At 2:00 p.m. on May 20, 2014, Employee #1 was in a tank railcar confined space containing residual sweet crude oil without prior entry assessment and without wearing a harness with stand-by extraction equipment. While Employee #1 was shoveling crude oil inside a permit-required confined space tank railcar. Employee #1 was wearing a full-face supplied-air respirator (SAR), MSA Type-C Ultraview, attached to shop air and filter pot with no carbon monoxide filtration.
One of Employee #1′ s co-workers was acting as the entry supervisor and remained outside of the tank. After Employee #1 had been working inside the tank for 40 minutes, he informed his co-worker that he wanted to exit at which point his co-worker lowered a ladder into the tank. Employee #1 collapsed against the ladder. In-house employees attempted entry rescue three times before 911 was called, 65 minutes after Employee #1 had collapsed. Fire and rescue service was able to extract the Employee #1 two hours after the employee collapse. An autopsy determined Employee #1’s cause of death as a cardiac arrhythmia which was caused by difluoroethane intoxication.
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Violation Summary
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|---|---|---|---|---|---|
| Serious | Willful | Repeat | Other | Total | |
| Initial Violations | 14 | 7 | 21 | ||
| Current Violations | 14 | 7 | 21 | ||
| Initial Penalty | $34,400 | $154,000 | $0 | $0 | $188,400 |
| Current Penalty | $24,080 | $107,800 | $0 | $0 | $131,880 |
| Violation Items | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| # | ID | Type | Standard | Issuance | Abate | Curr$ | Init$ | Contest | LastEvent |
| 1. | 01001A | Serious |
19100023 C01 – Rungs and steps of portable metal ladders are corrugated, knurled, dimpled, coated with skid-resistant material, or otherwise treated to minimize the possibility of slipping; |
11/18/2014 | 04/17/2015 | $1,400 | $2,000 | 12/10/2014 | F – Formal Settlement |
| 2. | 01001B | Serious |
19100132 A – Protective equipment, including personal protective equipment for eyes, face, head, and extremities, protective clothing, respiratory devices, and protective shields and barriers, shall be provided, used, and maintained in a sanitary and reliable condition wherever it is necessary by reason of hazards of processes or environment, chemical hazards, radiological hazards, or mechanical irritants encountered in a manner capable of causing injury or impairment in the function of any part of the body through absorption, inhalation or physical contact. |
11/18/2014 | 04/17/2015 | $0 | $0 | 12/10/2014 | F – Formal Settlement |
| 3. | 01002 | Serious |
19100134 D02 I B – A combination full facepiece pressure demand supplied-air respirator (SAR) with auxiliary self-contained air supply. |
11/18/2014 | 04/17/2015 | $1,960 | $2,800 | 12/10/2014 | F – Formal Settlement |
| 4. | 01003 | Serious |
19100134 E01 – The employer shall provide a medical evaluation to determine the employee’s ability to use a respirator, before the employee is fit tested or required to use the respirator in the workplace. The employer may discontinue an employee’s medical evaluations when the employee is no longer required to use a respirator. |
11/18/2014 | 04/17/2015 | $1,960 | $2,800 | 12/10/2014 | F – Formal Settlement |
| 5. | 01004 | Serious |
19100134 F01 – The employer shall ensure that employees using a tight-fitting facepiece respirator pass an appropriate qualitative fit test (QLFT) or quantitative fit test (QNFT) as stated in this paragraph. |
11/18/2014 | 04/17/2015 | $1,960 | $2,800 | 12/10/2014 | F – Formal Settlement |
| 6. | 01005 | Serious |
19100134 I07 – For oil-lubricated compressors, the employer shall use a high-temperature or carbon monoxide alarm, or both, to monitor carbon monoxide levels. If only high-temperature alarms are used, the air supply shall be monitored at intervals sufficient to prevent carbon monoxide in the breathing air from exceeding 10 ppm. |
11/18/2014 | 04/17/2015 | $1,960 | $2,800 | 12/10/2014 | F – Formal Settlement |
| 7. | 01006 | Serious | 19100146 D03 I – Specifying acceptable entry conditions | 11/18/2014 | 04/17/2015 | $1,400 | $2,000 | 12/10/2014 | F – Formal Settlement |
| 8. | 01007A | Serious |
19100146 D03 IV – Purging, inerting, flushing, or ventilating the permit space as necessary to eliminate or control atmospheric hazards |
11/18/2014 | 04/17/2015 | $1,960 | $2,800 | 12/10/2014 | F – Formal Settlement |
| 9. | 01007B | Serious |
19100146 D04 II – Ventilating equipment needed to obtain acceptable entry conditions; |
11/18/2014 | 04/17/2015 | $0 | $0 | 12/10/2014 | F – Formal Settlement |
| 10. | 01008 | Serious |
19100146 D04 VIII – Rescue and emergency equipment needed to comply with paragraph (d)(9) of this section, except to the extent that the equipment is provided by rescue services; and |
11/18/2014 | 04/17/2015 | $1,960 | $2,800 | 12/10/2014 | F – Formal Settlement |
| 11. | 01009A | Serious |
19100146 D09 – Develop and implement procedures for summoning rescue and emergency services, for rescuing entrants from permit spaces, for providing necessary emergency services to rescued employees, and for preventing unauthorized personnel from attempting a rescue |
