OSHA cited a chemical manufacturer after a chemical release at the manufacturing plant exposed workers to ethylene oxide. The company faces $262,548 in penalties. OSHA initiated an inspection after the exposure hospitalized one employee and left five others suffering symptoms of ethylene oxide (EtO) exposure. The Agency cited 25 serious violations, including deficient emergency action and response plans; failure to train employees on how to manage EtO leaks; and the use of fire protection, water-deluge systems, and emergency shutdown procedures. The company also failed to develop procedures for emergency responders to manage firewater amid an EtO release, activate the emergency alarm system, and provide employees with respiratory protection.
Here is a breakdown of the citations:
Citation 1 Item 1
Type of Violation: Serious; $11,934
29 CFR 1910.119(c)(2): The employer did not consult with employees and their representatives on the conduct and development of process hazards analyses and on the development of the other elements of process safety management in this standard:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to consult with operators and their representatives on the development of all hazard studies conducted as part of the pre-startup safety review, contributing to employee exposure to the toxic, fire, and explosion hazards posed by ethylene oxide.
The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury or illness.
Citation 1 Item 2a
Type of Violation: Serious; $11,934
29 CFR 1910.119(d)(3)(i)(B): The employer did not compile written process safety information including piping and instrument diagrams (P&ID’s):
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to update (finalize) the P&IDs before developing its final process hazard analysis and before conducting the pre-startup safety review of the EO plant. Incorrect or outdated P&IDs do not allow the employer and the employees involved in operating the process to identify and understand the hazards posed by the EO process exposing employees to the hazards of toxic and fire/explosion hazards.
Citation 1 Item 2b
Type of Violation: Serious
29 CFR 1910.119(e)(1): The employer did not perform a complete initial process hazard analysis (hazard evaluation) on processes covered by this standard.
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to perform an adequate initial PHA that was based on detailed design P&IDs when its 2015/2016 PHA prior to startup was based on information that pre-dated the Revision 0, set of P&IDs that were issued for construction. Incorrect or outdated P&IDs (e.g. Issued for Construction version) do not allow the employer and the employees involved in conducting PHAs or operating the process to identify and understand the hazards posed by the EO process exposing employees to the hazards of toxic and fire/explosion hazards.
Citation 1 Item 3
Type of Violation: Serious; $11,934
29 CFR 1910.119(d)(3)(i)(F): The employer did not compile written process safety information including design codes and standards employed:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to develop and compile process safety information related to the design codes and standards used for the design and construction of equipment used at the new EO plant such as but not limited to the following:
ASME B16.34 , API 620, API 618, API 674, NFPA 14, NFPA 15, NFPA 20, NFPA 22, NFPA 24, NFPA 72, NFPA 101, NFPA 496, NFPA 2113, ISA 84.00.01 , etc., contributing to employee exposure to the toxic, fire, and explosion hazards posed by ethylene oxide.
Citation 1 Item 4
Type of Violation: Serious; $11,934
29 CFR 1910.119(d)(3)(i)(G): Information pertaining to the equipment in the process did not include material and energy balances for processes built after May 26, 1982:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to develop and compile process safety information related to material and energy balances for the EO plant process streams, including the EO reaction process, contributing to employee exposure to the toxic, fire, and explosion hazards posed by ethylene oxide.
Citation 1 Item 5
Type of Violation: Serious; $11,934
29 CFR 1910.119(d)(3)(ii): The employer did not document that equipment complies with recognized and generally accepted good engineering practices (RAGAGEP):
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, due to the infiltration of EO into the EO control building, employees who remained in the EO control room to conduct emergency operations were exposed to toxic and explosion/fire hazards when the employer did not document that it complied with its chosen RAGAGEP, API 752, Management of Hazards Associated with Location of Process Plant Permanent Buildings , Sections 7.6.2, 8.4.1 and 8.4.2. The EO control building was not designated by the employer as a shelter-in-place and did not include equipment/building features that would have protected the control building, control equipment, and its employees from the infiltration of EO vapors such as:
sensors in the air intakes to alert the occupants of the ingress of hazardous materials, means to automatically limit air ingress from HVAC systems in the event of a sensor alarm; appropriately sealed windows and doors equipment for operators who must remain in the control room, such as a breathing air manifold system with supplied air masks, or SCBAs, and, equipment to facilitate an escape, if warranted, such as 5- or 10-minute escape packs that would provide enough clean air to allow the operators to evacuate to a safe location.
b) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to document it complied with its chosen RAGAGEP, ASME B31.3 (2016), Process Piping, Section 335.2.2, Bolting Torque when it assembled piping flanges in ethylene oxide service that were not torqued to their proper design loading including the flange bolts on the 1/2″ inch vent line of the Purification Column Steam Reboiler E-430 in Area 400 that was involved in the ethylene oxide release. In addition, approximately 85 other flanges were found post-incident to be under-torqued in Areas 400 and 1400 of the EO plant.
c) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to document it complied with its chosen recognized and RAGAGEP, ASME B31.3 (2016) , Process Piping, Section 308.4 Gaskets, when it assembled a piping flange with a gasket that was not suitable for the process conditions, i.e. the gasket material was not compatible for ethylene oxide service. This piping flange and gasket were part of the 1/2″ inch vent line of the Purification Column Steam Reboiler E-430 in Area 400 that was involved in the release of ethylene oxide.
d) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to document it complied with RAGAGEP, such as ASME PCC-1 (2013), Guidelines for Pressure Boundary Bolted Flange Joint Assembly, Section 8.1, Installation of Bolts, when it installed bolts for assembly of a piping flange, that were made of B7 Alloy material and did not meet the bolt design specification which required B8 stainless steel bolts for the application per specification . This piping flange and incorrect bolting materials were used on the 1/2 inch vent line located on the Purification Column Steam Reboiler, E-430 in Area 400 that was involved with the release of ethylene oxide.
e) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer did not document that it complied with RAGAGEP such as:
- NFPA 15, Standard for Water Spray Fixed Systems for Fire Protection Sections 7.1.10.3, 7.5.2, 9.2.1, and 9.2.2 for fixed water spray systems (deluge system);
- NFPA 20, Standard for the Installation of Stationary Pumps for Fire Protection Sections 4.6.4.1 and 4,6.2 for diesel firewater pumps and jockey pump;
- API 2510 [as referenced in employers chosen RAGAGEP, the Ethylene Oxide Product Stewardship Manual Third Edition (ACC)] Section 10.3.1.5 requires 4 hour firewater supply; and,
- NFPA 22, Standard for Water Tanks for Private Fire Protection Section 4.1.1 for firewater tank; when the existing firewater system was not adequately sized and designed to meet the additional firewater demands ( e.g. simultaneous operation of deluge system and fire monitors , and other non-firewater users) for mitigating an ethylene oxide release at the ECO[EP 1] Plant. This contributed to the firewater supply being undersized for a high firewater demand case involving flow from multiple users.
These conditions contributed to employee exposure to the toxic, fire, and explosion hazards posed by ethylene oxide.
Citation 1 Item 6
Type of Violation: Serious; $11,934
29 CFR 1910.119(e)(3)(iii): The process hazard analysis did not address engineering and administrative controls applicable to the hazards and their interrelationships such as appropriate application of detection methodologies to provide early warning of releases:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to address the need for an effective advanced warning ethylene oxide area detection system for employees required to investigate an ethylene oxide release.
b) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employers facility siting study (Croda Atlas Point Facility Siting Study Revised Report, November 2, 2015) identified that the EO Control Room was in an area of potential toxic release consequences/hazards, however, neither the facility siting report or the 2016 Updated PHA included engineering controls (i.e ., equipment/building features) such as, but not limited to, the following: sensors in the air intakes to alert the occupants of the ingress of hazardous materials, means to automatically limit air ingress from HVAC systems in the event of a sensor alarm; appropriately sealed windows and doors appropriate PPE; or administrative controls such as emergency procedures that designate the building as a place to immediately evacuate upon detection/notification of a toxic/flammable materials release.
c) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to address the adequacy of the firewater supply with respect to the deployment of the water deluge systems and firewater monitors to contain and quell a release of ethylene oxide.
These conditions contributed to employee exposure to the toxic, fire, and explosion hazards posed by ethylene oxide.
Citation 1 Item 7
Type of Violation: Serious; $11,934
29 CFR 1910.119(e)(3)(v): The process hazard analysis did not address facility siting:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to address the impact of toxic releases on the ECO Plant Control Building, a critical building that is occupied by operators, who conduct emergency operations. This building was not designed as a shelter-in-place location for protecting employees from toxic exposure to ethylene oxide during an emergency release.
b) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to address a suitable location for the nitrogen purge valves or a suitable means to activate these manual valves in the event of an emergency release that prevented operators from accessing these valves.
These conditions contributed to employee exposure to the toxic, fire, and explosion hazards posed by ethylene oxide.
Abatement Note: Feasible means of abatement of this hazard could include relocating the T-430 manual nitrogen purge valve to a safe, accessible location or consider installing an automatic nitrogen sweeping system (e.g. valves and instrumentation) to allow for remote de-inventory of the T-430 from the DCS.
Citation 1 Item 8
Type of Violation: Serious; $11,934
29 CFR 1910.119(e)(3)(vi): The process hazard analysis did not address human factors:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employers process hazard analysis failed to address human factors relating to the confusing displays on the Control Room Distributed Control System user-machine interface (e.g., Human Machine Interface) for activating the firewater deluge system resulting in operator errors, such as the erroneous activation of incorrect deluge systems during an emergency release, contributing to employee exposure to ethylene oxide.
