Case report: #11CA009*
Issued by: California Fatality Assessment and Control Evaluation
Date of incident: Nov. 15, 2011
A 62-year-old paint maker died from exposure to dichloromethane (methylene chloride) while using a paint stripper to clean the inside of a tank. The victim was working alone in the tank – which was not properly vented – and was never trained on entering a confined space. However, the company the victim worked for had a written confined space program that classified the tank involved in the incident as a permit-required confined space. The program included a 12-step procedure on how to perform work safely within a permit-required confined space. No one was monitoring the victim at the time of the incident. He was wearing a cartridge respirator, but it did not adequately protect against inhaling methylene chloride vapors. A co-worker found the victim unresponsive and entered the tank to attempt a rescue but was overcome by fumes. The co-worker recovered. According to investigators, the high concentration of methylene chloride in the paint stripper, the tank’s configuration, inadequate ventilation and insufficient training on confined space procedures were contributing factors to the victim’s death.
To prevent future occurrences:
- Employers should develop and implement policies and procedures to clean paint tanks more frequently with water-based materials before the paint is cured. If this cannot be done, the cured paint should be stripped by abrasive removal methods.
- If toxic chemicals are used inside a tank, employers must provide workers with proper training on chemical hazard communication and confined space entry procedures.
