CHARLES ZISHIRI

OSHEMAC 11

TOTAL LOSS CONTROL CASE STUDY ASSIGNMENT 1:

What went wrong :
The Employer:
 Workplaces with such dangerous chemicals require an occupational hygienist onsite but
the employer did not employ one.
 The employer should have automated handling and processing operations where
isocyanates are used e.g. transferring and drying.
 Using enclosures with a ventilation system e.g. fume cupboards, spray and downflow
booths and using local exhaust or dilution ventilation were other safety masures that the
employer could have consider to safe guard the health and safety of his employees.
 Providing workers with relevant information, training and instruction including
information from SDS.
 The was no first aider onsite

The Foreman:
 Did not have or did not follow the hand over- take over for machinery operators.
 The respirator that he brought for use by Tichaona was defective, and allowed unfiltered
air pass through to Tichaona’s respiratory system.
 The paint scraper which the foreman gave Tichaona to scrape the leaking foam from the
floor was the wrong tool for the job.
 Scrapping the foam from the pipe without fixing the leak must have extended Tichaona’s
exposure time to tolune di-isocynate.
 His instruction for Tichaona to go right under the machine brought Tichona too close to
the pollutant and increased his susceptibility.
 One and half hours that Tichaona spend under the machine was too long. The Foreman
did not arrange more labour to take turns with Tichaona.
 Local exhaust ventilation system was supposed to have been activated to remove the
contaminant and make the air tolune di-isocynate free and safer to breath.
 The foreman put Tichaona to tusk without prior induction or orientation
 The foreman did not restricting access to areas where isocyanates are being used,
processed or stored to authorised personnel only and allowed Tichaona access
  Limiting workers’ time near isocyanates was not done

Medical Officer
 The medical officer did not do medical monitoring of the workers or the workplace

Safety Officer
 Air monitoring was required to ensure exposure standards are not exceeded, but it was
not done. Atmospheric concentrations of isocyanates can be worked out by direct reading
instruments and detection badges or more complex methods for aerosols of higher
molecular weight monomers and pre-polymers but no such equipment was onsite.
 Leak detectors were supposed to have been fitted to in the plant especially along foam
conveying pipes.
 He did not provide the employee with appropriate PPE, an air-purifying respirator (APR).
and a full face shield
 Placing prominent notices of action to be taken in case of an emergency in areas where
isocyanates are used.
 The emergency procedures at the workplace e.g. procedures to be followed in case of
fire, spill or leak was nonexistent or was not followed

The Plant
 The concentration of tolune di-isocynate in the plant must have exceeded the 0,02mg/m3.
 Plant maintenance schedule must not have been followed properly to remove worn out
parts

The protection
 Was defective and ineffective since it allowed unfiltered, contaminated
Why it happen:
This incident happened because the employer did not supply his employees with the information
that he should have supplied, regarding chemical uses. At law, the employer is supposed to
furnish employees with all the information on all chemicals used on at his factory, Put protective
measures to safe guard the health and safety of employees following the hierarchy of control,
from elimination of hazards to provision of appropriate PPE.

It shows there was poor chemical handling that could have resulted from lack of education and
training on the part of the employees.

What should have been done:

Solid decontaminants should have been used to absorb initial spills of isocyanates. They
generally contain an absorbent material which soaks up the chemical and some pre-absorbed
liquid decontaminant which destroys the isocyanate.

 To ensure the correct remedial steps are taken quickly workers should be familiar with
decontamination procedures if spills or leaks happen. This includes:

 immediate evacuation and ventilation of the affected area

 only permitting trained personnel equipped with appropriate PPE to deal with the spill
keeping supplies of absorbent materials and decontaminants nearby to quickly deal with
spillages or leaks, and

 neutralising spills or leaks by spreading solid decontaminant over the area. This should be
left for at least 10 minutes and then collected and placed in a reserved bin that is kept outdoors.
These bins must not be sealed as carbon dioxide will be released as the isocyanate reacts. The
affected area should then be thoroughly washed with liquid decontaminant and rinsed well with
water.
Contaminated clothing should have been removed immediately and not re-worn until it is
decontaminated. Reference was supposed to be made to the SDS or supplier of the isocyanate
product for information on the appropriate decontamination procedure. Clothing that is highly
contaminated should have been properly disposed of.

An atmosphere-supplying respirator such as a self-contained breathing apparatus (SCBA) or a

supplied air respirator (SAR) in positive pressure or continuous flow mode should be worn

The Spill/ Leak Clean up procedure:

 Notify management and implement site emergency response plan.

 Evacuate nonemergency personnel.
 Ventilate and remove ignition sources.
 Isolate the area and prevent access of unauthorized personnel.
 Make all applicable and required notifications. Consult the SDS for reportable quantity
for the specific TDI product.
 Wear necessary personal protective equipment (PPE) as specified in the SDS or the site
emergency response plan.
 Control the source of the leak.
 Contain the released material by damming, diking, retaining, or diverting into an
appropriate containment area.
 Absorb or pump off as much of the spilled material as possible. When using absorbent,
completely cover the spill area with suitable absorbent material (e.g.,vermiculite, kitty
litter, Oil-Drio,etc …).
 Allow for the absorbent material to absorb the spilled liquid. Shovel the absorbent
material into an approved metal container.
 Do not fill the container more than 2/3 full to allow for expansion, and do not tighten the
lid on the container. Repeat application of absorbent material until all liquid has been
removed from the surface.
 Decontaminate the spill surface area using a neutralization solution scrubbing the surface
with a broom or brush helps the decontamination solution to penetrate into porous
 surfaces. Wait at least 15 minutes after first application of the neutralization solution.
Cover the area with absorbent material and shovel this into an approved metal container.
 Always wear proper PPE when cleaning up an isocyanate spill and using a neutralisation
solution to decontaminate surfaces, tools or equipment. Residual surface contamination
can be checked using a wipe test pad to verify decontamination is complete. If the wipe
test pad demonstrates that isocyanate remains on the surface (red color on pad), repeat
applications of neutralization solution, with scrubbing, followed by absorbent until the
surface is decontaminated (no color change on wipe pad).
 Apply lid loosely to metal waste container. Do not tighten the lid because carbon dioxide
gas and heat can be generated from the neutralization process. With the lid still loosely in
place, move the container to an isolated, well-ventilated area to allow release ofcarbon
dioxide.
 After 72 hours, seal the container, and properly dispose of the waste material and any
contaminated equipment (i.e., broom or brush) in accordance with existing state and local
regulations.