FATALITY INVESTIGATION REPORT 

INCIDENT FACTS 

DATE: 

July 2012 

TIME: 

4:40 p.m. 

VICTIM: 

64-year-old maintenance 

mechanic 

INDUSTRY/NAICS CODE: 

Manufacturing/ 33 

EMPLOYER: 

Aluminum foil processing 

facility 

SAFETY & TRAINING: 

There was a written hazardous 

energy control program, but it 

did not include isolating the 

system from retained liquid 

under pressure 

SCENE: 

Boric acid evaporation system 

LOCATION: 

Washington State 

EVENT TYPE: 

Burn 

REPORT #: 52-43-2018 

REPORT DATE: 07/10/2018 

Maintenance Mechanic Dies After Being Burned by 

Hot Boric Acid Solution While Removing Pump 

SUMMARY 

In July 2012, a 64-year-old maintenance mechanic at an aluminum foil processing 

facility died after being exposed to an approximately 180-degree Fahrenheit 

solution of boric acid and water while trying to remove a recirculation pump from 

its housing. 

The pump was part of a boric acid evaporation system. Workers believed that the 

system had been completely drained. As the victim and other workers used two 

1.5-ton “come-along” puller devices to free the pump from its housing, a small 

amount of hot water/boric acid solution fanned out from around the seal. Seconds 

later, the force of the solution pushed the pump out of the housing, and hundreds 

of gallons of hot liquid flowed out. The victim fell to the floor and was covered with 

the solution. He was wearing no personal protective equipment other than safety 

glasses, and received severe burns to over 80% of his body. He died two days later 

due to his injuries. 

RECOMMENDATIONS 

Washington State Fatality Assessment and Control Evaluation investigators 

concluded that to protect employees from similar exposure hazards, employers 

should: 

 Design new equipment for manufacturing processes using the concept of 

Prevention through Design (PtD) to control risks by incorporating prevention 

methods in the final product. 

 Enforce a comprehensive written hazardous energy control program. Train all 

potentially exposed workers in the hazardous energy control procedures for the 

system, and document training. 

 Develop written standard procedures for regular maintenance operations. These 

should include information about hazards, required PPE, necessary safety checks, 

lockout/tagout procedures, and coordination with other workgroups to be done 

prior to beginning the task. Ensure that all workers performing maintenance 

tasks are trained on the procedures. 

 Ensure that workers who may be exposed to hot liquids are provided with and 

use the proper personal protective equipment (PPE) for the job, including 

appropriate eye/face, hand, and body protection. 
DEFINITIONS 

ANSI American National Standards Institute 

APP Accident Prevention Program 

ASSE American Society of Safety Engineers 

DOSH Division of Occupational Safety and Health 

L&I Washington State Department of Labor and Industries 

NIOSH National Institute for Occupational Safety and Health 

OSHA Occupational Safety and Health Administration 

PHA Process Hazard Analysis 

PPE Personal Protective Equipment 

PSM Process Safety Management 

PtD Prevention through Design 

SHARP Safety and Health Assessment and Research for Prevention 

WA FACE Washington State Fatality Assessment and Control Evaluation 

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1-888-667-4277

CONTENTS 

SUMMARY............................................................................................................................................................................... 4 

INTRODUCTION....................................................................................................................................................................... 4 

EMPLOYER............................................................................................................................................................................... 4 

EMPLOYER SAFETY PROGRAMS and TRAINING ...................................................................................................................... 4 

WORKER INFORMATION......................................................................................................................................................... 4 

EQUIPMENT ............................................................................................................................................................................ 5 

INCIDENT SCENE...................................................................................................................................................................... 5 

INVESTIGATION....................................................................................................................................................................... 6 

CAUSE OF DEATH .................................................................................................................................................................... 7 

CONTRIBUTING FACTORS........................................................................................................................................................ 7 

POST-INCIDENT CORRECTIVE ACTIONS TAKEN BY EMPLOYER ............................................................................................... 8 

RECOMMENDATIONS/DISCUSSION ........................................................................................................................................ 9 

REFERENCES .......................................................................................................................................................................... 11 

INVESTIGATOR INFORMATION ............................................................................................................................................. 12 

