OSHA cites 50 safety violations, proposes $917,000 in fines after flammable liquid explosion

My apologies for missing this one back earlier this year!!!  OSHA has cited an adhesives manufacturing facility with 50 alleged violations of workplace safety standards following a March 13 explosion in which four workers were injured. The  faces a total of $917,000 in proposed fines.  OSHA’s inspection identified several serious deficiencies in the company’s PSM program. In this case, the chemical was acetone, used in a PSM-covered process known as direct solvation. On the day of the explosion, a valve on a transfer line inadvertently was left open, resulting in the release of flammable acetone vapors. The vapors exploded after being ignited by an undetermined source.   Specifically, OSHA found that the process safety information for the solvation process was incomplete. The employer’s analysis of hazards related to the process did not address previous incidents with a potential for catastrophic results, such as forklifts that struck process equipment, and did not address human factors such as operator error, communication between shift changes and employee fatigue from excessive overtime. In addition, the company did not ensure that a forklift and electrical equipment, such as a light fixture, switches and a motor, were approved for use in Class 1 hazardous locations where flammable gases or vapors are present.  Here is a breakdown of the OSHA citations and the State Fire Marshal Report …

Employee Participation

• the employer did not develop a written plan of action regarding the implementation of employee participation in the development of a process safety management plan or process hazard analysis (1910.119(c)(1); Serious; $7K)
• the employer did nor include employee involvement by non lead employees in the development of the process hazard analysis (PHA), standard operating procedures, mechanical integrity and incident investigations (1910.119(c)(2); Serious; $7K)

 

Process Safety Information

• the  process safety information (PSI) pertaining to the equipment in the process did not include documentation that equipment, including  but not limited to valves, electrical wiring and safety systems such as interlocks and suppression systems, complied with recognized and generally accepted good engineering practices (RAGAGEP) (1910.119(d)(3)(i)(H); Serious; $7K)
  • the process safety  information (PSI) pertaining to the equipment in the process did nor include documentation that equipment, including but not limited to valves, electrical wiring and safety systems such as interlocks and suppression systems, complied with recognized and generally accepted good engineering practices (RAGAGEP) (1910.119(d)(3)(ii); Serious; $0)
• the process safety information (PSI) pertaining to the equipment in the process was not adequate; (1910.119(d)(3)(i); Serious; $7K) examples include but are not limited to: 

1. 1. PSI for the emergency relief systems was missing elements such as  but not limited to design codes and upset scenarios. 
   2. PSI for the process vapor capture system was missing elements such as but not limited to design codes, materials of construction, and limitations of the system. 
   3. PSI for piping/pumps was missing elements such as  but not limited to materials of construction, pump curves and compatibilities between the pumps and piping. 
   4. PSI for flexible hoses was not available. 
   5. The PSI related to ventilation system design was missing elements such as but not limited to the volume of the process areas, surface area of exhaust vents, the number of air changes per hour and did not identify the areas where the exhaust system discharged. 

 

Process Hazards Analysis

• PHA did nor address the following incidents to control impacts to process equipment from powered industrial vehicles including damage to ventilation trunks, storage racks, water lines and electrical equipment. (1910.119(e)(3)(ii); Willful; $70,000)

1. 1. In Direct Solvation on 11/4/09, a ventilation trunk was struck by a tote being lifted by a forklift. 
   2. In Solvent Cement on 11/12/09 a forklift struck a storage rack. 
   3. In Polyester Building 36, on 4/27/09, a forklift struck a water line causing it to rupture and also damaged an electrical  box.

• the PHA did not address human factors including, but not limited to, shift changes for operators, operator error, critical alarms or sounds, and excessive overtime (1910.119(e)(3)(vi); Willful; $70,000)
• the process hazard analysis (PHA) did not  identify the hazards of power failure (1910.119(e)(3)(i); Serious; $7K)
• process hazard analysis did nor identify any previous incident which had a likely potential for  catastrophic consequences in the workplace.   The PHA did not identify the following  incidents: (1910.119(e)(3)(ii); Serious; $7K)

1. 1. In March 2009, a rupture disk blew resulting in a 1,000 pound spill of MEK, toluene, and polyester resin. 
   2. In March 2009, a rupture disk blew resulting in a 15 gallon spill of MEK. 
   3. In April  2009, an over-pressurization in the Solvator resulted in a spill of MEK. 
   4. In October 2009, a power outage occurred at the facility resulting in fires in the freezer pumps.

