On August 28 at 9:52 a.m., Deserie Castro Tagubasi was working in the chemical etching department at Tyntek Corp., a Taiwanese semiconductor component and LED manufacturer, when the hydrofluoric acid she was handling splashed onto her uncovered lower legs. Tagubasi suffered severe chemical burns and was administered treatment in a chaotic 35 minutes, of which details remain hazy. She was rushed to the specialist burns unit at Taipei Veterans General Hospital, where she died hours later.

Tagubasi’s death immediately raised suspicions that Tyntek did not uphold adequate workplace safety standards. Ketagalan Media has obtained a report, which has not yet been made public, compiled by Taiwan’s Occupational Safety and Health Administration (OSHA) which, in conjunction with independently obtained witness testimonies, points to a series of failures by Tyntek to safeguard the well-being of its employees. Following the accident, according to multiple employees, Tyntek also failed to implement adequate remedial measures in an apparent rush to restart operations.

The report by OSHA describes a culture of extreme negligence at the Zhunan, Miaoli factory of Tyntek, which is listed on the Taiwan Stock Exchange and has NT$3 billion (US$97.1 million) in capital. Staff working with hydrofluoric acid, among the most corrosive chemicals used in industry, did not receive the proper training in handling the acid and were not aware of first aid procedures in case of skin contact. Tyntek could not provide OSHA investigators with records of its health and safety plan being implemented, according to the report.

Multiple current and former Tyntek workers interviewed by Ketagalan Media, along with the Taoyuan-based NGO Serve the People Association (SPA), said they had never received training before being asked to work with hydrofluoric acid.

Foreign workers treated like “human machines”

At Tyntek, foreign workers from the Philippines, such as Tagubasi, were tasked with handling dangerous chemicals⁠—a job Taiwanese workers were unwilling to do.

“They call themselves human machines,” SPA international coordinator Lennon Wong (汪英達) said of the Filipino workers. “They have to hold the wafers by hand and put them into the hydrofluoric acid. Every few seconds, they need to change the position of it. They have to do many pieces a day.”

According to the contents of the OSHA report and the testimonies of several workers who spoke to Ketagalan Media and SPA, investigators from OSHA did not interview any non-Taiwanese employees at Tyntek in the process of compiling their report. Several workers expressed a willingness to speak to investigators but said they were never contacted.

Yeh Pei-chieh (葉沛杰), a section chief in the Ministry of Labor’s Division of Planning and Occupational Health, OSHA, told Ketagalan Media that while inspectors have the right to interview workers or eyewitnesses, there is no requirement that they do so.

But while OSHA’s report characterizes Tyntek’s training procedures as “inadequate,” multiple workers go one step further, saying training at Tyntek was nonexistent.

A decision by the Miaoli District Prosecutors Office is pending on whether to file criminal charges against Tyntek. In the meantime, operations have resumed in Tyntek’s chemical etching plant, according to multiple workers. (All Tyntek employees interviewed for this story asked to remain anonymous due to a fear of jeopardizing their employment status.) While Tyntek decommissioned the specific machine being used by Tagubasi at the time of her death, employees were asked to resume working with hydrofluoric acid five days later⁠—without receiving the legally required training beforehand.

Failure to comply with regulations

The OSHA report, which has been received by Tyntek, includes a list of nine instances of failures to conform to relevant laws and regulations. These include not providing adequate safety clothing, not providing adequate health and safety training, not providing training in first aid measures in case of an accident, not holding a required safety committee meeting every three months, and not providing adequate signage or safety data sheets (which, according to regulations, must be in Mandarin and, where appropriate, in the languages of the workers).

According to the report, the primary cause of Tagubasi’s death was direct skin contact with hydrofluoric acid. Secondary causes included the absence of standard safety and health procedures for bringing chemical etching solutions up to temperature, along with a lack of safety committee meetings, training that did not comply with regulations, and inadequate workplace supervision.

The report says that Tyntek submitted all required documentation to the government indicating its full understanding of the dangers and responsibilities of working with hydrofluoric acid. In practice, however, Tyntek failed to follow the safety guidelines it laid out and could provide investigators with no evidence of having implemented its own health and safety plan.

Tagubasi was, contrary to regulations, working unsupervised at the time of her fatal accident. According to the OSHA report and accompanying screenshots of CCTV footage of the factory floor, she had removed a container of mixed acid from a well to allow it to warm up to the correct temperature. She placed it on the unit and turned around. The container tilted and acid spilled onto her lower right leg, which was not covered with the legally required non-permeable safety clothing.

