CAL-OSHA cites refinery $963,200 (PSM)

Cal-OSHA issued 25 citations against a refinery with proposed penalties totaling $963,200, for state safety standard violations related to the August 6, 2012 fire at the refinery. The citations include eleven “willful serious” and twelve “serious” violations, resulting in the highest penalties in Cal-OSHA’s history. The penalties against the refinery are the highest allowed under state law. Cal-OSHA investigators found willful violations in the refinery’s response before, during and after the fire.   Here is a breakdown of the issues:

On August 6, 2012, a fire broke out at the refinery when a severely corroded pipe in the #4 Crude Unit began leaking. Refinery managers did not shut down the unit but instructed workers to remove insulation, which led to the pipe’s rupture and a massive fire. While there were no serious worker injuries, a reported 15,000 residents of surrounding communities sought treatment after breathing emissions from the fire.  Cal-OSHA immediately launched an investigation into the fire and the leak repair procedures throughout the refinery, and found the following:

• Refinery did not follow the recommendations of its own inspectors and metallurgical scientists to replace the corroded pipe that ultimately ruptured and caused the fire. Those recommendations dated back to 2002.
• Refinery did not follow its own emergency shutdown procedures when the leak was identified, and did not protect its employees and employees of a scaffolding contractor who were working at the leak site.

Twenty-three violations were classified as “serious” due to the realistic possibility of worker injuries and deaths in the fire. Eleven of these serious violations were also classified as “willful” because Cal-OSHA found the refinery did not take reasonable actions to eliminate refinery conditions that it knew posed hazards to employees, and because it intentionally and knowingly failed to comply with state safety standards.

The “willful serious” violations include the following:

• Refinery did not follow its own policies or act on repeated recommendations to replace the corroded pipe that ultimately ruptured; 
• Refinery did not test pipe thickness in areas identified as susceptible to corrosion and leaks because of the high temperature and high-sulfur content of the crude oil;
• Refinery did not implement its own emergency procedures to shut down the Crude Unit where the leak occurred, and exposed workers to harm by directing them to remove insulation;
• Refinery did not recognize the potential for a catastrophic release of ignitable diesel fuel from the leaking pipe, and ordered contractor employees to erect a scaffold at the leak site;
• Refinery allowed workers to enter the hazardous incident zone without proper personal protective equipment;
• Refinery had pervasive violations in its leak repair procedures throughout the refinery. Cal-OSHA investigators identified leaks in pipes that the refinery had clamped as a temporary fix. In some cases the clamps remained in place for years, rather than replacing the pipes themselves.

There were also violations in the refinery’s overall implementation of its own “process safety management” (PSM) procedures.  PLEASE NOTE I am NOT listing all citations below; only those directly related to the incident and Process Safety.  The link at the bottom of the page will provide access to ALL citations.

8 CCR 5155(e) Workplace Monitoring (General; $1350)

• Whenever it is reasonable to suspect that employees may be exposed to concentrations of airborne contaminants in excess of levels permitted in section 5155(c), the employer shall monitor (or cause to have monitored) the work environment so that exposures to employees can be measured or calculated.
• On August 6, 2012, the Employer failed to monitor the work environment for an uncontrolled leak of petroleum hydrocarbons located within the 4 Crude Unit so that exposures of employees to concentrations of airborne contaminants identified in 5155(c) (i.e. toluene, benzene, xylenes, particulates, etc.) could be measured or calculated.

8 CCR 5189(d)(3)(A)(2)- Information pertaining to the equipment in the process (General; $1350)

(A) Information pertaining to the equipment in the process shall include at least the following:

2. Piping and instrument diagrams (P&ID’s);

• The Employer’s piping and instrument diagrams (P&ID”s) Failed to include information pertaining to the guided wave monitoring devices on the 8-inch #4 side-cut line located on the C-llOO Column in Crude Unit #4.

8 CCR 1511. General Safety Precautions. (Serious; $25,000)
Prior to the presence of its employees, the employer shall make a thorough survey of the conditions of the site to determine, so far as practicable, the predictable hazards to employees and the kind and extent of safeguards necessary to prosecute the work in a safe manner in accordance with the relevant parts of Plate A-2-a and b of the Appendix

• On August 6, 2012, the Employer responsible for safety and health conditions at the work site, failed to make a thorough survey of the conditions of the site to determine, so far as practicable, the predictable hazards and the kind and extent of safeguards necessary to prosecute the work in safe manner which would protect contractor employees during the erection of scaffolding at the source of an uncontrolled leak of petroleum hydrocarbons located underneath piping insulation located within the 4 Crude Unit.