ACKNOWLEDGEMENTS ......................................................................................................................................................... 12 

WASHINGTON STATE FACE PROGRAM INFORMATION 

The Washington State Fatality Assessment and Control (WA FACE) program is one of many workplace health and safety programs 

administered by the Washington State Department of Labor & Industries’ Safety & Health & Research for Prevention (SHARP) 

program. It is a research program designed to identify and study fatal occupational injuries. Under a cooperative agreement with 

the National Institute for Occupational Safety and Health (NIOSH grant# 2U60OH008487), WA FACE collects information on 

occupational fatalities in WA State and targets specific types of fatalities for evaluation. WA FACE investigators evaluate 

information from multiple sources. Findings are summarized in narrative reports that include recommendations for preventing 

similar events in the future. These recommendations are distributed to employers, workers, and other organizations interested in 

promoting workplace safety. NIOSH-funded, state-based FACE programs include: California, Kentucky, Massachusetts, Michigan, 

New York, Oregon, and Washington. WA FACE does not determine fault or legal liability associated with a fatal incident. Names of 

employers, victims and/or witnesses are not included in written investigative reports or other databases to protect the 

confidentiality of those who voluntarily participate in the program. 

Additional information regarding the WA FACE program can be obtained from: 

www.lni.wa.gov/Safety/Research/FACE 

PO Box 44330 

Olympia, WA 98504-4330 

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SUMMARY 

In July 2012, a 64-year-old maintenance mechanic at an aluminum foil processing facility died after being exposed to an 

approximately 180-degree Fahrenheit solution of boric acid and water while trying to remove a recirculation pump from 

its housing. 

The pump was part of a boric acid evaporation system. The system took several days to completely cool through 

draining and flushing before it was safe to remove the pump. Workers in another department reported that they had 

completed draining the system. 

As the victim and other workers used two 1.5-ton “come-along” puller devices to free the pump from its housing, a small

amount of hot water/boric acid solution fanned out from around the seal. Seconds later, the force of the solution 

pushed the pump out of the housing, and hundreds of gallons of hot liquid flowed out. The victim fell to the floor and 

was covered with the solution. He was wearing no personal protective equipment other than safety glasses, and 

received severe burns to over 80% of his body. 

Some of the workers were able to get him to an emergency shower and began removing his soaked clothing, while 

others called 911. Emergency responders arrived within fifteen minutes and the victim was airlifted to a burn trauma 

unit. He died two days later due to his injuries. 

INTRODUCTION 

In July of 2012, the Washington State L&I Division of Occupational Safety and Health (DOSH) notified the Washington 

State Fatality Assessment and Control Evaluation (WA FACE) program of the death of a 64-year-old maintenance 

mechanic. 

WA FACE investigators interviewed the safety coordinator of the facility where the victim had been employed. 

Documents reviewed during the course of this FACE investigation include the DOSH investigation file, company accident 

records, and the death certificate. 

EMPLOYER 

The employer was a manufacturing company that processed aluminum foil for the production of electrolytic capacitors. 

Aluminum foil is anodized at the facility in boric acid baths where electrical current is applied. The company had been in 

business at the incident location for 18 years. 

EMPLOYER SAFETY PROGRAMS and TRAINING 

At the time of the incident, the employer had a written accident prevention program (APP), but it did not include specific 

information about potential hazards associated with removal of the recirculation pump. Safety training for new hires 

was tailored to the department they would be working in, and was documented. 

Each department conducted a monthly safety meeting, and there was a safety committee that also met once a month. 

There was a written lockout/tagout program for the electrical supply to the recirculation pump. 

WORKER INFORMATION 

The victim was a 64-year-old maintenance mechanic. He had worked at the company for approximately 14 years, and 

had previous experience in the manufacturing industry. He had regularly performed maintenance on the pump system 

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since it had been installed. He typically performed removal of the 

recirculation pump when necessary, and trained new employees in 

the procedure. 

EQUIPMENT 

The plant’s boric acid evaporation system had been designed, 

engineered, and installed by an outside contractor approximately 

eleven years prior to the incident. The 150 HP recirculation pump 

(photo 1) used to circulate solution in the boric acid evaporation 

system had been installed at the same time. It was typically removed 

1-3 times a year for maintenance. At the time of the incident, it needed to be removed to repair an oil leak. 