In the event of skin contact with hydrofluoric acid, it is essential to immediately remove clothing that might spread the acid and to rinse the affected area with high-pressure water, such as that found in an emergency shower. This process, technically called lavage, is the key first aid treatment for a hydrofluoric acid burn. International guidelines suggest the area should be treated with lavage for a minimum of 15 to 30 minutes, followed by the application of neutralizers such as hexafluorine, diphoterine and calcium gluconate.

According to the official report, the factory did have neutralizers on hand, contrary to various news reports in the immediate aftermath of the accident. The OSHA report states: “The hexafluorine, diphoterine and calcium gluconate were stored in the medical room, and standard usage procedures were established, except only domestic [i.e., Taiwanese nationals] workers were trained. Foreign workers were not trained and did not know how to use them.”

The report continues: “The amount of hexafluorine, diphoterine and calcium gluconate in stock were, respectively, 500 milliliters, 500 milliliters, and nine x 40 grams. After the victim was showered for six minutes and the affected clothing removed, hexafluorine, diphoterine and calcium gluconate were applied, respectively, for three minutes, three minutes and nine minutes, for a total of 15 minutes. The entire stock was used and was applied with the help of nurses.”

The report confirms that the accident occurred at 9.52 a.m. on August 28. A time stamped photo from Miaoli County Fire Department shows Tagubasi being wheeled out to the ambulance at 10.27 a.m., giving a 35-minute window for first aid treatment. However, the report only accounts for 21 minutes.

Eyewitness accounts

Workers from the factory paint an altogether different picture of that half hour.

Tagubasi, who had worked for close to three years on the chemical etching station, had not been given any training in how to deal with the situation. Her Taiwanese supervisors were not present at the time of the accident. Sources at the factory say that she initially went to a sink at the far side of the room to flush the wound. A petition given to the Ministry of Labor by the Taipei-based NGO Taiwan International Workers Association (TIWA) stated that workers at the factory had described the reaction to the accident as flustered.

At this point, international guidelines call for 15 to 30 minutes of lavage using high pressure water to thoroughly flush the acid off the skin. Tagubasi was persuaded to cross the factory floor to the emergency shower once supervisors and others arrived to help. This delay is not mentioned in the OSHA report, which states Tagubasi was “immediately” treated in the emergency shower for six minutes⁠—under half the minimum recommended time.

According to the report, the neutralizers were “applied with the help of nurses.” The company nurse is required by law to know the correct procedures for dealing with occupational injuries as appropriate to a workplace. However, according to witnesses, the company nurse refused to administer any first aid that required skin contact, instead leaving the task of applying calcium glutamate ointment to Tagubasi’s Filipino coworkers, who were untrained in the procedure. The nurse eventually took over to administer liquid treatments of hexafluorine and diphoterine, neither of which require skin contact. The company nurse’s failure to apply calcium glutamate was not mentioned in the OSHA report.

Despite the discrepancies between the accounts of witnesses and the report compiled by OSHA, neither the police nor the OSHA investigator appear to have sought out statements from workers in the factory.

Best practice calls for preventative measures to be the first line of defense against this kind of accident. Had Deserie been provided with the correct clothing, this accident would not have resulted in her death.

In place of proper safety clothing and shoes, the factory supplied a meager “uniform” consisting of an apron, gloves and half-sleeve cuffs. Parts of the skin were entirely unprotected—a gross oversight given the high risks involved with working with a high concentration (49%) of hydrofluoric acid.

According to Yeh of OSHA, the factory has had six surprise inspections over the past five years. However, workers have observed that only a single fully protective set of clothing was stored onsite. Government regulations mandate that enough sufficient and clean sets of clothing must be available for all workers handling dangerous acids. Given that Tyntek operates on a 24-hour cycle, one set of clothing does not meet these requirements. Six OSHA inspections appear to have failed to spot this issue.

Plight of Southeast Asian foreign workers in hazardous environments

Tyntek is likely not alone in its flagrant contravention of safety regulations. According to the U.S. State Department’s 2018 Human Rights Report on Taiwan, OSHA investigations were reduced by 89% between 2016 and 2017, the last year for which there is available data. In news reports following the accident, Yeh revealed that 64 factories in Taiwan use hydrofluoric acid and said the department plans to carry out extra inspections to ensure these factories are meeting safety standards.

The Tyntek case, therefore, is illustrative not only of the company’s own apparent negligence, but of the dangers facing the 435,875 Southeast Asian migrant workers employed in Taiwan’s manufacturing sector as of August 2019. These workers, prohibited from transferring jobs for the duration of their three-year contracts and financially beholden to third-party brokers in what the State Department’s report terms “debt bondage,” are left without the power to speak up. As the State Department report notes, many workers report being afraid to call 1955, Taiwan’s hotline for migrant workers reporting violations and abuse, due to a fear of retribution by employers and brokers.

