A polyethylene foam product manufacturing facility has been cited by OSHA with 21 safety violations carrying fines of $128,700. OSHA’s January inspection followed an explosion that resulted in the injury of three workers and significant property damage. The explosion occurred when isobutane gas entered exhaust ductwork associated with the foam extrusion manufacturing process, and it was ignited by the regenerative thermal oxidizer. When OSHA inspected the facility, it found multiple violations of OSHA’s standards for process safety management of highly hazardous chemicals. Seventeen serious violations related to PSM and four additional serious violations for machine guarding, LOTO, and not providing FRC for workers exposed to fire/explosion hazards. Here is a breakdown of the citations:
Process Safety Information
Citation 1 Item 1a
Type of Violation: Serious; $6,500
29 CFR 1910.119(d)(2)(i)(D): Information concerning the technology of the process did not include safe upper and lower limits for such items as temperatures, pressures, flows or compositions.
a. employer’s process safety information did not ensure the safe upper and lower pressures were documented for the resin pressure levels in the foam extruder. If resin levels are too low, isobutane gas can travel upstream and down-stream of the injection point and exit the extruder, causing fires or explosions.
b. employer’s process safety information did not ensure the safe upper and lower limits were documented for the die gap on the foam extruders. If the die gap is too large, isobutane could be ejected out of the extruder and cause a fire or explosion.
Citation 1 Item 1b
Type of Violation: Serious; $0
29 CFR 1910.119(d)(2)(i)(E): Information pertaining to the technology of the process did not include an evaluation of the consequences of deviations, including those affecting the safety and health of employees.
a. employer did not ensure the process safety information included the consequences of deviation for operating the foam extruders with low resin levels. Low resin levels could allow isobutane gas to escape the extrusion barrel, causing fires or explosions.
b. employer did not ensure the process safety information included the consequences of deviation for operating the foam extruders with a large die gap. A large die gap could cause isobutane to escape the extruder barrel and exit the extruder, causing fires or explosions.
Citation 1 Item 2
Type of Violation: Serious; $4,500 29
CFR 1910.119(d)(3)(i)(B): Information pertaining to the equipment in the process did not include piping and instrument diagrams (P&ID’s).
a. employer did not ensure process piping and instrument diagrams (P&IDs) for the high pressure isobutane pumping area were accurate in that the P&ID did not show the low pressure piping supplying isobutane to the second high pressure pump for Line #2 and the high pressure piping leading from the pump to the extruder.
b. employer did not ensure process piping and instrument diagrams (P &IDs) for the high pressure isobutane pumping area were accurate in that the P&ID did not show that an older high pressure pumping system was disconnected from the system.
c. employer did not ensure process piping and instrument diagrams (P &IDs) for the high pressure isobutane pumping area were accurate in that the P &ID did not show the numerous low pressure relief valves located on globe valves throughout the piping system.
Citation 1 Item 3
Type of Violation: Serious; $6,300
29 CFR 1910.119(d)(3)(ii): The employer did not document that equipment complied with recognized and generally accepted good engineering practices.
a. employer did not document that the exhaust system leading to the regenerative thermal oxidizer (RTO), used to remove isobutane vapors generated in the polyethylene foam extrusion process, was capable of operating beneath 25% of the LEL under all conditions, including the maximum loading of all potential sources; that the employer did not document that the exhaust system complied with recognized and generally accepted good engineering practices, in that it did not contain flammable vapor detection equipment or explosion isolation devices to isolate the work area from the RTO. At the time of the explosion on January 25, 2013, the ductwork was not equipped with flammable vapors sensors and explosion isolation devices.
b.employer did not document that the sizing on the relief system for the 18,000 gallon isobutane storage tank complied with recognized and generally accepted good engineering practices.
c. employer did not document that the relieving location for the relief valves on 18,000 gallon isobutane storage tank complied with recognized and generally accepted good engineering practices.
Process Hazards Analysis
Citation 1 Item 4
Type of Violation: Serious; $6,300
29 CFR 1910.119(e)(3)(i): The process hazard analysis did not address the hazards of the process.
a. employer did not ensure the process hazard analysis addressed the hazard of isobutane gas entering the regenerative thermal oxidizer during foam extrusion start-up operations and process upsets, resulting in fire and explosion hazards.
b. employer did not ensure the process hazard analysis addressed the hazard associated with isobutane gas traveling back up stream from the foam extruder injection point and catching fire in the resin feed tube.
c. employer did not ensure the process hazard analysis addressed the hazard of the relief valves on the 18,000 gallon isobutane storage tank located on the north side of the facility, relieving to a safe location. If a large quantity of isobutane vapor were to be relieved through the vessel’s pressure relief devices, the vapors would sink to the ground under the isobutane tank and potentially expose employees to the flammable vapors.
