At approximately 10:40 a.m. on April 2, 2019, the housing of a three-inch Y-strainer of an isobutylene line that fed into reactor K8 ruptured and isobutylene was released, forming a vapor cloud. Three employees responded to mitigate the isobutylene vapor in the reactor area.
As Employee #1 was at an old control room area and Employee #2 was approaching a tank farm area away from reactors K8 and K9, Employee #3 activated the fire water monitor located next to the hot oil area on the West side of the main control room. Shortly after 10:50 a.m., the isobutylene vapor cloud ignited, causing an explosion. Fire spread to a dry storage area. Employee #1 suffered injuries that affected his upper extremity and brachial artery on his right side, killing him. Employees #2 and #3 sustained thermal burns, which they were hospitalized and received treatment.
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Violation Summary
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|---|---|---|---|---|---|
| Serious | Willful | Repeat | Other | Total | |
| Initial Violations | 12 | 12 | |||
| Current Violations | 12 | 12 | |||
| Initial Penalty | $131,274 | $0 | $0 | $0 | $131,274 |
| Current Penalty | $131,274 | $0 | $0 | $0 | $131,274 |
| Violation Items | ||||||||
|---|---|---|---|---|---|---|---|---|
| # | ID | Type | Standard | Issuance | Abate | Curr$ | Init$ | Contest |
| 1. | 01001 | Serious |
19100028 B03 IV – Each employee is protected from falling into a ladderway floor hole or ladderway platform hole by a guardrail system and toeboards erected on all exposed sides, except at the entrance to the hole, where a self-closing gate or an offset must be used. |
09/30/2019 | 10/18/2019 | $6,819 | $6,819 | 10/22/2019 |
| 2. | 01002 | Serious |
19100038 E – An employer must designate and train employees to assist in a safe and orderly evacuation of other employees. |
09/30/2019 | 11/18/2019 | $11,934 | $11,934 | 10/22/2019 |
| 3. | 01003 | Serious | 19100119 D03 I A – Materials of construction | 09/30/2019 | 11/18/2019 | $11,934 | $11,934 | 10/22/2019 |
| 4. | 01004 | Serious | 19100119 D03 I D – Relief system design and design basis | 09/30/2019 | 11/18/2019 | $11,934 | $11,934 | 10/22/2019 |
| 5. | 01005 | Serious |
19100119 D03 II – The employer shall document that equipment complies with recognized and generally accepted good engineering practices. |
09/30/2019 | 01/02/2020 | $11,934 | $11,934 | 10/22/2019 |
| 6. | 01006 | Serious | 19100119 E03 I – The hazards of the process | 09/30/2019 | 01/02/2020 | $11,934 | $11,934 | 10/22/2019 |
| 7. | 01007A | Serious |
19100119 H02 I – The employer, when selecting a contractor, shall obtain and evaluate information regarding the contract employer’s safety performance and programs. |
09/30/2019 | 11/18/2019 | $11,934 | $11,934 | 10/22/2019 |
| 8. | 01007B | Serious |
19100119 H02 V – The employer shall periodically evaluate the performance of contract employers in fulfilling their obligations as specified in paragraph (h)(3) of this section. |
09/30/2019 | 11/18/2019 | $0 | $0 | 10/22/2019 |
| 9. | 01008 | Serious |
19100119 J04 I – Inspections and tests shall be performed on process equipment. |
09/30/2019 | 11/18/2019 | $11,934 | $11,934 | 10/22/2019 |
| 10. | 01009 | Serious |
19100119 L01 – The employer shall establish and implement written procedures to manage changes (except for “replacements in kind”) to process chemicals, technology, equipment, and procedures; and, changes to facilities that affect a covered process. |
09/30/2019 | 12/10/2019 | $11,934 | $11,934 | 10/22/2019 |
| 11. | 01010 | Serious |
19100119 O05 – Employers shall retain the two (2) most recent compliance audit reports. |
09/30/2019 | 11/18/2019 | $5,115 | $5,115 | 10/22/2019 |
| 12. | 01011A | Serious |
19100120 Q01 – 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 OSHA personnel. Employers who will evacuate their employees from the danger area when an emergency occurs, and who do not permit any of their employees to assist in handling the emergency, are exempt from the requirements of this paragraph if they provide an emergency action plan in accordance with 29 CFR 1910.38. |
09/30/2019 | 11/18/2019 | $11,934 | $11,934 | 10/22/2019 |
| 13. | 01011B | Serious |
19100165 B01 – The employee alarm system shall 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. |
09/30/2019 | 11/18/2019 | $0 | $0 | 10/22/2019 |
| 14. | 01012 | Serious |
19100303 B07 I – Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment. |
09/30/2019 | 11/18/2019 | $11,934 | $11,934 | 10/22/2019 |