A laborer in a metal-casting plant was killed when he fell into a vat of scalding hot water. He received burns to 90 per cent of his body. He had been walking on an insulated surface above the tank when he lost his balance and fell. The tank lacked a safety barrier on one side, allowing an unobstructed fall into the water by the victim.

There had been no barrier there for the last 15 years. Plant workers had not recognized it as a danger, nor was it noticed by government safety inspectors in at least seven plant inspections within the previous five years. However, just three months before this accident, another employee slipped and fell partially into the tank. He was not hurt because the water was cool at the time.

After the fatal fall, the inspectors ordered that a new fixed iron rail guard be installed on all sides of the hot water tank. They also ordered that the tank be covered; footing around the tank be improved; safety training and reporting procedures be improved within the company, and that other plants with similar quench tank hazards be alerted to this danger.

A close call is an opportunity to correct a hazard before it injures or kills someone. In this case, the earlier fall into the tank served as a warning that someone could be drowned, or be scalded to death if he fell when the water was hot, and that the tank should be barricaded. But for some reason, the warning went unheeded, and the result was a tragic death.