Photo 1 Recirculation pump, removed from housing. 

The power supply to the pump had been designed to accept lockout/ tagout devices, but the plumbing system in and 

out of the pump itself was not designed with the capability to be isolated or blocked to prevent the accidental release of 

solution during pump removal if system drainage was incomplete. 

INCIDENT SCENE 

The incident occurred in the indoor section of an area of the facility that housed the boric acid evaporation system 

(figure 1). The recirculation pump sat at the lowest point of the system, connected to incoming pipes from the heat 

exchanger above and the outside tank. It was located between the building wall and a support column for the heat 

exchanger (photo 2). 

Heat Exchanger 

Evaporator 

Recirculation Pump 

Indoor Section 

Drain Valve 

Figure 1 Boric acid evaporation system. 

Recirculation pump and location of 

drain are shown in red. 

Photo 2 Recirculation pump location behind heat 

exchanger support column. 

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INVESTIGATION 

At the time of the incident, the plant was undergoing a 

scheduled facility-wide maintenance shutdown. The 

recirculation pump for the boric acid evaporation system 

had developed an oil leak and was scheduled to be 

removed the following day as part of the maintenance 

outage. Before removing the pump, the evaporation 

system needed to be drained of boric acid solution and 

flushed through with city water to cool it and remove the 

boric acid solids. 

The recirculation pump had been removed using the 

same procedure approximately 10-12 times since it had 

been in use. There was no written procedure for removal 

of the pump. The victim had been involved in the original 

installation of the pump over a decade earlier, had 

removed and reinstalled the pump for maintenance 

purposes several times, and had trained newer 

employees in the pump removal process. 

Drainage of the boric acid evaporation system was done by a work crew from the plant’s environmental operations 

department, not by the maintenance workers who would actually remove the pump. To empty the system, hoses were 

attached to drainage valves and the solution was drained into a holding area outside the building. Before draining and 

flushing, the system contained between 20,000 to 25,000 gallons of solution that was approximately 12-15% boric acid 

solids, at a temperature of around 220°-230° Fahrenheit. 

Environmental crew workers reported that they had completed draining the system the night before the incident and 

checked to make sure that draining was complete. This check was done by confirming that no more solution was flowing 

out of the lowest ball valve in the system (photo 3). A worker ensured that boric acid solids were not blocking drainage 

by inserting a metal rod into the valve opening. There were no devices to measure the actual volume of fluid that had 

drained from or remained in the system. 

At around 4:20 on the day of the incident, less than an hour before the end of their shift, the victim and another 

maintenance worker began to remove the recirculation pump from its housing. It is unclear why the victim decided to 

remove the pump ahead of the scheduled time the following day. The victim had trained the other maintenance worker 

in the pump removal procedure. Before beginning, they locked out the electric power supply to the pump. The victim’s 

co-worker, the other maintenance worker, reported that he checked that all drain valves for the system were open and 

that no solution was coming out before they began the pump removal procedure. 

There was no mechanism to lockout the pump from other stored energy, such as fluid under pressure. 

When the victim and his co-worker initially attempted to remove the recirculation pump from its housing, it would not 

come loose. Four other employees were in the vicinity, and two came over to help. They attached two 1.5-ton manual 

lever pullers, or “come-alongs” to the sides of the pump (photo 4). The victim stood next to the pump and in front of the 

support column (photos 5 & 6). When they began to pull using the come-alongs, the pump loosened and a small amount 

of boric acid/ water solution sprayed out from around the pump housing. Workers reported that it was not unusual for a 

Photo 3 Red circle shows 

position of drain valve in 

lowest section of boric 

acid evaporation system. 

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small amount of residual solution to leak out during pump removal, and they 

stopped pulling to wait for the flow to stop. 

Seconds later, the pump suddenly slid several feet forward out of the 

housing, and 300-500 gallons of hot boric acid and water solution flowed out 

from behind it. The temperature of the solution was estimated to have been 

around 180° Fahrenheit. The area filled with steam as the workers rushed 

away from the flow. Everyone except the victim was able to get to safety. 