Citation 1 Item 5
Type of Violation: Serious; $6,300
29 CFR 1910.119(e)(3)(iv): The process hazard analysis did not address the consequences of failure of engineering and administrative controls.
a. employer did not ensure the process hazard analysis addressed the failure of engineering controls such as the combustible gas detectors located throughout the facility. The combustible gas detectors are one of the main safety mechanisms used to shut off the flow of isobutane to the process in the case of an emergency.
b. employer did not ensure the process hazard analysis addressed the failure of the combustible gas detectors not detecting isobutane vapors at the beginning of the process due to the environmental chamber doors being open, upsetting the designed ventilation airflow through the room.
c. employer did not ensure the process hazard analysis addressed the failure of the isobutane emergency shutdown system.
Citation 1 Item 6
Type of Violation: Serious; $6,300
29 CFR 1910.119(e)(3)(v): The process hazard analysis did not address facility siting.
a. employer did not ensure facility siting for the environmental capture rooms was addressed in the company’s process hazard analysis. On January 25, 2013, an explosion in the thermal oxidizer sent a flame front down the duct work and into the employee’s work area inside the environmental chambers.
b. employer did not ensure facility siting for the front offices and the main production building was addressed in the company’s process hazard analysis. The front offices are several hundred feet from the 18,000 gallon isobutane storage tank located at the North end of the facility.
Citation 1 Item 7
Type ofViolation: Serious; $6,300
29 CFR 1910.119(e)(3)(vi): The process hazard analysis did not address human factors.
a. employer did not ensure the process hazard analysis addressed human factors such as the employees working in the environmental chambers were unable to see the isobutane warning strobe light located on the east wall of the production area.
b. employer did not ensure the process hazard analysis addressed human factors such as employees not being able to access the e-stops for the isobutane delivery system if there was a fire or explosion.
c. employer did not ensure the process hazard analysis addressed human factors such as employees not being able to identify certain valves mentioned in the operating procedures because the valve identification tags had fallen off the valves in the high pressure pumping area.
Citation 1 Item 8
Type of Violation: Serious; $6,300
29 CFR 1910.119(e)(4): The process hazard analysis was not performed by a team with expertise in engineering and process operations, and the team did not include at least one employee who has experience and knowledge specific to the process being evaluated. Also, one member of the team was not knowledgeable in the specific process hazard analysis methodology being used.
a. employer did not ensure the process hazard analysis was performed by a team of individuals.
b. employer did not ensure the process hazard analysis was performed by an individual knowledgeable in the What-If process hazard analysis methodology.
Citation 1 Item 9
Type of Violation: Serious; $6,300
29 CFR 1910.119(e)(6): At least every five (5) years after the completion of the initial process hazard analysis, the process hazard analysis was not updated and revalidated by a team meeting the requirements in paragraph (e)(4) of this section, to assure that the process hazard analysis is consistent with the current process.
a. employer did not ensure the process hazard analysis was revalidated every 5 years. b. employer did not ensure a previous incident was included in the PHAs which included a 2007 fire in the resin feed tube leading to the foam extruder due to the escape of isobutane gas.
Operating Procedures
Citation 1 Item 10
Type ofViolation: Serious; $6,300
29 CFR 1910.119(f)(1)(i): The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process consistent with the process safety information and did not address steps for each operating phase.
a. employer did not ensure that procedures for the foam extrusion operation, such as but not limited to, start-up procedures, normal operating procedures, emergency shut down procedures, and start-up procedures after an emergency shut down, clearly identified the steps employees needed to take to operate the foam extruders.
Citation 1 Item 11
Type of Violation: Serious; $6,300
29 CFR 1910.119(f)(1)(ii): The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process consistant with the process safety information and did not address operating limits:
a. employer did not ensure that procedures for the foam extrusion operation, such as but not limited to, start-up procedures, normal operating procedures, emergency shut down procedures, and start-up procedures after an emergency shut down, clearly identified consequences of deviation for adding isobutane too quickly to the extruder before there is enough resin downstream of the isobutane injection point.
b. employer did not ensure that procedures for the foam extrusion operation, such as but not limited to, start-up procedures, normal operating procedures, emergency shut down procedures, and start-up procedures after an emergency shut down, clearly identified consequences of deviation for adding isobutane too quickly to the extruder before there is enough resin upstream of the isobutane injection point.
c. employer did not ensure that procedures for the foam extrusion operation, such as but not limited to, start-up procedures, normal operating procedures, emergency shut down procedures, and start-up procedures after an emergency shut down, clearly identified consequences of deviation regarding the size of the die gap.