“[Along with] the severe lack of full protection gear, which we are already aware of, the lack of safety seminars is also astonishing,” said Wong of SPA. “From all the workers we know in Tyntek, none of them had participated in any kind of safety seminar for all the years they worked in this company before Deserie’s tragedy.”

According to SPA, which has interviewed over 30 current and former Tyntek workers, this pattern of apathy toward safety measures stretches back to at least 2004. Interviews with workers by Ketagalan Media also confirmed that, despite clear regulations governing the hours of training that must be completed and recorded for such workers, Tyntek has provided zero hours of such official training to its employees for over a decade.

More experienced workers are tasked with mentoring new recruits and training them on the job. However, none of these workers prior to the accident had received proper training, nor had they been made aware of the real dangers of working with the acids.

The OSHA report notes that the company provided a record of Tagubasi receiving “training” on December 5, 2018. However the report also states that the content and length of the training was inadequate for the purposes of health and safety training, adding that three additional hours should have been completed.

According to regulations, however, the required amount of health and safety training for workers in this category is three hours every three years. This calls into question whether Tagubasi received training of any sort on December 5, 2018.

After the accident

Tagubasi’s accident should have spurred Tyntek into immediately training workers tasked with handling hydrofluoric acid. However, according to multiple Tyntek workers, the company recommenced work using the acids on September 3. The company did not provide training until September 10. Workers were also not issued fully protective “bunny suits” until September 10, one week after they resumed work using dangerous acids.

According to workers at the factory, safety data sheets in the workers’ languages have still not been provided as of the time of publication. These data sheets are available only in Chinese.

On September 2, four days after the accident, Tyntek held a forum with workers from the second floor of the factory, where chemicals are used. Brokers, supervisors, managers and upper level management were also present.

The forum was focused on protective measures, according to multiple workers, and concerns raised by employees were discussed. Workers were told that, if they wished to transfer out of the company, they could do so without penalty. This promise, according to workers, was retracted shortly afterward.

Workers were informed there would be changes in the process used in the chemical etching unit and were asked to cooperate. They were promised a raise in the extra allowance they receive for working with dangerous chemicals, which stood at NT$700 (US$22.66) per month.

No part of this forum, however, constituted legally required health and safety training. That training, carried out by full-time Tyntek staff, took place one week after workers returned to the factory floor.

On September 10, workers were trained for two hours in the safe handling of chemicals. On September 24, workers were trained for one hour in first aid measures.

The law states clearly that workers must have training prior to working with the chemical, and accounts from workers in the factory seem to suggest that Tyntek, rather than following the law completely once again failed to deliver in an adequate manner. Workers continued their work with the chemicals, using a new process involving a lower concentration of hydrofluoric acid, starting on September 3.

Workers also used a temporary set of clothing while working with acids between September 3 and September 10 which did not provide full protection. According to workers, Tyntek only had one set of fully protective clothing on hand. This set of clothing was given to a Taiwanese worker.

Tyntek had an opportunity to ensure its workers were prepared in case of another accident. However, workers returned to the floor for one week without required training in handling dangerous chemicals. For three weeks, workers continued to handle hydrofluoric acid without receiving the legally mandated hour of first aid training. (Tyntek declined an initial request for comment, citing the ongoing investigation, and did not respond to subsequent requests for comment.)

Following Tagubasi’s accident, OSHA ordered the work using the machine at her workstation to be suspended until Tyntek had proven it had implemented satisfactory safety measures. According to Yeh of OSHA, the agency only has the power to suspend operations at a specific unit. Yeh confirmed in an October 4 email that this suspension order was still in effect. But OSHA was unable to suspend the entirety of Tyntek’s chemical etching operations.

Taiwan has a system of immediately enforceable administrative fines for failing to comply with laws and regulations in the workplace. However, in cases where criminal liability is suspected, OSHA sends a report to the local prosecutor’s office in which they lay out the facts of a case and outline laws and regulations that they suspect have been contravened. OSHA cannot, therefore, make any judgments on criminal liability. The decision to pursue such a charge rests with the prosecutors. However, only one set of censures can be imposed: criminal or administrative, since the levying of penalties of each nature are handled by separate court systems.

The law allows for up to three years of imprisonment or up to NT$300,000 in fines for responsible parties should they be found guilty of causing the death of a worker due to noncompliance with safety or other measures. The Miaoli District Prosecutors Office will now be tasked with deciding whether the culture of negligence thoroughly laid out by the OSHA report, along with the accounts of multiple Tyntek workers, warrants a criminal prosecution.

Updated 10.7.2019 at 1:28 p.m. to add additional information about safety data sheets displayed in the Tyntek factory.

(Cover photo from OSHA report)

Read Part 2 of this story: She Died in a Taiwan Factory. Her Family Was Met With Indifference