Los Angeles – Cal/OSHA issued eleven citations totaling $371,250 to Baxter Healthcare Corporation dba Baxter Bioscience this week for deliberate and willful workplace safety violations which resulted in the death of one of their technicians and serious injury of two others. The violations included four willful citations, indicating intentional violation or knowledge of a violation. Baxter has 15 business days to appeal or pay the citations. “We will not tolerate employers who intentionally sacrifice the safety of their workers,” said DIR Acting Director Christine Baker. “Our goal is to prevent these needless tragedies and ensure employers live up to their responsibility of protecting their workers.”

On January 21, Baxter technician Henry Astilla, 33, collapsed when he entered a seven foot deep, 6,000 liter tank in which nitrogen gas was being bubbled through plasma as part of a protein extraction process. Air in the tank had been displaced by the nitrogen gas resulting in an oxygen deficient atmosphere in the tank. Cal/OSHA regulations require employers to have special protective procedures in place prior to the entrance by employees into these types of confined spaces. In this case, the employer had not tested the atmosphere prior to entrance to insure there was sufficient oxygen, which led to Astilla’s death.

Cal OSHA’s investigation further revealed that when Astilla was discovered, a supervisor ordered two other employees to enter the tank and retrieve him, without testing the atmosphere of the tank or providing proper equipment and other safeguards necessary for a safe rescue. As a result, Astilla died and the two employees sent to retrieve him were seriously injured. One remains hospitalized since January.

“The hazards of working in confined spaces are well documented and this is a classic example of the kind of injury that occurs when employers fail to adequately protect their employees,” said Cal/OSHA Chief Ellen Widess. “When confined space operations are not properly planned, it is unfortunately common for other employees to be injured or killed while attempting impromptu rescue of the initial victim.”

Cal/OSHA determined that Baxter’s confined space program failed to comply with all requirements, including appropriate atmospheric testing, protective equipment as well as rescue equipment and procedures. Baxter Bioscience is a multi-national pharmaceutical company with a Los Angeles plant located in Atwater Village. The facility is the largest of its kind in the nation, utilizing advanced technology to produce plasma proteins.

The citations Cal/OSHA issued this week included one classified as general and ten classified as serious, four of which were classified as willful. Willful classifications are issued when an employer either commits an intentional violation and is aware that it violates a safety law, or when an employer is aware that an unsafe or hazardous condition exists and makes no reasonable effort to eliminate the hazard.

So, it really boils down to this – what are the advantages of receiving training on the proper use of the equipment?

Obviously, the primary concern is safety – safety of the users and the rescue subjects. Another critical point includes using the equipment contrary to the manufacturer’s instructions, which can lead to questions of liability. While some manufacturers provide complete and “easy to understand” instructions for use of their equipment, others provide just enough to get the box open.

Note:  While it’s not an NFPA 1983 requirement, most manufacturers do include a statement concerning proper training prior to use.  In fact, there is no NFPA requirement that instructions for use be provided by the manufacturer.

Here are some important questions to consider

What are the working load limitations of the item?  If the gear is used for both planned work activities and for rescue activities, the maximum working loads may be different depending on the application.  In some cases, additional rigging configurations are required for exceptional uses and heavy loads.
What are the effects of using the equipment in a variety of configurations? Are there load multipliers involved in certain configurations that need to be addressed? What are the effects of eccentric loads on the equipment?  Many equipment items are to be used in static load applications only, and can be damaged or catastrophically fail if subjected to dynamic loads.  Oftentimes these issues are not addressed in the user manual, but may be a need to know and understand consideration.

Also, using the item as part of a system may not be covered in the user manual.  It’s important to understand this so that the equipment can be used to its full advantage – and to make sure it’s not subjected to unacceptable loads when used in a system.  Many times the user manual provides bare bones instructions for use and doesn’t cover any instruction for use as part of a system. Nor does it cover the precautions for use as part of a system.

While it seems that more and more manufacturers are moving towards pre-built, engineered systems, it’s not always feasible (or advantageous) to use a pre-built system. However, it is very common to use multiple bits of hardware, software, and rope to create a “build-as-you-go” system that’s appropriate for the job.  Without receiving the proper training on the compatibility of components used in a system, the user may be creating an unsafe condition or missing out on an opportunity for a more efficient solution. Or, miss out on the expanded use of equipment they already have in their cache.

In addition, more rescue gear is being designed to perform multiple functions.  It’s not uncommon for us to hear students say something like, “Wow, I didn’t know it could do that, too!”  Items that are put into the rescue equipment cache with the belief that it is designed to perform one function only, may be another opportunity lost.

Needless to say, we are big advocates of multifunction equipment.  This provides for a smaller, lighter, and quite possibly less expensive rescue equipment cache. It also provides the ability to adapt a given rescue plan and shift the role of the equipment from one function to another.  Typically, there are opportunities to use equipment in a manner that it can be quickly converted from one function to another as part of the plan.  Without the proper training, this may not be obvious by simply reading the user manual.

Finally, how clear is the user manual in explaining criteria for inspection and removal from service?  Depending on what’s provided by the manufacturer (i.e., text and graphics), a piece of equipment may require additional training for the proper inspection points and reasons for taking it out of service.

With that said, we hope it’s perfectly clear that the statement, “proper training is required prior to use” should be taken to heart. It always saddens us to hear of incidents where rescuers are hurt or injured while training for, or in the performance of their duties…especially when the root cause is listed as inadequate training.  Hopefully, you are seeking quality training from a reputable training institution on the proper use of your equipment.  Not just to satisfy a liability issue, but to keep your rescuers safe.  It also allows them to understand and take full advantage of the equipment in their rescue cache – keeping it safe, simple, and effective!