8CCR 5141(a)-(c) (Serious; $25,000)
8CCR 5141 (a) Engineering Controls. Harmful exposures shall be prevented by engineering controls whenever feasible. (b) Administrative Controls.
Whenever engineering controls are not feasible or do not achieve full compliance, administrative controls shall be implemented if practicable. (c) Control by Respiratory Protective Equipment. Respiratory protective equipment, in accordance with Section 5144, shall be used to prevent harmful exposures as follows:
(1) During the time period necessary to install or implement feasible engineering controls;
(2) Where feasible engineering controls and administrative controls fail to achieve full compliance; and
(3) In emergencies.

• On August 6, 2012, the Employer failed to prevent harmful exposures to employees by failing to implement effective engineering controls, administrative controls, or by requiring the use of respiratory protective equipment for refinery employees and contract employees located in direct vicinity of an uncontrolled leak of petroleum hydrocarbons located within the 4 Crude Unit.

8CCR 5189(e) Process Hazard Analysis. (Serious; $25,000)
(1) The employer shall perform a hazard analysis appropriate to the complexity of the process for identifying, evaluating, and controlling hazards involved in the process and shall determine and document the priority order for conducting process hazard analyses based on the extent of process hazards, number of potentially affected employees, age of the process and process operating history, using at least one of the following methodologies.
(A) What-If;
(B) Checklist;
(C) What-If/Checklist;
(D) Hazard and Operability Study (HAZOP);
(E) Failure Mode and Effects Analysis (FMEA); or
(F) Fault-Tree Analysis.

• The Employer failed to perform an effective Process Hazard Analysis of the 4 Crude Unit. Specifically, it failed to identify, evaluate and control potential hazards caused by upstream and downstream units that provide and receive feed from the #4 Crude Unit.

8 CCR 5189(l)(2)(A) – Management of Change. (Serious; $25,000)
(2) The procedures shall assure that the following are addressed prior to any change:
(A) The technical basis for the proposed change;
(B) Impact of change on safety and health

• The Employer failed to address in writing in the Management of Change (MOC number 25789) completed on November 21, 2012, the technical basis for the change and the impact of the change on safety and health with regard to changing the 8-inch section of pipe from carbon steel to 9 Chrome piping on the 4 Sidecut line located within the 4 Crude Unit.

8CCR 5192 (q)(3)(D) (Serious; $25,000)
Employees engaged in emergency response and exposed to hazardous substances presenting an inhalation hazard or potential inhalation hazard shall wear positive pressure self-contained breathing apparatus (SCBA) while engaged in emergency response, until such time that the individual in charge of the IeS determines through the use of air monitoring that a decreased level of respiratory protection will·not result in hazardous exposures to employees.

• On August 6,2012, an emergency responder, the engineer in charge on Engine Foam Truck 60, was operating a fire monitor in the direct vicinity of an uncontrolled release of petroleum hydrocarbons located in the 4 Crude Unit. This responder was not wearing a positive pressure self-contained breathing apparatus (SCBA).

8CCR 5192(q)(3)(E) (Serious; $25,000)
(E) The individual in charge of the ICS shall limit the number of emergency response personnel at the emergency site in those areas of potential or actual exposure to incident or site hazards, to those who are actively performing emergency operations. However, operations in hazardous areas shall be performed using the buddy system in groups of two or more.

• On August 6, 2012, the Employer’s incident commander failed to limit the number of personnel in the direct vicinity of an uncontrolled leak of petroleum hydrocarbons that expanded into a catastrophic event within the 4 Crude Unit, in that multiple employees not actively performing emergency operations were present in areas of potential or actual exposure to incident or site hazards.

3203(a)(2). Injury and Illness Prevention Program. (Willful; $70,000)
(a) Effective July 1, 1991, every employer shall establish, implement and maintain an effective Injury and Illness Prevention Program (Program). The Program shall be in writing and, shall, at a minimum: (2) Include a system for ensuring that employees comply with safe and healthy work practices. Substantial compliance with this provision includes recognition of employees who follow safe and healthful work practices, training and retraining programs, disciplinary actions, or any other such means that ensures employee compliance with safe and healthful work practices.