• the employer’s process hazard analysis did nor identify appropriate safeguards  to control high consequence hazards such as leaving valves open.  The employer instead used administrative controls such as training and procedures to safeguard against catastrophic hazards where engineering controls should have been used (1910.119(e)(3)(iii); Serious; $7K)
• the employer did not establish a system to promptly address the process hazard analysis team’s findings  and recommendations.  The employer did  not  adequately address team findings and recommendations in the Solvator process hazard  analysis (PHA) in a timely manner or that the resolution was documented and closed, such as  but nor  limited to: (1910.119(e)(5); Serious; $7K)

1. 1. The recommendation for verifying that the pressure relief valves were in place and what the valve was rated for; 
   2. The recommendation that a check valve be installed to prevent back flow when adding flammable liquids to the Solvator; 
   3. The recommendation to upgrade the Solvator cooling system; 
   4. The recommendation to automate pressure control for Nitrogen; and 
   5. The recommendation to add relief valve in filter housing to vent back to Solvator.

Operating Procedures

• operating procedures were not developed and implemented to address communication and other activities involving shift changes (1910.119(f)(1); Serious; $7K)
• the written operating procedure, DS-028; Rev: 2-Breaking Vacuum on R8, did not provide procedures for operating the backup vacuum pumps (1910.119(f)(1)(i)(C); Serious; $7K)
• the written operating procedure, DS-028; Rev: 2-Breaking Vacuum on R8, did not adequately outline the specific steps to be performed to stop the process in the event of an emergency (1910.119(f)(1)(i)(E); Serious; $7K)
• the  written  operating  procedure,  DS-011;  Rev: 2 – Transfer of Resin from R8 to Solvator did not describe symptoms that would indicate a potential emergency condition nor did it address methods  of investigation  if one  of these symptoms  is  observed.  Further, the company did nor have an operating procedure to describe what to do in the event that a potential flammable mixture has been released into the facility (1910.119(f)(1)(i)(E); Serious; $7K)
• the written operating procedure, DS-028; Rev: 2-Breaking Vacuum on R8 , did not adequately address consequences of deviation beyond operating limits (1910.1 19(f)(1)(ii)(A); Serious; $7K)
• the written operating procedure  DS-011; Rev :2 -Transfer of Resin from R8 to Solvator, did not address consequences of mixing of high temperature product with solvent in the solvator (1910.1 19(f)(1)(ii)(A); Serious; $7K)
• the written operating  procedure, DS-028; Rev: 2-Breaking Vacuum on R8, did not adequately address the steps required to correct or avoid deviation beyond operating limits (1910.119(f)(1)(ii)(B); Serious; $7K)
• the written operating procedure DS-011; Rev:2- Transfer of Resin from R8 to Solvator, did not  include the steps required to correct or avoid mixing high temperature product with solvent in the solvator. 

 

Training

• the employer did nor provide refresher training and assure that employees understood current operating procedures (1910.119(g)(2); Serious; $7K)

 

Contractors

• the employer did not inform electrical contract employees working on or near a covered process of the known fire and explosion hazards (1910.119(h)(2)(ii); Serious;$7K)

 

Mechanical Integrity

• the company did nor have a written mechanical integrity program that addressed the preventive maintenance, inspection and testing for pumps (1910.119(j)(2); Serious; $7K)
• inspection and testing frequency of the process vapor ventilation system was not frequent enough to prevent clogging of vapor system components due to excessive buildup of vapor condensate (1910.119(j)(4)(iii); Serious; $7K)
• the  employer did not correct deficiencies on process equipment before further use or in a timely manner (1910.119(j)(5); Serious; $7K)

 

Management of Change

• the procedure followed in managing the change of two manually controlled valves with an air actuated valve was not adequately implemented (1910.119(l)(1); Serious; $7K)
• the piping & instrument diagrams (P&ID) for the solvator was nor updated to show the replacement of two manual valves with a single air actuared valve/transfer valve (1910.119(l)(4); Serious; $7K)
• the operating procedure DS-0 11; Rev: 2 – Transfer of Resin from R8  to Solvator, was not updated to reflect the replacement of two manual valves referenced in the procedure with a single air actuated valve/transfer valve (1910.119(l)(5); Serious; $7K)

 

Incident Investigation

• the employer did not conduct an investigation of an incident that occurred prior to the explosion in which solvent was added to high temperature product in the Solvator prior to cooling resulting in a vapor release of polyester distillate (1910.119(m)(1); Serious; $7K)
• recommendations made to resolve findings resulting from an incident investigation conducted on 10/24/2008, which involved a vapor release due to clogged vent lines, had not been resolved (1910.119(m)(5); Serious; $7K)
  • recommendations made to resolve findings resulting from an incident investigation conducted on 09/13/2010, which involved over pressurization of a vessel due to a plugged flame arrestor, had not been resolved

