A global manufacturer of industrial gas could have prevented a May 2023 explosion that severely injured several employees by following required operating procedures in the manufacturing process where diborane — a toxic, colorless, and pyrophoric gas — is produced, distilled, mixed, and transferred.
OSHA determined the explosion occurred as a 25-year-old product technician used a heat gun to transfer gas from an aluminum source cylinder to a steel cylinder. The blast propelled the worker through the building’s wall, causing severe injuries. They were flown to a Hospital’s trauma center and treated for brain injuries, third-degree burns, and a leg amputation. Four other workers suffered various injuries and were treated at the hospital. In addition, first responders aiding in the employees’ rescue suffered chemical burns to their hands and necks and were taken to the Hospital Burn Center.
After its investigation, OSHA cited the business for willfully exposing workers to fire and explosion hazards by requiring them to use equipment not intrinsically safe in the presence of flammable chemicals and vapors. OSHA proposed $201,573 in penalties to address the safety violations found in the investigation. The agency also cited the employer for 12 serious violations for the following failures:
The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury or illness.
Citation 1 Item 1a
Type of Violation: Serious; $10,938
29 CFR 1910.119(d)(1)(vi): Process safety information (PSI) pertaining to the hazards of the highly hazardous chemicals in the process did not contain thermal and chemical stability data of the chemicals used in the process:
a) On or about May 4, 2023, process safety information for the processes of synthesizing, purification, transfilling (mixing), etc. of Diborane and its mixtures did not contain information on the thermal degradation and reactivity of the product during the manufacturing. The facility failed to stipulate temperature limits for the aluminum vessels and for the chemical(s) inside the vessels. Employees working on and in the vicinity of equipment containing highly hazardous chemicals were exposed to fire, explosion, respiratory and contact hazards.
Citation 1 Item 1b
Type of Violation: Serious
29 CFR 1910.119(d)(2)(i)(D): Process safety information pertaining to the technology of the process did not include the safe upper and lower limits for such items as temperatures, pressures, flows or compositions:
a) On or about May 4, 2023, process safety information was incomplete; in that the documents provided did not properly include safe upper and lower limits for temperatures concerning vessels used in the process of synthesizing, purification, transfilling (mixing), etc. of Diborane and its mixtures. The facility failed to stipulate temperature limits for the aluminum vessels and for the chemical(s) inside the vessel. Employees working on and in the vicinity of equipment containing highly hazardous chemicals were exposed to fire, explosion, respiratory and contact hazards.
Citation 1 Item 1c
Type of Violation: Serious
29 CFR 1910.119(d)(2)(i)(E): Information concerning 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) On or about May 4, 2023, information concerning the technology of the process system information required in the process the employer failed to include an evaluation of consequences of exceeding temperature limits for the vessels and the chemical(s) within them as required for the processes using diborane. Failure to accurately establish safe operating limits for process involved in the production of diborane and evaluating consequences of exceeding limits led to the employees working on and in the vicinity of the highly hazardous chemical being exposed to fire, explosion, respiratory and contact hazards.
Citation 1 Item 2
Type of Violation: Serious; $10,938
29 CFR 1910.119(e)(3)(i): The process hazard analysis did not address the hazards of the process:
a) On or about May 4, 2023, the employer did not conduct a PHA that adequately addressed the issue of the hazards related to impure or contaminated materials that may be produced in mixing and reaction processes. Activities concerning vessels used in the process of synthesizing, purification, transfilling (mixing), etc. of Diborane and its mixtures may produce by-products that affect the stability of vessels when heated. Employees working on and in the vicinity of equipment containing highly hazardous chemicals are exposed to fire, explosion, respiratory and contact hazards.
The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury or illness.
Citation 1 Item 3a
Type of Violation: Serious; $10,938
29 CFR 1910.119(e)(5): The employer shall establish a system to promptly address the team’s findings and recommendations; assure that the recommendations are resolved in a timely manner and that the resolution is documented; document what actions are to be taken; complete actions as soon as possible; develop a written
schedule of when these actions are to be completed; communicate the actions to operating, maintenance and other employees whose work assignments are in the process and who may be affected by the recommendations or actions.
a) On or about May 4, 2023, the employer failed to promptly address Process Hazard Analysis recommendations, track resolutions of the recommendations as soon as possible and communicate the actions to operating employees who may be affected by the recommendations or actions. Employees working on and in the vicinity of equipment containing highly hazardous chemicals were exposed to fire, explosion, respiratory and contact hazards.
Citation 1 Item 3b
Type of Violation: Serious
29 CFR 1910.119(e)(7): Employers shall retain process hazards analyses and updates or revalidations for each process covered by this section, as well as the documented resolution of recommendations described in paragraph (e)(5) of this section for the life of the process.
a) On or about May 4, 2023, the employer failed to retain and address Process Hazard Analysis recommendations and track resolutions of the recommendations. Employees were exposed to fire, explosion, respiratory and contact hazards.
