Seafood Canning

NarrativeAt approximately 6:30 a.m. on October 11, 2012, Employee #1 was engaged in the production of canned tuna, salmon, and other seafood. He was a basket pusher with responsibilities that included using a pallet jack to load 10 horizontal and cylindrical type pressure-cooker ovens called retorts. The ovens were 54 in. in width and height and 36 ft in length. They were used to sterilize aluminum cans for the tuna canning operation. Employee #1 would load each retort with 12 rolling metal baskets. The baskets were approximately 42.5 in. by 46.75 in. by 34.5 in. and filled with cans of tuna. Only one pallet jack was used to load the retort ovens. Shortly after beginning his shift, Employee #1 started loading the retort ovens until he took his first break around 5:45 am. At the start of his shift on that day, his supervisor instructed him to load Retort Oven Number 5. Sometime before 5:00 a.m., a coworker noticed the pallet jack was not being used. He assumed that Employee #1 stepped away from the area. The coworker decided to use the pallet jack and staged four baskets of tuna in front of Retort Oven Number 6. He went to get four more baskets and completed staging eight baskets in front of Retort No. 6. At approximately 5:00 a.m., Employee #1 loaded the eight baskets into one of the ovens. He continued the process until 12 baskets were loaded. Around the same time, the supervisor questioned the coworker about using the pallet jack and began asking other employees if they had seen Employee #1. An announcement was made on the intercom that Employee #1 was missing and could not be located. Several employees started searching the property including the parking lot and noticed Employee #1's vehicle was still there. After searching for approximately 1 hour, a coworker, the boiler operator, suggested they open the last oven that was loaded. After letting the retort cool for approximately 30 minutes, they opened the front end of Retort Number 6 and found nothing. They went around to the exit side of Retort Number 6 opened the door and found Employee #1. The fire department was summoned. At approximately 7:20 a.m., they arrived and pronounced Employee #1 had died. From the coroner's report, Employee #1 had sustained a fatal thermal injury from being trapped inside Retort Oven Number 6. The oven was not identified or treated as a confined space.