Suburban Propane LP: OSHA inspections and violations

Incident on Sep 25, 1993: Employee suffers burns when propane tank ignites

AT 6:00 A.M. ON SEPTEMBER 25TH, EMPLOYEE #1, A GROUND CREWPERSON FOR ABOVE THE W EST HOT AIR BALLOON, WAS PREPARING TO REFILL PROPANE TANKS IN A BARNES AX8 HOT A IR BALLOON SO IT COULD BE FLOWN THAT MORNING. HE WAS AT SUBURBAN PROPANE IN YOUN TVILLE, CALIFORNIA, WHERE HIS COMPANY HAD A SELF-SERVE AGREEMENT TO FILL TANKS. NORMALLY, EMPLOYEE #1 USED THE COMPUTERIZED CARDLOCK STATION, BUT IT WAS INOPERA TIVE AND ALL FILLING HAD TO BE DONE FROM A NOZZLE ON THE OUTSIDE OF THE FILL BUI LDING. EMPLOYEE #1 STARTED TO RIG THE FUEL HOSES TO REFUEL BY TAKING THE MAIN HO SES OFF THE BURNERS TO ATTACH THEM TO A "T" ADAPTOR, WHICH HE WOULD CONNECT TO S UBURBAN'S FILL NOZZLE AND HOSE. EMPLOYEE #1 FOUND HE HAD NO T-ADAPTOR ON HIS TRU CK, SO HE BORROWED ONE FROM ANOTHER CUSTOMER AND RETURNED TO HIS CHASE TRUCK TO FINISH THE HOOKUP, MAKING SURE ALL CONNECTIONS WERE TIGHT. THE NEXT STEP WHEN FI LLING WAS TO MANUALLY TURN ON THE ELECTRIC PROPANE PUMP USING A SWITCH INSIDE TH E FILL BUILDING. ANOTHER CUSTOMER IN THE BUILDING OFFERED TO TURN ON THE PUMP SW ITCH. BEFORE TURNING IT ON, SHE ASKED EMPLOYEE #1 IF EVERYTHING WAS READY TO GO; HE SAID EVERYTHING WAS OK. THE CUSTOMER TURNED ON THE PUMP SWITCH AND LEFT THE FILL BUILDING. EMPLOYEE #1 STARTED REFUELING BY FILLING THE RIGHT FRONT CYLINDER . HE OPENED THE 10 PERCENT VALVE, WHICH VENTS THE TANK, THEN OPENED THE MAIN TAN K VALVE AND THE NOZZLE VALVE TO FILL THE TANK. WHEN THE FIRST TANK WAS NEARLY FU LL (WHEN FULL, THE 10 PERCENT VALVE STOPS VENTING VAPOR AND STARTS VENTING LIQUI D PROPANE), EMPLOYEE #1 TURNED AROUND IN THE TRUCK BED TO FUEL THE TWO TANKS IN THE LEFT REAR CORNER. AS HE TURNED AND BENT OVER TO OPEN THE 10 PERCENT AND FILL VALVES, HE FELT HEAT ON HIS LEGS. EMPLOYEE #1 TURNED BACK TO DETERMINE THE SOUR CE OF THE HEAT AND SAW THE PROPANE VENTING FROM THE 10 PERCENT VALVE. THE PROPAN E IGNITED, FLASHING IN HIS FACE AND SINGEING HIS FACE AND HAIR. HE PULLED BACK F ROM THE FLAME AND ROLLED OUT OF THE TRUCK. HE THEN RAN AWAY FROM THE TRUCK, OBSE RVING THE GONDOLA BASKET ON FIRE. EMPLOYEE #1 SUFFERED FIRST-DEGREE BURNS ON HIS FACE, AS WELL AS FIRST- AND SECOND-DEGREE BURNS ON HIS LEGS. HE WAS WEARING A L EATHER JACKET AND LEATHER GLOVES WHILE REFUELING. BECAUSE HE WORE NYLON SHORTS, HOWEVER, HIS LEGS WERE NOT PROTECTED AND WERE BURNED MORE SEVERELY. WITNESSES HE ARD THE SOUND OF THE INITIAL EXPLOSION AND, WHEN THEY FIRST OBSERVED THE SCENE, SAW THAT THE FIRE WAS CONFINED TO THE GONDOLA. THUS, IT IS REASONABLE TO ASSUME THAT THE INITIAL POINT OF IGNITION WAS INSIDE OF THE GONDOLA. EMPLOYEE #1 STATED THAT NO CONNECTIONS WERE LEAKING, HE WAS NOT SMOKING, THE TRUCK'S ENGINE HAD BE EN SHUT OFF EARLIER, AND HE HAD NOT USED ANY TOOLS AFTER THE FUEL VALVE HAD BEEN TURNED ON. IT IS NOT POSSIBLE TO DETERMINE THE ACTUAL SOURCE OF IGNITION FROM T HE PHYSICAL EVIDENCE AND WITNESS STATEMENTS. A POSSIBLE SOURCE THAT CANNOT BE EL IMINATED IS A STATIC ELECTRICITY SPARK FROM EMPLOYEE #1'S NYLON SHORTS TO A GROU NDED SURFACE IN THE GONDOLA, POSSIBLY CREATED AS EMPLOYEE #1 TURNED AND BENT OVE R TO FILL THE TWO LEFT REAR TANKS. NO ACCIDENT-RELATED VIOLATIONS WERE FOUND. TH E EMPLOYER WAS CITED FOR NOT HAVING ANY DOCUMENTATION OF QUALIFIED LP GAS TRANSF ER ATTENDANT TRAINING AS REQUIRED BY 8CCR 472(E)(1) AND FOR NOT HAVING A WRITTEN HAZARD COMMUNICATION PROGRAM (8CCR 5194(E)). WITNESSES AS WELL AS FORMER AND PR ESENT EMPLOYERS ALL CLASSIFIED EMPLOYEE #1 AS A VERY EXPERIENCED BALLOON GROUND CREWPERSON, WHO WAS DOING EVERYTHING AS IT WAS SUPPOSED TO BE DONE DURING REFUEL ING AT THE TIME OF THE ACCIDENT.