Duke fined for deadly explosion
Nov. 18, 2008
DUKE U. — Duke University has been cited for nine "serious violations" and fined $35,000 as a result of investigations into a fatal steam pipe explosion May 14 in the basement of the Levine Science Research Center.
The N.C. Department of Labor's Division of Occupational Safety and Health released its findings in a 13-page report Friday that detailed violations in the LSRC and other campus facilities.
The accident killed 63-year-old Rayford Cofer, a master steamfitter, when 348-degree steam spewed from a ruptured steam line while he was starting the system in the LSRC's mechanical room. The cause of the accident is still being investigated, but the University said in a statement that the incident may have occurred "in part because of 'water hammer,' a surge or wave with potentially explosive pressure that can develop inside pipes when steam mixes with cooler water."
"We have been cooperating with the state and other safety experts to understand the circumstances that contributed to this incident," Vice President for Campus Services Kemel Dawkins said in the statement Friday. "The tragedy has helped bring together many people within the department and the University in an effort to ensure such an accident never happens again."
Inspectors found that Duke employees in the LSRC were not given proper instructions and testing practices for the steam line system; more than two exits were not available for emergencies; doors swung into the rooms instead of in the direction of the exit; and equipment placement prevented clear access to exits.
Michael Schoenfeld, vice president for public relations and government affairs, said the facilities satisfied the codes when they were constructed, but the codes have changed and Duke had not been inspected again until recently.
"We've done some significant upgrades and changes in making our safety program even more robust," he said. "The safety of our employees is our highest priority, so we're taking all these things very seriously."
The University has replaced and repaired "critical systems" that were affected by the accident and installed a new steam station in a room down the hall from where the accident took place, Schoenfeld said. Dawkins noted that employees are also receiving safety training, and committees are reviewing old procedures and developing new plans to enhance safety.
The University was also cited for violations in other facilities, including three emergency exits in the East Campus tunnels that require keys to open, faulty emergency safeguards in the tunnels and the Facilities Maintenance Department and the absence of signs warning employees of the danger of the nearby steam line.
"Duke is a very large and complex place-there are a lot of systems and procedures and policies," Schoenfeld said. "We're constantly upgrading, updating, inspecting, reviewing workplace procedures."
The University has 15 days to request an informal conference with the state or appeal the citations. Schoenfeld said Duke officials have not yet determined how they will proceed.
Schoenfeld declined to comment on how Cofer's family has reacted to the report, but said the University reached out to the family immediately following the accident and informed them of the results.
Raleigh attorney Lacy Presnell, the family's lawyer, was not available for comment.
The steam pipe incident was not the first fatal accident in the University's maintenance division. In November 2000, 57-year-old Ralph Clayton, a maintenance mechanical specialist, died at the Duke University Medical Center after an accident in the hospital's loading dock.
State investigators said the accident occurred because of human safety errors and gaffes in operational procedures. In light of Clayton and Cofer's deaths, the University has been taking a closer look at its safety procedures and policies, Schoenfeld said.
"Safety is a very high priority," he said. "With an accident especially this tragic that results in the death of a committed and valued employee, we want to ensure these kinds of things never happen again. We have strengthened even further our commitment to programs or training and safety protocols because we are absolutely committed to the safety of our employees."
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