• The Employer’s Injury and Illness Prevention Program was not effectively implemented, because on August 25, 2012, the employer failed to ensure that employees were following the refinery’s safe work procedures for access to the fire-damaged restricted area, which was also designated by Cal/OSHA as an Order to Preserve zone. Employees did not follow the safe work procedures jointly established by the refinery and CallOSHA and entered the restricted area carrying a rolling ladder to take a lower explosive limit (LEL) gas sample at the hole in the C-llOO 4 Sidecut piping located within the 4 Crude Unit.

3203(a)(6)(B). Injury and Illness Prevention Program. (Willful; $70,000)
(a) Effective July 1, 1991, every employer shall establish, implement and maintain an effective Injury and Illness Prevention Program (Program). The Program shall be in writing and, shall, at a minimum: (6) Include methods and/or procedures for correcting unsafe or unhealthy conditions, work practices and work
procedures in a timely manner based on the severity of the hazard: (B) When an imminent hazard exists, which cannot be immediately abated without endangering employee(s) and/or property, remove all exposed personnel from the area except those necessary to correct the existing condition. Employees necessary to correct the hazardous condition shall be provided the necessary safeguards.

• The employer’s Injury and Illness Prevention Program was not effectively implemented, because on August 25, 2012, the Employer failed to prohibit employees from entering a fire-damaged restricted area where imminent hazards existed as a result of the August 6, 2012 fire within the 4 Crude Unit. The restricted area was also designated by Cal/OSHA as an Order to Preserve zone. Employees were instructed to breach the red “danger” tape barricades that designated the restrictive area. Employees entered the restricted area carrying a rolling ladder to take a lower explosive limit (LEL) gas sample at the hole in the C-llOO 4 Sidecut piping located within the 4 Crude Unit.

8CCR 3383(b). Body Protection. (Willful; $70,000)
8CCR 3383(b) Clothing appropriate for the work being done shall be worn. Loose sleeves, tails, ties, lapels, cuffs, or other loose clothing which can be entangled in moving machinery shall not be worn.

• On August 6, 2012, the Employer responsible for safety and health conditions at the work-site, failed to ensure that contract employees, who were erecting scaffolding to provide access to the leaking 4 Sidecut piping located within the 4 Crude Unit, were wearing clothing appropriate for the work that would protect the contract employees from the hazards of uncontrolled leaking petroleum hydrocarbons exceeding 600 degrees Fahrenheit, including potential thermal burns.

8CCR 5144(c)(1)(D) Respiratory Protection Program. (Willful; $70,000)
In any workplace where respirators are necessary to protect the health of the employee or whenever -respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite-specific procedures. The program shall be updated as necessary to reflect those changes in workplace conditions that affect respirator use. The employer shall include in the program the following provisions, as applicable: (D) Procedures for proper use of respirators in routine and reasonably foreseeable emergency situations.

• On August 6, 2012, the Employer failed to implement the requirements of its respiratory protection program for proper use of respirators in routine and reasonably foreseeable emergency situations while responding to an uncontrolled petroleum hydrocarbon leak located within the 4 Crude Unit as follows:

1. 1. as the Employer responsible for safety and health conditions at the work-site, failed to ensure that contract employees were using respiratory protection where reasonably foreseeable exposures to leaking petroleum hydrocarbons existed during the erection of scaffolding to provide access to the source of the leak.
   2. the Employer failed to ensure that employees who were not part of the emergency response to an uncontrolled petroleum hydrocarbon leak located within the 4 Crude Unit, but were working in the direct vicinity of the leak were using respiratory protection where reasonably foreseeable exposures to leaking petroleum hydrocarbons existed. Several non-incident response employees working in the vicinity of the 4 Crude Unit were engulfed in a dense vapor cloud without respiratory protection.

8CCR 5189(f)(1)(A)(4) Operating Procedures. (Willful; $70,000)
(1) The employer shall develop and implement written procedures that provide clear instructions for safely conducting activities involved in each process consistent with the process safety information and shall address at least the following:
(A) Steps for each operating phase:
4. Emergency operations, including emergency shutdowns, and who may initiate these procedures;

• On August 6, 2012, the Employer failed to implement its Emergency Procedure, 4CU-XE-103 (” C-llOO Overhead Small Leak, No Fire or Small Leak, Small Fire”) to shutdown the 4 Crude Unit where an uncontrolled hydrocarbon leak was located underneath the #4 side-cut piping insulation. Instead of using this Emergency Procedure, which was developed precisely for this type of event, the Employer took an offensive action using a pike pole and fire hoses to pry and blast the insulation from the pipe.