Standing in the tight space next to the pump, the victim was not able to 

quickly escape the flood of hot solution and was knocked to the floor. He 

had been wearing safety glasses, but no other personal protective 

equipment. The other workers could hear him screaming in pain. His coworker ran back and found him sitting in hot solution. He helped the victim 

to his feet as another worker turned on the emergency shower. They moved 

the victim to the emergency wash and began to remove his clothing while 

another worker called 911 on his cell phone. 

Emergency medical services arrived in 10-15 minutes. The victim was 

airlifted to a burn trauma unit with burns to over 80% of his body. He died in 

the hospital two days later as a result of his injuries. 

CAUSE OF DEATH 

The death certificate listed the immediate cause of death as “Thermal burns 

(200 degree F aqueous boric acid solution) to 80% total body surface area.”

CONTRIBUTING FACTORS 

 Incomplete draining of the evaporation system before pump removal. 

 No method to identify the potential for solution to remain in the system 

after standard draining procedures were conducted. 

 No way to adequately determine the level and temperature of solution 

left in system. 

 No method to estimate the time need for cooling of the system to a safe 

level. 

 No mechanism to lock out the pump from other stored energy, such as 

solution under pressure. 

 The pump was located directly behind the heat exchange support 

column, leading to limited access and egress for workers during pump 

maintenance. 

 Not wearing appropriate personal protective equipment. 

Photo 4 “Come-along” lever pullers

attached to recirculation pump. 

Photos 5 & 6 Red Xs indicate the 

approximate position of victim at time of 

incident. 

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Photo 9 Photo 10 

 

Photo 7 Photo 8 

POST-INCIDENT CORRECTIVE ACTIONS TAKEN BY EMPLOYER 

Following the incident, the employer added two 20” isolation valves on the pipes connected to the recirculation pump 

system. These valves allow the plumbing around the pump to be effectively locked out after the system is drained for 

pump removal (photo 7). 

Additional digital temperature indicators were added at an easier to see level (photo 8). 

An additional sample port was installed above the level of the drain valve that had been used to determine if the system 

had drained completely. The new valve was designed to be located high enough that it would avoid getting clogged with 

boric solids and workers could more accurately test if all of the solution had drained (photos 9 & 10). 

The employer also created a detailed written procedure for the removal of the recirculation pump, including steps for 

lockout using the new isolation valves, and necessary personal protective equipment to be worn during the procedure. 

Photo 7 Red arrows point to valves 

installed post-incident that allow 

the pump to be isolated and 

locked out. 

Photo 8 New system temperature 

indicator installed post-incident. 

Photo 9 Boric acid evaporation 

system drain valve at time of 

incident. 

Photo 10 New sample port 

installed post-incident above drain 

level. 

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RECOMMENDATIONS/DISCUSSION 

Recommendation 1: Design new equipment for manufacturing processes using the concept of Prevention through 

Design (PtD) to control risks by incorporating prevention methods in the final product. 

Discussion: Prevention through design, or PtD, emphasizes anticipating possible hazards to workers who will use and 

maintain the system in the design and engineering phase. When possible, employers should include workers who will be 

impacted by the hazards in the design process. 

The concept behind PtD is that one of the most effective ways to control hazards in the workplace is to “design out” or

control for risks during the design, redesign, or retrofit of equipment or processes.1 Before designing or altering a system 

or work process, an in-depth hazard analysis and risk assessment should be done to identify potential exposures.2 

Workers who are or will be using the systems may offer important insights and should be involved in the risk assessment 

process. 

The hazard identification process should specifically look to identify tasks where workers are at risk for unwanted energy 

release. In this case, the potential for solution to be retained in the boric acid evaporation system behind the 

recirculation pump after the drain valves had been opened was apparently not anticipated, and no mechanism to 

lockout or otherwise protect workers from an unwanted release of solution was designed into the system. ANSI/ASSE 

guidelines exist for addressing occupational hazards using PtD.

3 

In this incident, the boric acid evaporation system had been designed, enigineered and installed by an outside 

contractor over a decade prior to the incident. Employers should ensure that outside contractors and vendors 

understand and employ PtD principles in their design and engineering processes, and that company safety experts and 

workers are involved in any design or redesign phases. 

