel-in-safety.com