Citation 1 Item 12
Type of Violation: Serious; $6,300
29 CFR 1910.119(f)(l)(iii)(A): The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process consistent with the process safety information and did not address the properties of, and hazards presented by, the chemicals used in the process.
a. employer did not ensure that procedures for the foam extrusion operation, such as but not limited to, start-up procedures, normal operating procedures, emergency shut down procedures, and start-up procedures after an emergency shut down, clearly identified the safety and health considerations including the properties and fire and explosion hazards presented by the isobutane used in the process.
Citation 1 Item 13
Type of Violation: Serious; $6,300
29 CPR 1910.119(f)(1)(iii)(B): The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process consistent with the process safety information and did not address the precautions necessary to prevent exposure, including engineering controls, administrative controls, and personal protective equipment.
a. employer did not ensure that procedures for the foam extrusion operation, such as but not limited to, start-up procedures, normal operating procedures, emergency shut down procedures, and start-up procedures after an emergency shut down, addressed safety and health considerations including the engineering controls, personal protective equipment, and administrative controls such as:
1. The fire detection and suppression systems used to control a fire at the die head;
2. The static dissipating devices such as the static blowers and the static mats the employees stand on when running the process to eliminate the build-up of static electricity which could ignite flammable isobutane gas;
3. Personal protective equipment such as flame retardant clothing to protect employees from flash fires and explosions when operating the extrusion process.
Training
Citation 1 Item 14a
Type of Violation: Serious; $6,300
29 CFR 1910.119(g)(1(i): Each employee presently involved in operating a process, and each employee before being involved in operating a newly assigned process, was not trained in an overview of the process and in the operating procedures as specified in paragraph (f) of this section. The training did not include emphasis on the specific safety and health hazards, emergency operations including shutdown, and safe work practices applicable to the employee’s job tasks.
a. employer did not ensure assistant extruder operators were properly trained on the isobutane emergency shutdown system, how it operates, and at what levels the combustible gas sensors located throughout the facility activate.
Citation 1 Item 14 b
Type ofViolation: Serious; $0
29 CFR 1910.119(g)(3): The employer did not ascertain that each employee involved in operating a process had received and understood the training required by this paragraph. The employer did not prepare a record which contained the identity of the employee, the date of training, and the means used to verify that the employee understood the training.
a. employer did not ensure assistant extruder operator training was documented.
Mechanical Integrity
Citation 1 Item 15
Type of Violation: Serious; $6,300
29 CFR 1910.119(j)(2): The employer did not establish and implement written procedures to maintain the on-going integrity of process equipment.
a. employer did not ensure a mechanical integrity program was established and implemented for the inspection and testing of the 18,000 gallon isobutane storage tank.
b. employer did not ensure a mechanical integrity program was established and implemented for the inspection and testing of the underground low pressure isobutane piping which carries isobutane from the storage tank to the high pressure pumps.
c. employer did not ensure a mechanical integrity program was established and implemented for the inspection and testing of the high and low pressure isobutane pumps.
d. employer did not ensure a mechanical integrity program was established and implemented for the inspection and testing of the facility’s combustible gas detectors located throughout the facility.
e. employer did not ensure a mechanical integrity program was established and implemented for the inspection and testing of the pressure relief devices on the isobutane storage tank, low pressure piping, and high pressure piping.
f. employer did not ensure a mechanical integrity program was established and implemented for the inspection and testing of the of the isobutane safety shutdown system used to shut down the flow of isobutane from the storage tank in the case of an emergency.
g. employer did not ensure a mechanical integrity program was established and implemented for the inspection and testing of the regenerative thermal oxidizer.
Citation 1 Item 16
Type of Violation: Serious; $4,500
29 CFR 1910.119(j)(4)(i): Inspections and tests were not performed on process equipment.
a. employer did not ensure the 18,000 gallon isobutane storage tank located at the north end of the facility, received adequate inspections per the National Board Inspection Code.
Management of Change
Citation 1 Item 17
Type of Violation: Serious; $6,300
29 CFR 1910.119(l)(1): The employer did not 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.
a. employer did not ensure management of change procedures were developed and implemented prior to installing a second foam extrusion process line and a thermal oxidizer in 2006.
b. employer did not ensure management of change procedures were developed and implemented prior to installing a low pressure isobutane sensor at the isobutane injection point on the extruders in 2007.
