The Cal/OSHA Process Safety Management Unit has cited a refinery and three contractors a combined $1,753,375 for serious safety violations following a confined space death of a 35-year-old worker who suffocated in a regenerator overflow well. Cal/OSHA inspectors cited three of the four employers with willful and serious violations after determining that they failed to follow confined space regulations, including the failure to determine acceptable entry conditions for the employee, which resulted in exposure to an oxygen-deficient atmosphere.
Shortly before midnight on November 12, 2021, the worker lost consciousness after descending into a regenerator overflow well at the refinery to evaluate the condition of the well interior and perform cleaning operations in advance of a welding crew. He was found inside the regenerator suspended by fall protection equipment. A refinery emergency rescue team retrieved him. The community Fire Department and Refinery Fire Department performed medical treatment on-site but were unable to resuscitate him.
Inspectors determined that a welding torch was left in the well that was leaking argon, an odorless gas that displaced oxygen inside the confined space.
| Employer Name | Industry | Worksite Location | Proposed Penalties |
|---|---|---|---|
| REMOVED | Petroleum Refinery | Willful Serious: 4 Serious: 5 |
$528,750 |
| REMOVED | Specialty Trade Contractor | Willful Serious: 6 Serious: 7 General: 4 |
$988,000 |
| REMOVED | Masonry Contractor | Willful Serious: 1 Serious: 1 Regulatory: 4 |
$135,500 |
| REMOVED | Other Foundation, Structure, and Building Exterior Contractor |
Serious: 8 General: 3 Regulatory: 5 |
$101,125 |
The violations issued to the refinery were:
Citation 1 Item
Type of Violation: Serious; $16,875
5141(c)(3) Control of Harmful Exposure to Employees
(c) Control by Respiratory Protective Equipment. Respiratory protective equipment, in accordance with Section 5144, shall be used to prevent harmful exposures as follows:
(3) In emergencies.
Violation:
Prior to and during the course of the inspection, including, but not limited to, on November 13, 2021, the employer failed to use respiratory protective equipment, in accordance with Section 5144, to prevent harmful exposures in the emergency confined space rescue performed on November 12, 2021, in the R-702 Regenerator.
Citation 2 Item 1
Type of Violation: Serious; $16,875
5144(d)(1)(C) Respiratory Protection
(d) Selection of respirators. This subsection requires the employer to evaluate respiratory hazard(s) in the workplace, identify relevant workplace and user factors, and base respirator selection on these factors. The subsection also specifies appropriately protective respirators for use in IDLH atmospheres and limits the selection and use of air-purifying respirators.
(1) General requirements.
(C) The employer shall identify and evaluate the respiratory hazard(s) in the workplace; this evaluation shall include a reasonable estimate of employee exposures to respiratory hazard(s) and an identification of the contaminant’s chemical state and physical form. Where the employer cannot identify or reasonably estimate the employee exposure, the employer shall consider the atmosphere to be IDLH.
Violation:
Prior to and during the course of the inspection, including, but not limited to, on November 13, 2021, the employer failed to identify and evaluate the respiratory hazard(s) in the workplace; this evaluation shall include a reasonable estimate of employee exposures to respiratory hazard( s) and an identification of the contaminant’s chemical state and physical form. Where the employer cannot identify or reasonably estimate the employee exposure, the employer shall consider the atmosphere
to be IDLH.
Citation 3 Item 1
Type of Violation: Serious; $16,875
5144(d)(2) (A). Respiratory Protection
[d) Selection of respirators. This subsection requires the employer to evaluate respiratory hazard(s) in the workplace, identify relevant workplace and user factors, and base respirator selection on these factors. The subsection also specifies appropriately protective respirators for use in IDLH atmospheres, and limits the selection and use of air-purifying respirators.
(2) Respirators for IDLH atmospheres.
(A) The employer shall provide the following respirators for employee use in IDLH atmospheres:
1. A full facepiece pressure-demand SCBA certified by NIOSH for a minimum service life of thirty minutes, or
2. A combination full facepiece pressure-demand supplied-air respirator (SAR) with auxiliary self-contained air supply.
Violation:
Prior to and during the course of the inspection, including, but not limited to, on November 13, 2021, the employer failed to evaluate respiratory hazard(s) in the workplace, identify relevant workplace and user factors, and base respirator selection on these factors. Where the employer cannot identify or reasonably estimate the employee exposure, the employer shall consider the atmosphere to be IDLH. The employer failed to provide the following respirators for employee use in IDLH atmospheres:
1. A full facepiece pressure-demand SCBA certified by NIOSH for a minimum service life of thirty minutes, or
2. A combination full facepiece pressure-demand supplied-air respirator (SAR) with auxiliary self-contained air supply.
Instances of this violation include, but may not be limited to, the following:
Rescuers not using SCBA, Respiratory protection during the initial atmospheric testing of the confined space during the course of R-702 Rescue Operations on or about November 12, 2021.