Citation 1 Item 9
Type of Violation: Serious; $11,934
29 CFR 1910.119(f)(1)(i)(D): The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process consistent with the process safety information that addressed emergency shutdown including the conditions under which emergency shutdown is required, and the assignment of shutdown responsibility to qualified operators to ensure that emergency shutdown is executed in a safe and timely manner:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to develop and implement written operating procedures to de-inventory the ethylene oxide from equipment, such as (but not limited to) that contained in the Purification Tower (T-430), to divert ethylene oxide away from Purification Column Steam Reboil er E-430, the location of the compromised flange leaking ethylene oxide, contributing to employee exposure to ethylene oxide.
Citation 1 Item 10
Type of Violation: Serious; $11,934
29 CFR 1910.119(f)(1)(i)(E): The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process consistent with the process safety information that addressed emergency operations:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to develop and implement written operating procedures to identify the correct deluge system(s) to activate in the event of an ethylene oxide leak.
b) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to develop and implement written operating procedures to follow in order to manage firewater supply during its use in an emergency.
Citation 1 Item 11
Type of Violation: Serious; $11,934
29 CFR 1910.119(g)(1)(i): The employer did not train each employee in the operating procedures as specified in paragraph (f) of29 CFR 1910.119:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to train employees on how to manage ethylene oxide leaks.
b) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to train employees on how to use fire protection systems;
c) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to train employees on the correct use and activation of the water deluge system; and,
d) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to train employees on the consequences of deviation with respect to effective measures to mitigate hazards.
The hazardous conditions listed in the above instances exposed employees to toxic, fire, and explosion hazards posed by ethylene oxide.
Citation 1 Item 12
Type of Violation: Serious; $11,934
29 CFR 1910.119(i)(2)(i): Construction and equipment was not in accordance with design specifications:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employers PSSR failed to assure that the flange joint assembly for the 1/2-inch-diameter vent line on the Purification Column Steam Reboiler (E-430) in Area 400 was installed/constructed in accordance with design specifications with respect to flange assembly (i.e. the gasket and bolt material of construction, and the bolt torquing did not meet the design specification), resulting in failure of the flange assembly and employee exposure to ethylene oxide.
Citation 1 Item 13
Type of Violation: Serious; $11,934
29 CFR 1910.119(i)(2)(ii): The pre-startup safety review did not confirm that safety, operating, maintenance, and emergency procedures were in place and were adequate prior to the introduction of highly hazardous chemicals into a process:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to assure that Control Room evacuation procedures in the event of toxic ethylene oxide infiltration were developed and implemented to minimize employee exposure to ethylene oxide.
b) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to assure that emergency operating procedures were developed and implemented to mitigate an ethylene oxide leak including specific steps to isolate/de-inventory quantities of ethylene oxide to a safe location.
c) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to assure that written[HA-O2) procedures were developed and implemented for 1) the operation of the deluge systems in the Control Room and, 2) for managing firewater usage, were in place and adequate.
d) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to assure that written [HA-O3) procedures were developed and implemented which would enable connection to other firewater make-up sources, such as to Suez water, in order to maximize available water supply during an emergency release.
e) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to assure that written [HA-O4) procedures were developed and implemented for operating the fire pumps and fire water tank at the Powerhouse.
The hazardous conditions listed in the above instances exposed employees to toxic, fire, and explosion hazards posed by ethylene oxide.
Citation 1 Item 14
Type of Violation: Serious; $11,934 29 CFR 1910.119(i)(2)(iii): The pre-startup safety review did not confirm that for new facilities, a process hazard analysis (PHA) was completed before startup;
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to perform a final process hazard analysis to ensure that all hazards were identified, evaluated and controlled before startup. The PHA update in 2016 did not identify process hazards such as how the firewater system did not take into account the flow from multiple users when designing the system for the maximum firewater demand. In addition, the DCS graphical interface for the firewater deluge system was difficult to understand resulting in the incorrect deluge system being activated , the control building was not designed to prevent toxic vapor ingress, and the nitrogen purge system for the 430 EO Purification Column could not be accessed during an EO release, resulting in employee exposure to ethylene oxide.
Citation 1 Item 15
Type of Violation: Serious; $11,934 29
CFR 1910.119(i)(2)(iv): The PSSR conducted by the employer did not assure that each employee involved in operating a process was trained prior to startup/introduction of highly hazardous chemicals into a process:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employers PSSR failed to ensure that employees were trained on how to properly use the firewater system, the emergency shutdown system for the EO processes, and how to execute emergency actions based on the emergency response plan for the EO plant, resulting in employee exposure to flammable and toxic hazards from the ethylene oxide release.