Personal Protective Equipment
Citation 1 Item 18
Type of Violation: Serious; $6,300
29 CFR 1910.132(a): Protective equipment, including personal protective equipment for eyes, face, head, and extremities, protective clothing, respiratory devices, and protective shields and barriers, were not provided, used, and maintained in a sanitary and reliable condition wherever it was 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.
a. employer did not ensure employees working around the foam extruders were wearing flame retardant clothing to protect the upper torso, lower torso, and the head from fire and explosion hazards created by the ignition of isobutane gas.
LOTO
Citation 1 Item 19a
Type of Violation: Serious; $6,300
29 CFR 1910.147(c)(4)(i): Procedures shall be developed, documented and utilized for the control of potentially hazardous energy when employees are engaged in the activities covered by this section.
a. employer did not ensure lockout procedures were documented when employees were exposed to struck by hazards while entering the line # 1 foam winding area to perform servicing operations.
Citation 1 Item 19b
Type of Violation: Serious; $0
29 CFR 1910.147(d)(2): The machine or equipment was not turned off or shut down using the procedures established for the machine or equipment. An orderly shutdown was not utilized to avoid any additional or increased hazard( s) to employees as a result of the equipment stoppage.
a. employer did not ensure employees shut down the foam winder on line # 1 prior to performing servicing operations, thereby exposing themselves to struck by hazards and rotating equipment.
Citation 1 Item 19c
Type of Violation: Serious; $0
29 CFR 1910.147( d)(3): All energy isolating devices that were needed to control the energy to the machine or equipment were not physically located and operated in such a manner as to isolate the machine or equipment from the energy source(s).
a. employer did not ensure employees isolated the electrical, pneumatic, and potential energy to the foam winder on line #1 prior to performing servicing operations, thereby exposing themselves to struck by hazards and rotating equipment.
Citation 1 Item 19d
Type of Violation: Serious; $0
29 CFR 1910.147(d)(4)(i): Lockout or tagout devices were not affixed to each energy isolating device by authorized employees. a. employer did not ensure employees attached lockout devices to the electrical, pneumatic, and potential energy isolation points an the line #1 foam winder prior to performing servicing operations, thereby exposing themselves to struck by hazards and rotating equipment.
Citation 1 Item 20
Type of Violation: Serious; $6,300
29 CFR 1910.147(c)(7)(i)(A): Each authorized employee did not receive training in the recognition of applicable hazardous energy sources, the type and magnitude of the energy available in the workplace, and the methods and means necessary for energy isolation and control.
a. employer did not ensure foam line operators were properly trained as authorized employees on the company’s lockout program. Employees were exposed to struck by hazards when entering the line #1 foam winding area to perform servicing operations and were not locking out the equipment prior to entry.
Machine Guarding
Citation 1 Item 21a
Type of Violation: Serious; $6,300
29 CFR 1910.212(a)(1): One or more methods of machine guarding were not provided to protect the operator and other employees in the machine area from hazards such as those created by point of operation, ingoing nip points, rotating parts, flying chips and sparks.
a. employer did not ensure the mandrels for line #2 winder were guarded to prevent employees from contacting the rotating mandrel when working in front of and traveling under the mandrel to start a new roll of foam.
b. employer did not ensure the mandrels for line #2 winder were guarded to prevent employees from being exposed to ingoing nip points between the rotating mandrel and the foam sheet when tucking foam around the mandrels.
c. employer did not ensure the s-wrap machine located on line #2 was properly guarded to prevent employee exposures to the rotating rollers.
d. employer did not ensure the pneumatic holding arm on the indexing mandrel for the line #1 winder was guarded to prevent employees from pinch point and struck by hazards created by the holding arm as it moved into position to secure the end of the mandrel.
e. employer did not ensure the indexing winder for the line #1 foam winding process was properly guarded to prevent employees from being struck by the winder as it indexed.
Citation 1 Item 21b
Type of Violation: Serious
29 CFR 1910.212(a)(3)(ii): The point of operation of machines whose operation exposes an employee to injury, shall be guarded. The guarding device shall be in conformity with any appropriate standards therefor, or, in the absence of applicable specific standards, shall be so designed and constructed as to prevent the operator from having any part of his body in the danger zone during the operating cycle.
a. employer did not ensure the saw was guarded on line #1 to prevent employees from contacting the rotating 10 inch blade when pulling foam from the extruder and through the saw blade.
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