The April 2022 incident that was reported as “two (2) men down on the property” was actually a PRCS accident involving a railcar at the repair facility. IN-OSHA released its findings last month and issued $113,400 to the business. One worker passed away, and the other survived. Here is a breakdown of IN-OSHA’s PRCS citations:
Safety Order 1Item 1
Type of Violation: Serious; $6,300
29 CFR 1910.146(d)(2): Identify and evaluate the hazards of permit spaces before employees enter them:
On or about 4/1/2022, under the permit-required confined space program required by 29 CFR 1910.146(c)(4), the employer did not identify and evaluate the hazards of permit spaces before employees entered Railcar TILX 150459 for the assigned tasks that included inspection, cleaning, etc. with unknown residual amount of molten sulfur, which produces atmospheric hazards associated with hydrogen sulfide and carbon monoxide gases.
Identify all railcars to be entered before each shift and discuss identified hazards with exposed employees prior to start of job task. Recommended hazards to include, but not limited to, safety data sheet information, bump testing pumps, obtaining and proper use of necessary P.P.E., understand the repercussions of exposure to any given hazardous atmosphere, etc.
Safety Order 1 Item 2
Type of Violation: Serious; $6,300
29 CFR 1910.146(d)(5)(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;
On or about 4/1/2022, under the permit-required confined space program required by 29 CFR 1910.146(c)(4), the employer did not evaluate permit space conditions when entry operations were conducted by testing conditions in the permit space to determine if Railcar TILX 150459 entry conditions were acceptable for cleaning technicians to enter the confined space containing unknown residual amount of molten sulfur, which produce hydrogen sulfide and carbon monoxide gases.
Conduct atmospheric testing in accordance with 1910.146 App. B
Safety Order 1 Item 3
Type of Violation: Serious; $6,300
29 CFR 1910.146(d)(5)(ii): Test or monitor the permit space as necessary to determine if acceptable entry conditions are being maintained during the course of entry operations;
On or about 4/1/2022, under the permit-required confined space program required by 29 CFR 1910.146(c)(4), the employer did not evaluate permit space conditions when entry operations conducted by testing or monitoring the permit space as necessary for Railcar TILX 150459 to determine if acceptable entry conditions for cleaning technicians were being maintained during the course of entry operations of the confined space containing unknown residual amount of molten sulfur, which produce hydrogen sulfide and carbon monoxide gases.
Safety Order 1 Item 4
Type of Violation: Serious; $6,300
29 CFR 1910.146(f)(4): The entry permit that documents compliance with this section and authorizes entry to a permit space shall identify the authorized entrants within the permit space, by name or by such other means (for example, through the use of rosters or tracking systems) as will enable the attendant to determine quickly and
accurately, for the duration of the permit, which authorized entrants are inside the permit space;
NOTE: This requirement may be met by inserting a reference on the entry permit as to the means used, such as a roster or tracking system, to keep track of the authorized entrants within the permit space.
The entry permits documented compliance and authorized entry to a permit space did not identify the authorized entrants within the permit space by name or by such other means; entry into railcars for the assigned tasks that included inspection, cleaning, service and/or repair, etc. with potential to expose employees to hazardous materials.
Safety Order 1 Item 5
Type of Violation: Serious; $6,300
29 CFR 1910.146(f)(5): The entry permit that documents compliance with this section and authorizes entry to a permit space shall identify the personnel, by name, currently serving as attendants:
The entry permits documented compliance and authorized entry to a permit space did not identify the personnel, by name, currently serving as attendants: entry into railcars for the assigned tasks that included inspection, cleaning, service and/or repair, etc., with potential to expose employees to hazardous materials.
Safety Order 1 Item 6
Type of Violation: Serious; $6,300
29 CFR 1910.146(f)(6): The entry permit that documents compliance with this section and authorizes entry to a permit space shall identify the individual, by name, currently serving as entry supervisor, with a space for the signature or initials of the entry supervisor who originally authorized entry:
The entry permits documented compliance with 29 CFR 1910.146 and authorized entry to a permit space did not identify the individual, by name, currently serving as entry supervisor, with a space for the signature or initials of the entry supervisor who originally authorized entry into railcars for assigned tasks that included inspection, cleaning, service and/or repair, etc. with potential to expose employees to hazardous materials.
Safety Order 1 Item 7
Type of Violation: Serious; $6,300
29 CFR 1910.146(f)(10): The entry permit that documents compliance with this section and authorizes entry to a permit space shall identify the results of initial and periodic tests performed under paragraph (d)(5) of this section, accompanied by the names or initials of the testers and by an indication of when the tests were performed:
The entry permits documented compliance and authorized entry to a permit space did not identify the results of initial and periodic tests performed under 29 CFR 1910.146(d)(5), accompanied by the names or initials of the tester as required for assigned tasks that included entry into railcars for the purpose of inspection, cleaning, service and/or repair, etc. with potential to expose employees to hazardous materials.