 

Emergency Planning and Response

• Exit routes were not kept free of explosive or highly flammable furnishings or other decorations: (1910.37(a)(1); Serious; $7K)
  • numerous fifty five gallon drums of flammable liquids  were stored along the exit access to the south west exit. 
  • two fifty five gallon drums of flammable liquids were stored in the exit access of the specialty area in the southwest corner of the building.
• employer did not implement an adequate emergency response plan to handle anticipated emergencies prior to commencement  of emergency response operations (1910.120(q)(1); Serious; $7K)
• the employer’s emergency response plan did not adequately nor effectively address elements included in 1910.120(q)(2) including but not limited to the following: (1910.120(q)(2); Serious; $7K)

• • Personnel roles, lines of authority, training, and communication, 
  • Emergency recognition and prevention, 
  • Safe distances and places of refuge, 
  • Evacuation routes and  procedures, 
  • Decontamination, 
  • Emergency alerting and response procedures, 
  • Critique  of response and follow-up , 
  • Personal protective equipment and emergency equipment. 
• the  employer did not take adequate precautions to coordinate and/or control use of communications equipment including, but not limited to; portable radios, cell phones, and other equipment which were not rated for use in the presence of flammable  liquids and/or vapors (1910.120(q)(3)(i); Serious; $7K)
• numerous employees that the employer’s Integrated Contingency Plan (ICP) identified as being required to participate in emergencies as hazardous material technicians had not received at least 24 hours of training equal to the first responder operations level and in addition had not been certified as competent (1910.120(q)(6)(iii); Serious; $7K)
• employees expected to perform incident commander duties had not received twenty four hours required training at the first responder operations level and had not been certified as having competency in (A) through (F) of this section (1910.120(q)(6)(v); Serious; $7K)
• the employer did not provide adequate and/or effective annual refresher training or a chance for employees to demonstrate continued competency in implementing the integrated contingency plan in the event of an emergency response to a release of hazardous chemicals (1910.120(q)(8)(i); Serious; $7K)
• the employer did not establish a written personal protective equipment program for employees who are members of the on site Emergency Response Team (ERT) (1910.120(q)(10); Serious; $7K)
• employees on the emergency response team were expected to use a tight-fitting facepiece respirator as part of a self-contained breathing apparatus (SCBA) and had not been fit tested (1910.134(f)(1); Serious; $7K)
• employees who are required to use fire extinguishers to extinguish fires of substantial quantities of flammable liquids were not provided with adequate training in the use of the appropriate equipment (1910.157(g)(3); Serious; $7K)
• employees required to use fire extinguishers were not provided training at least annually in the use of appropriate equipment (1910.157(g)(4); Serious; $7K)

 

Hotwork

• the employer failed to ensure that areas were inspected prior to welding and cutting being permitted (1910.252(a)(2)(iv); Serious; $7K)
• the employer did not designate an individual responsible for authorizing cutting and welding operations in areas not specifically designed for such processes (1910.252(a)(2)(xiii)(B); Serious; $7K)
• two compressed gas cylinders were stored in close proximity to the stairway for the mezzanine in Building 37 (1910.253(b)(2)(ii); Serious; $7K)

 

Flammable Liquids

• the employer did not take adequate precautions to prevent the ignition of flammable vapors when using radios, cell phones, and other equipment which were not intrinsically safe (1910.106(h)(7)(i)(a); Serious; $0)

 