Citation 1 Item 16
Type of Violation: Serious; $11,934
29 CFR 1910.119(j)(6)(ii): Appropriate checks and inspections were not performed to assure that equipment was installed properly and consistent with design specifications and the manufacturer’s instructions:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to assure that pipe joints were assembled correctly. In particular, the employer failed to recognize that a gasket, made of materials incompatible with ethylene oxide, was used on a vent line flange at Reboiler E-430, part of the Ethylene Oxide Purification Section.
b) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to assure that the studs used in the flange assembly were constructed of the correct materials.
c) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to assure that piping flanges were torqued correctly. These conditions contributed to employee exposure to the toxic, fire, and explosion hazards posed by ethylene oxide.
Citation 1 Item 17
Type of Violation: Serious; $11,934
29 CFR 1910.119(n): The employer did not establish an emergency plan for the entire plant in accordance with the provisions of 29 CFR 1910.38:
a) On or about November 25, 2018, the employer failed to develop and implement procedures to be followed by Ethylene Oxide Batch Plant employees who remain to operate critical plant equipment before they evacuate. One feasible means of abatement would be to comply with 29 CFR 1910.38(c)(3).
b) On or about November 25, 2018, the employer failed to include procedures to account for all employees after evacuation due to an emergency release of ethylene oxide.
One feasible means of abatement would be to comply with 29 CFR 1910.38(c)(4).
c) On or about November 25, 2018, the employer failed to include the name and job title of every employee who may be contacted by employees who need more information about the plan or an explanation of their duties under the plan. One feasible means of abatement would be to comply with 29 CFR 1910.38( c)(6).
These conditions contributed to employee exposure to the toxic, fire, and explosion hazards posed by ethylene oxide.
The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury or illness.
Citation 1 Item 18a
Type of Violation: Serious; $11,934
29 CFR 1910.120(q)(2)(i): The employer did not develop and implement an emergency response plan to address pre-emergency planning and coordination with outside parties:
a) On or about November 25, 2018, the employer failed to adequately protect employees from toxic exposure to ethylene oxide during an emergency release in that planning and coordination with outside parties, prior to an emergency, was not complete, contributing to employee exposure to toxic, fire, and explosion hazards posed by ethylene oxide.
Citation 1 Item 18b
Type of Violation: Serious
29 CFR 1910.1047(h)(1)(i): A written plan for emergency situations was not developed for each ethylene oxide workplace where there was the possibility of an emergency:
a) On or about November 25, 20 I 8, the employer failed to develop a written plan for emergency situations, contributing to employee exposure to ethylene oxide.
The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury or illness.
Citation 1 Item 19a
Type of Violation: Serious; $11,934
29 CFR 1910.120(q)(2)(xi): The employer did not develop an emergency response plan for emergencies addressing PPE and emergency equipment:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to address PPE, such as air-supplied respirators , for employees remaining in the Control Room during an emergency ethylene oxide release, contributing to employee exposure to ethylene oxide.
Citation 1 Item 19b
Type of Violation: Serious
29 CFR 1910.1047(h)(1)(ii): The ethylene oxide emergency plan did not specifically provide that employees engaged in correcting emergency conditions be equipped with required respiratory protection until the emergency is abated:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to plan to equip operators responding to an emergency release of ethylene oxide with respiratory protection, contributing to employee exposure to ethylene oxide.
Citation 1 Item 20
Type of Violation: Serious; $11,934
29 CFR 1910.165(b)(1): The employee alarm system did not provide warning for necessary emergency action as called for in the emergency action plan, or for reaction time for safe escape of employees from the workplace or the immediate work area, or both:
a) On or about November 25, 2018, the employer failed to activate the emergency alarm system , prolonging the potential for employee exposure to the hazards of ethylene oxide.
Citation 1 Item 21
Type of Violation: Serious; $11,934
29 CFR 1910.1047(h)(2): Employees were not immediately evacuated from the area when exposed to ethylene oxide during an emergency situation:
a) On or about November 25, 2018, the employer failed to immediately evacuate employees exposed to ethylene oxide during an emergency release of ethylene oxide.
Citation 1 Item 22
Type of Violation: Serious; $11,934
29 CFR 1910.1047(i)(1)(i)(B): Medical examinations and consultations were not made available to all employees who had been exposed to ethylene oxide in an emergency situation:
a) Ethylene Oxide Batch Plant – On or about November 25, 2018, the employer failed to ensure that medical examinations and consultations , in accordance with paragraph (i) of this Section were made available to employees exposed to ethylene oxide during an emergency release.
ABATEMENT NOTE: The OSHA Ethylene Oxide Standard , 29 CFR 1910.1047 mandates that medical examinations & consultations be in accordance with subparagraphs: (i)(2) – frequency and content; (i)(3) – information provided to the employer; and, (i)(4) – physician’s written opinion.
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