8CCR 5189(f)(l)(C) Operating Procedures. (Willful; $70,000)
The employer shall develop and implement written procedures that provide clear instructions for safely conducting activities involved in each process consistent with the process safety information and shall address at least the following:
(C) Safety and Health Considerations:
1. Properties of, and hazards presented by, the chemicals used in the process;
2. Precautions necessary to prevent exposure, including administrative controls, engineering controls, and personal protective equipment;
3. Control measures to be taken if physical contact or airborne exposure occurs;
4. .safety procedures for opening process equipment (such as pipeline breaking).
5. Verification of raw materials and control of hazardous chemical inventory levels; and,
6. Any special or unique hazards.

• On August 6, 2012, the Employer failed to implement its own written procedures to prevent exposure consistent with the Employer’s process safety information to respond to an uncontrolled petroleum hydrocarbon leak located within the 4 Crude Unit, as follows:

1. 1. The Employer failed to shutdown the 4 Crude Unit consistent with engineering controls outlined in the Emergency Procedure “C-lIOO Overhead Small Leak, No Fire or Small Leak, Small Fire – 4CU-XE-103”; 
   2. The Employer, after deciding to not shut down the 4 Crude Unit, failed to perform a Joint Job Site Visit (JJSV), Job Hazard Analysis (JHA), and Health and Safety Evaluation (HSE) consistent with the Employer’s administrative controls, which are required by the Employer’s written safety programs, prior to responding to the leak;
   3. the employer responsible for safety and health conditions at the work site, supervising contractor employees, failed to abide by its own Stop Work Authority program when contractor employees raised concerns about the hazardous conditions present at the work site and ordered the contractor employees to continue.
   4. The Employer failed to ensure that personal protective equipment was adequate and used by all exposed refinery employees and contractor employees prior to engaging in response efforts; and
   5. The Employer failed to utilize available information pertaining to the unique hazards identified from past piping inspections related to the piping condition prior to engaging in response efforts for the uncontrolled leak.

8 CCR 51890) (3) Mechanical Integrity. Equipment Deficiencies. (Willful; $70,000)
0)(3) Equipment deficiencies. The employer shall correct deficiencies in equipment which are outside acceptable limits defined by the process safety information in subsection (d) before further use, or in a safe and timely manner provided means are taken to assure safe operation.

• The Employer failed to correct deficiencies in its high-temperature 4 Sidecut piping located within the 4 Crude Unit that were identified by its Reliability Department after conducting inspection and testing in accordance with recognized and generally accepted good engineering practices, with the American Petroleum Institute document, RP 939C “Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries,” and with the Employer’s own guidelines, entitled, “Corrosion Mitigation Plan 2006 and Updated Inspection Strategies for Preventing Sulfidation Corrosion Failures in XXXXXXX Refineries.” The Employer failed to replace the 4 Sidecut line located within the 4 Crude Unit, in accordance with recommendations received from its Reliability Department as early as 2002.

8 CCR 5192(q)(2). Emergency Response to Hazardous Substance Releases. (2) Elements (Willful; $70,000)
(1) Emergency response plan: An emergency response plan shall be developed and implemented to handle anticipated emergencies prior to the commencement of emergency response operations. The plan shall be in writing and available for inspection and copying by employees, their representatives, and Division
personnel.
(2) Elements of an emergency response plan: The employer shall develop an emergency response plan for emergencies which shall address, as a minimum, the following to the extent that they are not addressed elsewhere:
(A) Pre-emergency planning and coordination with outside parties.
(B) Personnel roles, lines of authority, training and communication.
(C) Emergency recognition and prevention
(D) Safe distances and places of refuge
(E) Site security and control
(F) Evacuation routes and procedures
(8) Decontamination
(I) Emergency alerting and response procedures
(K) Personal protective equipment (PPE) and emergency equipment

• On August 6, 2012, the Employer failed to implement its emergency response plan for an uncontrolled petroleum hydrocarbon leak located within the 4 Crude Unit. The Employer, specifically, failed to address and implement the following elements in the plan prior to commencement of emergency operations:

1. 1. Personnel roles, lines of authority, training, and communication: Lines of authority were unclear regarding when the unit would be shutdown and actions which could disturb the leaking pipe would cease. Firefighters used a pike pole and then fire hoses to remove insulation off of a leaking pipe while it was on line and under pressure. Emergency shutdown of the unit was not initiated until after a major release and fire occurred. Emergency responders were not clear regarding what frequency they were to communicate on.
   2. Emergency recognition and prevention: The Employer failed to recognize the potential for a large release of ignitable hydrocarbon liquid, aerosol and vapor from a pressurized leaking pipe-line during the erection of the scaffolding or from the offensive actions using a pike pole and fire hoses to pry and blast the insulation from the pipe.
   3. Safe distances and places of refuge: The exclusion zone was not sized adequately to provide safe distances to protect all employees in the area from the release of hydrocarbon aerosol and vapor.
   4. Site security and control: Access to the leak area was not adequately controlled. Individuals not actively performing response actions were allowed close access to the source of the leak. 
   5. Decontamination: Decontamination equipment, such as deluge showers, was not staged in appropriate locations. One employee, soaked with hydrocarbon in the release, was hosed off with a water hose that was located after his exposure.
   6. Personal protective equipment: Requirements for protective clothing and respirators were not adequately planned or implemented. When the release expanded, many employees were not protected by respiratory protection and were engulfed in a dense hydrocarbon mist and vapor cloud. This cloud later ignited.

8CCR 6845. Piping, Fittings, and Valves. (Willful; $70,000)
8 CCR 6845(a)(1). Excluded and optional piping systems specified in Section 1.2.2 of API 570-2003, are subject to inspection and testing by the employer in accordance with good engineering practices. Reference 8 CCR 5189G)(2)(B). Inspection and testing procedures shall follow recognized and generally
accepted good engineering practices.

• The Employer failed to conduct inspection and testing of its high-temperature 4 Sidecut piping located within the 4 Crude Unit in accordance with recognized and generally accepted good engineering practices, with the American Petroleum Institute document, RP 939C, “Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries,” and with the Employer’s own guidelines, entitled, “Corrosion Mitigation Plan 2006 and Updated Inspection Strategies for Preventing Sulfidation Corrosion Failures in XXXXXXXX Refineries.” Both guidelines recommend that 100 percent of areas of vulnerability be inspected to identify damaged mechanisms.

T8CCR5189G)(3). Process Safety Management of Acutely Hazardous Materials. (Serious; $6,750)
Equipment deficiencies. The employer shall correct deficiencies in equipment which are outside acceptable limits defined by the process safety information in subsection (d) before further use, or in a safe and timely manner provided means are taken to assure safe operation.

• On or before 08/30112 the Employer failed to ensure that every broken or damaged electrical conduit, fitting, receptacle, or vapor proof light fixture installed at each processing unit in the refining plant was effectively repaired or replaced in a timely manner.

T8CCR5189(1).Process Safety Management of Acutely Hazardous Materials. (Willful; $70,000)
(1) The employer shall establish and implement written procedures to manage changes (except for “replacement in kind”) to process chemicals, technology, and equipment, and changes to facilities.
(2) The procedures shall assure that the following are addressed prior to any change:
(A) The technical basis for the proposed change;
(B) Impact of change on safety and health;
(C) Modifications to operating procedures;
(D) Necessary time period for the change; and,
(E) Authorization requirements for the proposed change.

• As of the September 2012 dates indicated below, the Employer had not implemented its written procedures with regard to (A) Technical basis for the change, and (D) Necessary time period for the change, for the following three changes to its facilities.
• As of September 12, 2012, MOC (Management of Change) number 16210, an injection fitting seal of a leak in a 3 inch block valve controlling flow at the east natural gas split at furnace F-305C on the 4th deck in South Isomax was in place 13 months beyond its MOC expiration date. The necessary time period for the change was not implemented.
• As of Se ptember 27, 2012, MOC number 18408, a globe valve injection fitting on the 1SIC to 2 SIC on a 400 degree hydrocarbon line in the D&R 4 Crude plant was 2 years and 7 months beyond its MOC expiration date. The necessary time period for the change was not implemented.
• As of September 27, 2012, MOC number 21513, an injection fitting for valve packing on a motor operated valve controlling the flow of 600 psi flammable product at the base of V-4030A in the D&R PenHex area had been in place since January, 2010. It was not replaced, as recommended in the MOC, at the next opportunity. In the technical basis for the change, the maximum time period before replacement was stated to be 5 years.