The second and third gas testing, after the report of an employee, feeling dizzy inside of the Regenerator Overflow Tube located in the R-702 Regenerator on or about November 19, 2021
Citation 4 Item 1
Type of Violation: Serious; $16,875
5144(g)(3)(A). Respiratory Protection
(3) Procedures for IDLH atmospheres. For all lDLH atmospheres, the employer shall ensure that:
(A) One employee or, when needed, more than one employee is located outside the IDLH atmosphere;
Violation:
Prior to and during the course of the inspection, including, but not limited to, on November 13, 2021, the employer failed to ensure that one employee or, when needed, more than one employee is located outside the IDLH atmosphere. Instances of this violation include, but may not be limited to, the following:
The second and third gas testing, after the report of an employee feeling dizzy inside of the Regenerator Overflow Tube located in the R-702 Regenerator on or about November 19, 2021
Citation 5 Item 1
Type of Violation: Serious; $16,875
5144(g)(3)(B). Respiratory Protection
(3) Procedures for IDLH atmospheres. For all lDLH atmospheres, the employer shall ensure that:
(B) Visual, voice, or signal line communication is maintained between the employee(s) in the IDLH atmosphere and the employee(s) located outside the IDLH atmosphere;
Violation:
Prior to and during the course of the inspection, including, but not limited to, on November 13, 2021, the employer failed to ensure that communication is maintained between employees in the IDLH atmosphere and employees located outside the IDLH atmosphere. Instances of this violation include, but may not be limited to, the following:
The second and third gas testing, after the report of an employee feeling dizzy inside of the Regenerator Overflow Tube located in the R-702 Regenerator on or about November 19, 2021
Citation 6 Item 1
Type of Violation: Willful-Serious; $112,500
5157(c)(1). Permit-Required Confined Spaces.
(c) General requirements.
(1) The employer shall evaluate the workplace to determine if any spaces are permit-required confined spaces.
Violation:
Prior to and during the course of the inspection, including, but not limited to, on November 13, 2021, the employer failed to evaluate the workplace to determine if any spaces are permit-required confined spaces. Instances of this violation include, but may not be limited to, the R-702 overflow well located inside the of R-702 Regenerator
Citation 7 Item 1
Type of Violation: Willful-Serious; $112,500
5157(d)(4)(I). Permit-Required Confined Spaces.
(d) Permit-required confined space program (permit space program). Under the permit required confined space program required by subsection (c)(4), the employer shall:
(4) Provide the following equipment (specified in subsections (A) through (I), below) at no cost to employees, maintain that equipment properly, and ensure that employees use that equipment properly:
(I) Any other equipment necessary for safe entry into and rescue from permit spaces. Prior to and during the course of the inspection, including, but not limited to, on November 13, 2021, the employer failed to ensure that employees use equipment properly during the Emergency and Rescue of an employee from the R-702 Regenerator Down Tube. Instances of this violation include, but may not be limited to, the following:
Rescuers not using SCBA, Respiratory protection during the initial atmospheric testing of the confined space.
Rescuers not using Fall Protection Harnesses during the course of R-702 Rescue Operations.
Rescuers using a previously shock loaded Self Retracting Lanyard (Model# 10121778 and SN# 131008657) as a secondary Belay Device during a victim recovery using a rope retrieval system.
Citation 8 Item 1
Type of Violation: Willful-Serious; $112,500
5157(d)(5)(A). Permit-Required Confined Spaces
(5) Evaluate permit space conditions as follows when entry operations are conducted:
(A) 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;
Violation:
Prior to and during the course of the inspection, including, but not limited to, on November 12, 2021 and November 19, 2021, the employer failed to evaluate permit space conditions as follows when entry operations are conducted: Employer failed to test conditions in the R-702 Regenerator Overflow Well to determine if acceptable entry conditions exist before entry is authorized to begin. The employer failed to perform pre-entry testing to the extent feasible before entry is authorized. The employer failed to continuously monitor entry conditions in the areas where authorized entrants are working at R-702 Regenerator Overflow Well jobsite
Citation 9 Item 1
Type of Violation: Willful-Serious; $112,500
5157(d)(5)(B). Permit-Required Confined Spaces
(d) Permit-required confined space program (permit space program). Under the permit required confined space program required by subsection (c) (4), the employer shall:
(5) Evaluate permit space conditions as follows when entry operations are conducted:
(B) Test or monitor the permit space as necessary to determine if acceptable entry conditions are being maintained during the course of entry operations,
Violation:
Prior to and during the course of the inspection, including, but not limited to, on November 12, 2021 and November 19, 2021, the employer failed to evaluate permit space conditions as follows when entry operations are conducted: Employer failed to test or monitor the permit space as necessary to determine if acceptable entry conditions are being maintained during the course of entry operations at R-702 Regenerator Overflow Well jobsite
