There are new details regarding the March fire at a Memphis, TN refinery that killed one contract worker and injured two others. TOSHA has completed its investigation and the refinery was hit with a proposed $63,000 in fines for 16, serious, alleged violations. TOSHA listed the potential cause as “failure to isolate and control ignition sources and allowing air into the piping that allows ignition.” Not only do I have the citations, I have the investigation report from TOSHA giving us insight into how fatality investigations at a PSM covered facility takes place. For more on the TOSHA investigation and a breakdown of the citations and the investigation report …
According to the TOSHA investigation, on the day of the fire, three contract employees were working between a knock out drum and the South Flare tower. These workers weren’t protected from dangerous gases still left in the drum, and a pipe; plus, the pilot to the south flare was still on. A person whose name was redacted said during an interview that workers were protected from the inhalation hazard, but not the fire hazard. The report states during the incident, the workers clothes were on fire and protective gear was not provided. Inspectors discovered the workers had asked for fire protection clothing, but that request was denied. One of the violations is “protective equipment and clothing were not provided and used when necessary.” Among some of the others, TOSHA says the refinery didn’t develop and implement safe work practices to provide for the control of hazards, and the employer did not establish a program consisting of energy control procedures. Workers filed a lawsuit in Texas that alleges severe and gross negligence. As for the workers, one is still in the hospital with burns to more than 70% of his body; his brother was the one who passed away after the fire. The third worker was released, but suffered burns to 45% of his body.
Breakdown of the TOSHA Citations
- 1910.119(f)(4) Safe Work Practices – Serious and $7K; The 36″ pipe had not had its flammable vapors purged when the contractors broke into the line to install a flange.
- Issues with Line Break procedures
- Failure to address hazards ID’ed on JSA
- Safe Work Permit issues
- 1910.132(a) PPE – Serious and $7K; No Flame Retardant Clothing (FRC) provided for the contractors performing the line break on the 36″ line at a flare knockout drum
- 1910.132(d)(1) PPE Hazard Assessment – Serious and $0; A PPE Hazard Assessment had not be done on the job of opening the 36″ line at the flare
- 1910.147(c)(1) LOTO – Serious and $7K; A breakdown in the implementation of the overall LOTO program
- Inadequate written specific LOTO procedure for a first line break,
- no management oversight of those procedures developed by employees,
- procedure did not contain the means to verify zero energy in the 36″ line,
- Inadequate training for affected personnel
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- 1910.147(c)(4)(i) LOTO – Serious and $0; Adequate written isolation procedures were not developed, documented, and utilized.
- 1910.147(c)(4)(ii) LOTO – Serious and $0; the “Energy isolation list” did not clearly and specifically include techniques to isolate and control hazardous energy from the contractors make a first line break on the 36″ line
- 1910.147(c)(4)(ii)(A) LOTO – Serious and $0; the job description on the energy isolation list the contractors were working under to make the first break and install a blind was “hook up hoses for steaming”.
- 1910.147(c)(4)(ii)(B) LOTO – Serious and $0; LOTO procedures did not contain procedures to isolate energy, no adequate procedures to isolate the pilot flame on the flare, no procedures to isolate a 36″ gate valve in the line
- 1910.147(c)(4)(ii)(D) LOTO – Serious and $0; the procedures did not include specific requirements for testing equipment to determine and verify the effectiveness of LOTO devices and other control measures.
- 1910.147(c)(4)(7)(i) LOTO – Serious and $0; Training was not adequate regarding hazard identification, including both ignition sources and energy sources, verification of effective isolation and control of hazardous energy.
- 1910.147(d)(1) LOTO – Serious and $0; the refinery employee overseeing the 36″ line break job did not know the adequate methods to control the energy prior to the installation of the blind
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- 1910.147(d)(2) LOTO – Serious and $7K; the equipment was not shutdown using the procedures for the equipment, the south flare pilot light was not shutoff or isolated
- 1910.147(d)(3) LOTO – Serious and $7K; All isolating devices were no located and operated to isolate flammable gas and ignition sources from the 36″ pipe outlet flange
- 1910.147(d)(5)(i) LOTO – Serious and $7K; after the knockout pop was drained of its flammable liquid, the residual flammable vapors in the pot and 36″ line were not controlled, rendered safe, or isolated
- 1910.147(d)(5)(ii) LOTO – Serious and $0; where reaccumlation of stored energy could occur, verification of isolation was not continued until the servicing and maintenance was complete or until the possibility of such reaccumulation no longer existed
- 1910.147(d)(6) LOTO – Serious and $7K; Prior to starting work on equipment that had been locked out, the authorized employees did not verify that isolation and deenergization of the equipment had been accomplished
CLICK HERE to download the TOSHA Citations and Investigation Documents. PLEASE NOTE that OSHA has blocked out personal names and I have blocked out even more names, as this is NOT about the names of the workers or refinery management, but an opportunity to have an inside look at the details of this accident and to see the level of detail that OSHA looks at during a fatality investigation.