11/18/2014 | 04/17/2015 | $1,960 | $2,800 | 12/10/2014 | F – Formal Settlement |
| 12. | 01009B | Serious |
19100146 I07 – Summon rescue and other emergency services as soon as the attendant determines that authorized entrants may need assistance to escape from permit space hazards; |
11/18/2014 | 04/17/2015 | $0 | $0 | 12/10/2014 | F – Formal Settlement |
| 13. | 01010 | Serious |
19100146 D14 – Review the permit space program, using the canceled permits retained under paragraph (e)(6) of this section within 1 year after each entry and revise the program as necessary, to ensure that employees participating in entry operations are protected from permit space hazards. |
11/18/2014 | 04/17/2015 | $1,400 | $2,000 | 12/10/2014 | F – Formal Settlement |
| 14. | 01011 | Serious |
19100146 E05 I – The entry operations covered by the entry permit have been completed |
11/18/2014 | 04/17/2015 | $1,120 | $1,600 | 12/10/2014 | F – Formal Settlement |
| 15. | 01012 | Serious |
19100146 G02 IV – Whenever the employer has reason to believe either that there are deviations from the permit space entry procedures required by paragraph (d)(3) of this section or that there are inadequacies in the employee’s knowledge or use of these procedures. |
11/18/2014 | 04/17/2015 | $1,120 | $1,600 | 12/10/2014 | F – Formal Settlement |
| 16. | 01013A | Serious |
19100146 K01 I – Evaluate a prospective rescuer’s ability to respond to a rescue summons in a timely manner, considering the hazard(s) identified |
11/18/2014 | 04/17/2015 | $1,960 | $2,800 | 12/10/2014 | F – Formal Settlement |
| 17. | 01013B | Serious |
19100146 K01 II – Evaluate a prospective rescue service’s ability, in terms of proficiency with rescue-related tasks and equipment, to function appropriately while rescuing entrants from the particular permit space or types of permit spaces identified |
11/18/2014 | 04/17/2015 | $0 | $0 | 12/10/2014 | F – Formal Settlement |
| 18. | 01014A | Serious |
19100146 K01 IV – Inform each rescue team or service of the hazards they may confront when called on to perform rescue at the site |
11/18/2014 | 04/17/2015 | $1,960 | $2,800 | 12/10/2014 | F – Formal Settlement |
| 19. | 01014B | Serious |
19100146 K01 V – Provide the rescue team or service selected with access to all permit spaces from which rescue may be necessary so that the rescue service can develop appropriate rescue plans and practice rescue operations |
11/18/2014 | 04/17/2015 | $0 | $0 | 12/10/2014 | F – Formal Settlement |
| 20. | 02001A | Willful |
19100134 G03 VI A – Pressure demand or other positive pressure SCBAs, or a pressure demand or other positive pressure supplied-air respirator with auxiliary SCBA; and either |
11/18/2014 | 04/17/2015 | $9,800 | $14,000 | 12/10/2014 | F – Formal Settlement |
| 21. | 02001B | Willful |
19100146 K02 I – An employer whose employees have been designated to provide permit space rescue and emergency services shall take the following measures |
11/18/2014 | 04/17/2015 | $0 | $0 | 12/10/2014 | F – Formal Settlement |
| 22. | 02002 | Willful |
19100134 H04 – The employer shall ensure that respirators that fail an inspection or are otherwise found to be defective are removed from service, and are discarded or repaired or adjusted in accordance with the following procedures: |
11/18/2014 | 04/17/2015 | $9,800 | $14,000 | 12/10/2014 | F – Formal Settlement |
| 23. | 02003 | Willful |
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; |
11/18/2014 | 04/17/2015 | $9,800 | $14,000 | 12/10/2014 | F – Formal Settlement |
| 24. | 02004 | Willful |
19100146 D05 II – Test or monitor the permit space as necessary to determine if acceptable entry conditions are being maintained during the course of entry operations; and |
11/18/2014 | 04/17/2015 | $9,800 | $14,000 | 12/10/2014 | F – Formal Settlement |
| 25. | 02005A | Willful |
19100146 E01 – Before entry is authorized, the employer shall document the completion of measures required by paragraph (d)(3) of this section by preparing an entry permit. |
11/18/2014 | 04/17/2015 | $9,800 | $14,000 | 12/10/2014 | F – Formal Settlement |
| 26. | 02005B | Willful |
19100146 J02 – Verifies, by checking that the appropriate entries have been made on the permit, that all tests specified by the permit have been conducted and that all procedures and equipment specified by the permit are in place before endorsing the permit and allowing entry to begin |
11/18/2014 | 04/17/2015 | $0 | $0 | 12/10/2014 | F – Formal Settlement |
| 27. | 02006 | Willful |
19100146 K02 IV – Ensure that affected employees practice making permit space rescues at least once every 12 months, by means of simulated rescue operations in which they remove dummies, manikins, or actual persons from the actual permit spaces or from representative permit spaces. Representative permit spaces shall, with respect to opening size, configuration, and accessibility, simulate the types of permit spaces from which rescue is to be performed |
11/18/2014 | 04/17/2015 | $9,800 | $14,000 | 12/10/2014 | F – Formal Settlement |
| 28. | 02007 | Willful |
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 |
11/18/2014 | 04/17/2015 | $49,000 | $70,000 | 12/10/2014 | F – Formal Settlement |