Recommendation 2: Enforce a comprehensive written hazardous energy control program. Make sure all potentially 

exposed workers are trained in the hazardous energy control procedures for the system, and document training. 

Discussion: Ensure that all parts of a system capable of releasing stored energy, including water pressure, are equipped 

with mechanisms to isolate and lockout the system during maintenance or repair. 

Workers servicing equipment can be injured or killed by the unexpected release of hazardous stored energy. Hazardous 

energy is any electrical, mechanical, hydraulic, pneumatic, chemical, nuclear, thermal, gravity or other energy that could 

cause harm to personnel.4 As part of a hazardous energy control program, systems or equipment must have energyisolating mechanisms, and lockout devices to make sure the energy-isolating mechanism remains in place during repair 

and maintenance. 

In this incident, the employer’s hazardous energy control procedures were not comprehensive. The victim was able to 

lock out the electrical power supply to the recirculation pump before removal, but deenergizing the pump did not 

address all potential forms of hazardous energy in the system. There was no way to physically isolate the pump from the 

residual solution in the system, and therefore also no way to lock the system out during maintenance. 

Both OSHA and Washington State rules require that employers protect workers from hazardous stored energy during 

maintenance and service operations.

5,6,7 This includes appropriate means to control hazardous energy, and 

lockout/tagout systems for energy-isolating devices. Hazardous energy control programs must: 

 Be written. 

 Specifically address when the procedures will be used. 

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 Include the specific steps that need to be taken to shut down, isolate, block, and secure systems or equipment; 

and how to lockout/tagout the system. 

 Designate who is responsible for doing it. 

Any worker who may be at risk of exposure to hazardous stored energy needs to be trained in these procedures. 

Employers should document the training and make sure the procedures are being followed through spot-checks. 

In this case, the boric acid solution that remained in the evaporation system was at a high temperature at the time of 

the incident. It was ultimately thermal burns caused by the temperature of the solution that led to the victim’s death, 

and not chemical exposure or physical injury caused by the force of the solution. However, had the system been isolated 

and locked out at the time of the incident, exposure to the residual solution would not have been a risk to workers 

performing pump maintenance. 

Both OSHA and the Washington State Department of Labor and Industries have established standards requiring the 

process safety management (PSM) of highly hazardous chemicals.8,9 (29 CFR 1910.119 and WAC 296-67.) Although the 

boric acid solution involved in this incident is not specified in these standards, following some of the guidelines, such as 

those for conducting a thourough process hazard analysis (PHA), set forth in the PSM safety standards could aid in 

identifying hazards. 

A PHA is a methodology to identify the hazards of a specific process, including the range of safety and health effects to 

workers should the controls in place fail. The PHA is performed by a team, including an employee, with expertise in the 

process, and is updated at least every five years. 

PSM also requires that there be written operating procedures for a number of processes, including normal shutdown, 

that there is a training process for maintenance activities, and that there are safe work practices for opening process 

equipment. 

Recommendation 3: Develop written standard procedures for regular maintenance operations. These should include 

information about hazards, required PPE, necessary safety checks, lockout/tagout procedures, and coordination with 

other workgroups to be done prior to beginning the task. Ensure that all workers performing maintenance tasks are 

trained on the procedures. 

Discussion: In this incident, while there were established lockout procedures in place, the employer did not have written 

standard maintenance procedures for the process of removing and replacing the recirculation pump. Removal of the 

recirculation pump was done periodically, though infrequently. Since its installation, the victim had been the primary 

employee to remove the pump when required, and trained other employees to do the task. 

Just as there are standard operating procedures (SOPs) for manufacturing processes, employers should consider creating 

standard written procedures for maintenance processes that need to be done on a routine or periodic basis to ensure 

that these tasks are done the correct way each time and that workers are reminded of hazards and safety procedures. 

Written maintenance procedures should be reviewed prior to each time the process is to be completed and should 

include: clear, detailed information about how the maintenance process should be performed, including any necessary 

photographs or diagrams; checks to be done before beginning the task; hazards; and required personal protective 

equipment. 

