On May 5, 2018, Employee #1 was retrieving a plastic liner bag from a chemical container that had fallen into Reactor CP-2; a confined space. The permitting process, including air monitoring and setting up of ventilation, had not been conducted. As Employee #1 descended a ladder to access the reactor, he passed out at the first rung and fell to the bottom of the reactor. A coworker, who witnessed Employee#1 enter the space, contacted the control room to notify them of the incident. Emergency services were contacted and, upon arrival, recovered Employee #1 from the reactor. Employee #1 was determined dead. Air monitoring conducted by emergency services, following the incident, showed an oxygen concentration of eleven (11) percent.
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Violation Summary
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|---|---|---|---|---|---|
| Serious | Willful | Repeat | Other | Total | |
| Initial Violations | 5 | 5 | |||
| Current Violations | 5 | 5 | |||
| Initial Penalty | $25,000 | $0 | $0 | $0 | $25,000 |
| Current Penalty | $25,000 | $0 | $0 | $0 | $25,000 |
| Violation Items | |||||||
|---|---|---|---|---|---|---|---|
| ID | Type | Standard | Issuance | Abate | Curr$ | Init$ | Contest |
| 01001A | Serious |
19100146 D01 – Implement the measures necessary to prevent unauthorized entry |
10/10/2018 | 10/24/2018 | $5,000 | $5,000 | 11/16/2018 |
| 01001B | Serious |
19100146 G03 – The training shall establish employee proficiency in the duties required by this section and shall introduce new or revised procedures, as necessary, for compliance with this section. |
10/10/2018 | 10/24/2018 | $0 | $0 | 11/16/2018 |
| 01002 | Serious |
19100146 D03 IV – Purging, inerting, flushing, or ventilating the permit space as necessary to eliminate or control atmospheric hazards; |
10/10/2018 | 10/24/2018 | $5,000 | $5,000 | 11/16/2018 |
| 01003 | Serious |
19100146 D05 I – Test conditions in the permit space to determine if acceptable entry conditions exist before entry is authorized to begin, except that, if isolation of the space is infeasible because the space is large or is part of a continuous system (such as a sewer), pre-entry testing shall be performed to the extent feasible before entry is authorized and, if entry is authorized, entry conditions shall be continuously monitored in the areas where authorized entrants are working; |
10/10/2018 | 10/24/2018 | $5,000 | $5,000 | 11/16/2018 |
| 01004 | Serious |
19100146 I10 – Performs no duties that might interfere with the attendant’s primary duty to monitor and protect the authorized entrants. |
10/10/2018 | 10/24/2018 | $5,000 | $5,000 | 11/16/2018 |
| 01005 | Serious |
19100146 K03 – To facilitate non-entry rescue, retrieval systems or methods shall be used whenever an authorized entrant enters a permit space, unless the retrieval equipment would increase the overall risk of entry or would not contribute to the rescue of the entrant. Retrieval systems shall meet the following requirements. |
10/10/2018 | 10/24/2018 | $5,000 | $5,000 | 11/16/2018 |