Electrical

• the employer did not adequately ensure that electrical equipment, electric motor, was free from recognized hazards including but not limited to; mechanical strength, durability,  classification by type and other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment (1910.303.(b)(1); Serious; $7K)
  • the employer did not adequately ensure that electrical equipment, liquid tight flexible metal conduits, were free from recognized hazards including but not limited to; mechanical strength, durability,  classification by type and other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
  • the employer did not adequately ensure that electrical equipment, manually operated electrical timer switch, was free from recognized hazards including but not limited to; mechanical strength, durability,  classification by type and other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
• the employer did not ensure that unused openings in boxes,  raceways,  auxiliary gutters, cabinets,  equipment cases, or housings were effectively closed (1910.303(b)(7)(i); Serious; $7K)
• an energized electric outlet did not have a cover (1910.305(b)(2); Serious; $7K)
• the employer did not ensure that threaded conduit was used where required per the requirements of CFR 1910.307 (Class I, Division  1 and Division 2) (1910.307(d); Serious; $7K)
• the light fixture and operating switch in a hazardous location on top of the Solvator was not approved for Class I hazardous locations nor for the ignitable properties of the vapor (1910.307(c)(2)(i); Willful; $70K)
• the service disconnect switch, which was in a hazardous location, for the reflux pump adjacent to Reactor 8 was not approved for Class I hazardous locations nor for the ignitable properties of the vapor (1910.307(c)(2)(i); Willful; $70K)
• the motor for Reactor 6 hot oil pump, which was in a hazardous location, was nor approved for a Class I hazardous location nor for the ignitable properties of the vapor (1910.307(c)(2)(i); Willful; $70K)
• the electrical timer switch and enclosure for Reactor 8’s internal sight light,  both of which were in a hazardous location, were not approved for Class I hazardous locations nor for the ignitable properties of the vapor (1910.307(c)(2)(i); Willful; $70K) 
• the motor switch and enclosure for the exhaust fan for Reactor 8, both of which were in a hazardous location, were not approved for Class I hazardous locations nor for the ignitable properties of the vapor (1910.307(c)(2)(i); Willful; $70K)

 

Forklift

• the employer did not train their powered industrial truck operators on the hazards of operating in a classified location (1910.178(1)(3)(ii)(F); Serious; $7K)
• three electric powered industrial trucks designated as “E”  were used in Class I hazardous locations (1910.178(m)(11); WILLFUL; $7K)

 

Source(s): 1  2

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MA State Fire Marshal Memo

The Department of Fire Services has concluded its code compliance investigation into the March 13, 2011 Middleton explosion and the results of the investigation into code issues at the Bostik chemical processing facility are being released today.

Explosion Caused by Ignition of Flammable Vapors

The State Police assigned to the Office of the State Fire Marshal have also concluded their cause and origin investigation and determined the cause of the explosion was the result of flammable vapors within the structure being ignited by an undetermined source. At the time of the explosion, a chemical reaction process was underway where a Class I flammable liquid solvent is added to a 4,000-gallon reaction vessel containing polyester resin solution.   Fire protection engineering staff in the Division of Fire Safety examined local records for compliance by the Bostik Company with the existing state laws and fire and building codes and also examined the current state fire and building codes and laws to see if adequate protection exists to prevent or contain a similar explosion in buildings built today.  As a result of this investigation, three non-criminal notices of violation were issued and several recommendations for the passage of laws and regulations to improve chemical process safety in Massachusetts were made. 

Fire Code Violations

The Department of Fire Services on behalf of the Middleton Fire Department issued a notice of violation to Bostik Corporation. The violations were: storing flammable liquids in excess of amounts the company was licensed to store on the premises; failure to obtain a permit for a dust-producing grinding operation; and failure to obtain a permit for the storage of flammable liquids.

Building Code

The building in which the explosion occurred has been operating for decades as a high hazard use, predating the adoption of a State Building Code. As such, the facility was not subject to requirements of the current building code that contains requirements for modern fire and life safety systems, such as explosion venting, properly designed ventilation of flammable vapors, and manual emergency alarms to notify other building occupants of non-fire emergencies. These features could have mitigated the potential damage and injuries of the explosion, but were not required of the facility because there was no change in use.  One of the recommendations in the report is to amend the State Building Code such that upgrades to new construction fire and life safety standards be required upon any renovation, modification, addition or change of use involving high hazard use group occupancies. This could trigger installation of safety features over time to keep safety as modern as possible in the state’s chemical processing industry. The report also recommends a requirement for continuous flammable vapor monitoring in any H-2 use (installation of gas detection equipment) and a clarification of existing definitions for Open Use processes to include any process where containers or process vessels are opened for any duration. 

Fire Prevention Regulations on Chemical Process Safety

The current Massachusetts Fire Code does not presently address hazards associated with many industrial operations and processes. However, regulations have been developed and are currently awaiting final approval. The report urges swift final promulgation of these regulations.

Chemical Processing Safety Legislation

One of the main recommendations of the report is the passage of chemical process safety legislation originally filed in the wake of the 2006 Danvers explosion at a chemical processing facility. The bill would create a comprehensive oversight and permitting program to safely regulate chemical process safety and improve the capabilities of the state Department of Fire Services to address the issue and to assist local fire departments in meeting their code compliance and enforcement responsibilities. Neither the state nor local communities currently have the technical expertise to comprehensively analyze chemical processing safety or to completely identify and manage the public safety risk associated with high-hazard occupancies.

State Fire Marshal Concludes Investigation into Bostik Explosion