Safety Order 1 Item 8
Type of Violation: Serious; $6,300
29 CFR 1910.146(f)(13): The entry permit that documents compliance with this section and authorizes entry to a permit space shall identify equipment, such as personal protective equipment, testing equipment, communications equipment, alarm systems, and rescue equipment, to be provided for compliance with this section:
The entry permits documented compliance and authorized entry to a permit space did not identify equipment, such as personal protective equipment, testing equipment, communications equipment, alarm systems, and rescue equipment for entry into railcars for the assigned tasks that included inspection, cleaning, service and/or repair, etc. with potential to expose employees to hazardous materials.
Safety Order 1 Item 9a
Type of Violation: Serious; $6,300
29 CFR 1910.146(g)(1): The employer shall provide training so that all employees whose work is regulated by this section acquire the understanding, knowledge, and skills necessary for the safe performance of the duties assigned under this section.
On or about 4/1/2022, the employer did not provide training so that all employees whose work was regulated by 29 CFR 1910.146 (permit required confined spaces) acquired the understanding, knowledge, and skills necessary for the safe performance of the duties assigned under 29 CFR 1910.146 to ensure that the Authorized Supervisor, Safety Attendant, and the Confined Space Entrant each had the understanding, knowledge, and skills necessary to perform assigned task(s) associated with Railcar TILX 150459 for the assigned tasks that included inspection, cleaning, etc. with unknown residual amount of molten sulfur, which produces atmospheric hazards associated with hydrogen sulfide and carbon monoxide gases.
Whenever employees are introduced to hazardous chemicals within a railcar, before entry they should be trained on things such as, but not limited to, the safety data sheet, PPE requirements, atmospheric testing requirements, exposure consequences, etc.
Safety Order 1 Item 9b
Type of Violation: Serious
29 CFR 1910.146(g)(3): 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:
On or about 4.1.2022, the employer did not provide training that established employee proficiency in duties required by 29 CFR 1910.146 (permit required confined spaces), and did not introduce new or revised procedures, as necessary, for compliance in hazards associated with a permit-required confined space entry into a railcar with molten sulfur, which produces atmospheric hazards associated with hydrogen sulfide and carbon monoxide gases before they were tasked with cleaning Railcar TILX 150459, resulting in one employee loss of life and one employee reported to have lifelong disability.
Whenever employees are introduced to hazardous chemicals within a railcar, before entry they should be trained on things such as, but not limited to, the safety data sheet, PPE requirements, atmospheric testing requirements, exposure consequences, etc.
Safety Order 1 Item 10
Type of Violation: Serious; $6,300
29 CFR 1910.146(h)(1): The employer shall ensure that all authorized entrants know the hazards that may be faced during entry, including information on the mode, signs or symptoms, and consequences of the exposure:
On or about 4.1.2022, the employer did not ensure that all authorized entrants knew the hazards that could be faced during entry, including information on the mode, signs or symptoms, and consequences of the exposure to molten sulfur, which produces atmospheric hazards associated with hydrogen sulfide and carbon monoxide gases, before employees were tasked with cleaning Railcar TILX 150459, resulting in one employee loss of life and one employee reported to have lifelong disability.
Identify all railcars to be entered in a given day and go through the hazards with the crew before any work is started. Things to go over should include such as, but not limited to, safety data sheet information, bump testing pumps, obtain necessary P.P.E., understand the repercussions of exposure to any given hazardous atmosphere, etc.
Safety Order 1 Item 11
Type of Violation: Serious; $6,300
29 CFR 1910.146(i)(1): The employer shall ensure that each attendant knows the hazards that may be faced during entry, including information on the mode, signs or symptoms, and consequences of the exposure:
On or about 4.1.2022, the employer did not ensure that each attendant knew the hazards that could be faced during entry, including information on the mode, signs or symptoms, and consequences of the exposure to molten sulfur, which produces atmospheric hazards associated with hydrogen sulfide and carbon monoxide gases, before employees were tasked with cleaning Railcar TILX 150459, resulting in one employee loss of life and one employee reported to have
lifelong disability.
Safety Order 1 Item 12
Type of Violation: Serious; $6,300
29 CFR 1910.146(i)(2): The employer shall ensure that each attendant is aware of possible behavioral effects of hazard exposure in authorized entrants:
On or about 4.1.2022, the employer did not ensure that each attendant was aware of possible behavioral effects of hazard exposure for authorized entrants to molten sulfur, which produces atmospheric hazards associated with hydrogen sulfide and carbon monoxide gases, before employees were tasked with cleaning Railcar TILX 150459, resulting in one employee loss of life and one employee reported to have lifelong disability.