Recommendation 4: Ensure that workers who may be exposed to hot liquids are provided with and use the proper 

personal protective equipment (PPE) for the job, including appropriate eye/face, hand, and body protection. 

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Discussion: In this incident, the victim wore safety glasses, but no other PPE specificly designed for working with hot 

liquid or chemical solutions. Although the victim and his co-workers did not anticipate that a large volume of solution 

could have remained in the system after draining, several workers reported that it was not unusual for some boric 

acid/water solution to spray out from around the housing during pump removal. Even small amounts of solution at high 

temperatures can cause burn injuries. A PPE assessment10 could have identified possible worker exposure to hot boric 

acid/water solution during recirculation pump removal and prompted a requirement that workers wear appropriate 

foot, hand, body, and face protection during the procedure.11 

REFERENCES 

1. The National Institute for Occupational Safety and Health. “Prevention Through Design.”

www.cdc.gov/niosh/topics/ptd/default.html. Accessed August 2017. 

2. Renshaw, F. (2013). Prevention through design: Design methods for implementing PtD. American Society of Safety 

Engineers: Professional Safety. March 2013. 

3. American National Standards Institute/American Society of Safety Engineers. (2012). Prevention through Design: 

Guidelines for Addressing Occupational Hazards and Risks in Design and Redesign Processes (ANSI/ASSE Z590.3 –

2011). 

4. American National Standards Institute/American Society of Safety Engineers. (2016). The Control of Hazardous 

Energy Lockout, Tagout and Alternative Methods (ANSI/ASSE Z244.1 – 2016). Accessed August 2017. 

5. Occupational Safety and Health Administration. Occupational Safety and Health Standards: The control of 

hazardous energy, 29 CFR 1910.147. Available at: 

www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=9804&p_table=STANDARDS. Accessed August 2017. 

6. Washington Administrative Code. Chapter 296-803 WAC Safety Standards for Lockout/Tagout. Available at: 

apps.leg.wa.gov/WAC/default.aspx?cite=296-803 

7. U.S Department of Labor, Occupational Safety and Health Administration. (2002). OSHA Fact Sheet: 

Lockout/Tagout. Available at: www.osha.gov/OshDoc/data_General_Facts/factsheet-lockout-tagout.pdf. Accessed 

August 2017. 

8. Washington Administrative Code. Chapter 296-67 WAC Safety Standards for Process Safety Management of Highly 

Hazardous Chemicals. Available at: apps.leg.wa.gov/WAC/default.aspx?cite=296-67 

9. U.S Department of Labor, Occupational Safety and Health Administration. (2000). Process Safety Management, 

OSHA 3132. Available at: www.osha.gov/Publications/osha3132.pdf. Accessed February 2018. 

10. U.S Department of Labor, Occupational Safety and Health Administration, OSHA Office of Training and Education. 

PPE Assessment. Available at: www.osha.gov/dte/library/ppe_assessment/ppe_assessment.html. Accessed August 

2017. 

11. U.S Department of Labor, Occupational Safety and Health Administration. (2004). Personal Protective Equipment, 

OSHA 3151-12R 2004. Available at: www.osha.gov/Publications/osha3151.pdf. Accessed August 2017. 

Report 52-43-2018 P a g e | 11 
 

INVESTIGATOR INFORMATION 

Todd Schoonover has a PhD in Industrial Hygiene from the University of Illinois at Chicago. He is a Certified Industrial 

Hygienist (CIH) and Certified Safety Professional (CSP). Todd is currently the Principle Investigator for the WA FACE 

Program. 

Christina Rappin has a BAS from The Evergreen State College. She is a Research Investigator with the WA FACE program. 

Randy Clark has a BA from the Evergreen State College. He is a Safety and Health Specialist with the WA FACE Program. 

ACKNOWLEDGEMENTS 

This report was reviewed by stakeholders from labor and business communities and various Washington State and 

Federal worker safety agencies. Though we are unable to acknowledge specific individuals for their contributions to this 

report, we would like to recognize the following for their help and support of the FACE mission and objectives: 

 The employer involved in the incident 

 Occupational Safety and Health Administration (OSHA) 

 Federal FACE Program management (NIOSH) 

 Safety & Health Assessment & Research for Prevention (SHARP) 

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