T8CCR6773(b). Fire Protection and Fire Fighting Equipment. (Serious; $6750)
(b) Fire protection and fire fighting equipment shall be inspected, tested and maintained in serviceable condition. A record shall be kept showing the date when fire extinguishers and hose lines were last inspected, tested, repaired, or renewed. Fire protection and fire fighting equipment after any use shall promptly be made serviceable and restored to its proper location.

• On or before 08/30/2012, the Employer failed to inspect, test, and maintain a section of an exposed fire service main, thus leaving it in a non-serviceable condition. Fire protection systems served by this fire service main \ include onsite fire hydrants and fixed monitor nozzles strategically placed to provide fire protection in the following areas: Flare gas recovery compressor, C-730 and associated furnace, north and south flare areas, cooling water tower, and the east side of TKN and RLOP plants.  As of September 20, 2012, the fire service main remained in a non-serviceable condition.

T8CCR6845(a). Piping, Fittings, and Valves. (Willful; $70,000)
(a) The design, fabrication, and assembly of piping systems installed prior to July 26, 2006, shall comply with General Industry Safety Orders and ASME B31.3- 1990, Chemical Plant and Petroleum Refinery Piping herein incorporated by reference. The design, fabrication, and assembly of piping systems installed on or after July 26, 2006, and the testing, inspection, and repair of all piping systems shall comply with Article 146 of the General Industry Safety Orders; API 570, Piping Inspection Code, Second Edition, October 1998, Addendum 3, August 2003; and ASME B31.3-2002, Process Piping; herein incorporated by reference.

• As of September, 2012, dates indicated, a total of nine temporary nonwelding repairs identified below were not removed at the most recent turnaround:

1. 1. MOC number 20968, a clamp covering two flanges and a valve at the outlet of furnace F-340 in South Isomax., conveying hot (> 600 deg F) natural gas. As of September 12, 2012, this was in place 2 years and 6 months past its last turnaround.
   2. MOC number 18856, a valve packing injection fitting for a valve conveying natural gas to furnace F305 in South Isomax. As of September 18, 2012, this had been in place 30 months past its last turnaround.
   3. MOC number 16210, an injection fitting in a block valve for the F 305 east split in South Isomax, conveying hot (>600 deg F) natural gas. As of September 12, and 18, 2012. It had been in place for 6 years and was 30 months beyond the last turnaround.
   4. MOC number 17395, a clamp covering the mating surface edge of two flanges for a feed gas orifice for furnace F 305 in South Isomax, conveying natural gas. As of September 12, 2012, it was still in place more than 5 years later and 30 months past the last turnaround.
   5. MOC number 19758, a clamp enclosing an elbow at Stanchion A6 overhead in the TKN plant of North Isomax, conveying nitrogen at up to 200 psi. As of September 20, 2012. was still in place 2 years and 7 months past the last turnaround.
   6. MOC number 21513, an injection fitting in a valve on a 6 inch line conveying flammable liquid/vapor at the base of V-4030A in D & R PenHex. As of September 27, 2012, was still present 11 months beyond the last turnaround maintenance opportunity.
   7. MOC number 21434,a valve packing injection fitting at 40 MOV inlet block valve for drier V4030A in D&R, PenHex, conveying hydrogen. As of September 27, 2012, this was still present 11 months beyond the last turnaround maintenance opportunity.
   8. MOC number 18408, a globe valve injection fitting at on the 1 SIC to 2 SIC on the D-308312 line in D&R unit, 4 Crude plant, conveying hydrocarbon at 400 deg F. 300 psi. As of September 27. 2012, this fitting was in place for 4 years, 5 months and was still present 11 months past the most recent turnaround.
   9. MOC number 15197. consisting of3 injection fittings, two for packing and one for a flange, on LT 92 top block valve to V4090. conveying Cl to C5 hydrocarbons and and chlorine. M of September 27, 2012, these three injection fittings were still present, 7 years later, and 1 year and 8 months past the most recent turnaround.

CLICK HERE for a listing of ALL the citations involved with this accident inspection.