Safety Order 1 Item 13
Type of Violation: Serious; $6,300
29 CFR 1910.146(i)(4): The employer shall ensure that each attendant remains outside the permit space during entry operations until relieved by another attendant:
NOTE: When the employer’s permit entry program allows attendant entry for rescue, attendants may enter a permit space to attempt a rescue if they have been trained and equipped for rescue operations as required by paragraph (k)(1) of this section and if they have been relieved as required by paragraph (i)(4) of this section.
On or about 4/1/2022, the employer did not ensure that the authorized attendant, for Railcar TILX 150456, was equipped with non-entry rescue equipment prior to the authorized entrant making entry.
Provide non-entry rescue equipment for authorized attendants and entrants.
Safety Order 1 Item 14
Type of Violation: Serious; $6,300
29 CFR 1910.146(i)(6): The employer shall ensure that each attendant monitors activities inside and outside the space to determine if it is safe for entrants to remain in the space and orders the authorized entrants to evacuate the permit space immediately under any of the following conditions:
On or about 4/1/2022, the employer did not ensure that the authorized attendant, for Railcar TILX 150456, monitored the permit-required confined space from outside of the space and utilized non-entry rescue procedures.
Provide non-entry rescue equipment for authorized attendants and entrants.
Safety Order 1 Item 15
Type of Violation: Serious; $6,300
29 CFR 1910.146(j)(1): The employer shall ensure that each entry supervisor knows the hazards that may be faced during entry, including information on the mode, signs or symptoms, and consequences of the exposure:
On or about 4/1/2022, the employer did not ensure that each entry supervisor knew the hazards that could be faced during entry, including information on the mode, signs or symptoms, and consequences of the exposure to molten sulfur, which produces atmospheric hazards associated with hydrogen sulfide and carbon monoxide gases, before employees were tasked with cleaning Railcar TILX 150459, resulting in one employee loss of life and one employee reported to have lifelong disability.
Identify all railcars to be entered on a given day and go through the hazards with the crew before any work is started.
Things to go over should include such as, but are not limited to, safety data sheet information, bump testing pumps, obtain necessary P.P.E., understand the repercussions of exposure to any given hazardous atmosphere, etc.
Safety Order 1 Item 16
Type of Violation: Serious; $6,300
29 CFR 1910.146(j)(2): The employer shall ensure that each entry supervisor 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:
On or about 4.1.2022, the employer did not ensure that each entry supervisor verified, by checking that the appropriate entries had been made on the permit, that all tests specified by the permit had been conducted and that all procedures and equipment specified by the permit were in place before endorsing the permit and allowing entry to begin on Railcar TILX 150459, which contained an unknown residual amount of molten sulfur, which produces atmospheric hazards associated with hydrogen sulfide and carbon monoxide gases, resulting in one employee loss of life and one employee reported to have lifelong disability.
Mandate entry supervisors work with the crews to make sure procedural steps are being taken correctly before endorsing permits.
Safety Order 1 Item 17
Type of Violation: Serious; $6,300
29 CFR 1910.146(k)(3)(i): Each authorized entrant shall use a chest or full body harness, with a retrieval line attached at the center of the entrant’s back near shoulder level, above the entrant’s head, or at another point which the employer can establish presents a profile small enough for the successful removal of the entrant. Wristlets may be used in lieu of the chest or full body harness if the employer can demonstrate that the use of a chest or full body harness is infeasible or creates a greater hazard and that the use of wristlets is the safest and most effective alternative:
On or about 4.1.2022, each authorized entrant did not use a chest or full body harness, with a retrieval line attached at the center of the entrant’s back near shoulder level, or above the entrant’s head when tasked with cleaning Railcar TILX 150459, which contained an unknown residual amount of molten sulfur, which produces atmospheric hazards associated with hydrogen sulfide and carbon monoxide gases resulting in one employee loss of life and one employee reported
to have lifelong disability.
Provide non-entry rescue equipment for authorized attendants and entrants.
Safety Order 1 Item 18
Type of Violation: Serious; $6,300
29 CFR 1910.146(k)(4): If an injured entrant is exposed to a substance for which a Material Safety Data Sheet (MSDS) or other similar written information is required to be kept at the worksite, that MSDS or written information shall be made available to the medical facility treating the exposed entrant.
On or about 4/1/2022, Material Safety Data Sheets or other similar written information required to be kept at the worksite were not made available to the medical facility treating entrants exposed to a hazardous substance when tasked with cleaning Railcar TILX 150459, which contained an unknown residual amount of molten sulfur, which produces atmospheric hazards associated with hydrogen sulfide and carbon monoxide gases resulting in one employee loss of life and one employee reported to have lifelong disability.
In an incident of chemical overexposure, medical facilities need accurate information as quickly as possible. Know what railcars are being entered on what days and train everyone to know the hazards associated with the permit entry.
CLICK HERE for the Citations