Citation 1 Item 4
Type of Violation: Serious; $10,938
29 CFR 1910.119(f)(1)(ii): The employer’s written operating procedures did not address the requirements for the operating limits related to temperatures of cylinders:
a) On or about May 4, 2023, the employer’s written operating procedures were incomplete; in that the documents provided did not properly include safe instructions for chemical transfer activities concerning vessel exposure to heat before, during and after the process of synthesizing, purification, transfilling (mixing), etc. of Diborane and its mixtures. Employees working on and in the vicinity of equipment containing highly hazardous chemicals were exposed to fire, explosion, respiratory and contact hazards.
Citation 1 Item 5
Type of Violation: Serious; $10,938
29 CFR 1910.119(j)(6)(ii): Appropriate checks and inspections shall be performed to assure that equipment is installed properly and consistent with design specifications and the manufacturer’s instructions.
a) On or about May 4, 2023, the employer exposed employees to fire and explosion hazards in that the employer failed to require and complete inspections and checks to assure design and manufacturers specifications are met with equipment such as, but not limited to vacuum pumps and heat guns used in the process of synthesizing, purification, transfilling (mixing), etc. of Diborane and its mixtures.
Citation 1 Item 6
Type of Violation: Serious; $10,938
29 CFR 1910.307(c)(2)(i): Equipment in hazardous (classified) location(s) was not approved for the ignitable or combustible properties of the specific gas, vapor, dust, or fiber that was or could be present:
a) On or about May 4, 2023, within the H-Space building number 3 in the Synthesis 1 Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use improperly rated equipment such as, but not limited to vacuum pumps within a Class I Division II Group B manifold/hood while synthesizing a flammable chemical.
b) On or about May 4, 2023, within the H-Space building number 3 in the Synthesis 2 Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use improperly rated equipment such as, but not limited to vacuum pumps within a Class I Division II Group B
manifold/hood while synthesizing a flammable chemical.
c) On or about May 4, 2023, within the H-Space building number 3 in the Mixing 1 Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use improperly rated equipment such as, but not limited to vacuum pumps within a Class I Division II Group B manifold/hood while
mixing/transfilling a flammable chemical.
d) On or about May 4, 2023, within the H-Space building number 3 in the Mixing 2 Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use improperly rated equipment such as, but not limited to vacuum pumps within a Class I Division II Group B manifold/hood while
mixing/transfilling a flammable chemical.
e) On or about May 4, 2023, within the H-Space building number 3 in the Mixing 3 Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use improperly rated equipment such as, but not limited to vacuum pumps within a Class I Division II Group B manifold/hood while
mixing/transfilling a flammable chemical.
f) On or about May 4, 2023, within the H-Space building number 3 in the Purification Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use improperly rated equipment such as, but not limited to vacuum pumps within a Class I Division II Group B
manifold/hood while purifying/distilling a flammable chemical.
g) On or about May 4, 2023, within the H-Space building number 3 in the Cryotrap Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use improperly rated equipment such as, but not limited to vacuum pumps within a Class I Division II Group B manifold/hood while
cryotrapping a flammable chemical.
h) On or about May 4, 2023, within the H-Space building number 3 in the Quality Control Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use improperly rated equipment such as, but not limited to vacuum pumps within a Class I Division II Group B manifold/hood while checking quality of the products of a flammable chemical.
The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury or illness.
Citation 1 Item 7a
Type of Violation: Serious; $10,938
29 CFR 1910.307(g)(2)(ii): Each room, section, or area was not considered individually in determining its classification.
a) On or about May 4, 2023, the employer exposed employees to fire, explosion, respiratory and contact hazards, in that the H-Space or Building 3 was not electrically classified properly as a Class I Division II environment where diborane would become hazardous in case of an accident or some unusual operating condition.
Citation 1 Item 7b
Type of Violation: Serious
29 CFR 1910.119(d)(3)(i)(C): Electrical classification; In instances of areas within the same facility classified separately, Class I, Zone 2 locations may abut, but not overlap, Class I, Division 2 locations. Class I, Zone 0 or Zone 1 locations may not abut Class I, Division 1 or Division 2 locations.
a) On or about May 4, 2023, the employer exposed employees to fire, explosion, respiratory, and contact hazards, in that the H-Space or Building 3 was not electrically classified properly as a Class I Division II environment where diborane would become hazardous in case of an accident or some unusual operating condition.
Citation 1 Item 7c
Type of Violation: Serious
29 CFR 1910.119(d)(3)(ii): The employer did not document that equipment complies with recognized and generally accepted good engineering practices.
a) On or about May 4, 2023, the employer exposed employees to fire, contact and explosion hazards in that the employer required and failed to document that equipment such as, but not limited to, heat guns used in the process of synthesizing, purification, transfilling(mixing), etc. of Diborane and its mixtures complied with recognized and generally accepted good engineering practices as identified in the equipment’s manufacturer’s manual.
Citation 2 Item 1
Type of Violation: Willful – Serious; $125,007
29 CFR 1910.307(c): Equipment, wiring methods, and installations of equipment in hazardous (classified) locations were not intrinsically safe, approved for the hazardous (classified) location, or safe for the hazardous (classified) location:
a) On or about May 4, 2023, within the H-Space building number 3 in the Synthesis 1 Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use equipment such as, but not limited to, heat guns that were not intrinsically safe or designed to be used within a Class I Division II Group B manifold/hood where flammable chemicals and vapors are present while synthesizing Diborane.
b) On or about May 4, 2023, within the H-Space building number 3 in the Synthesis 2 Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use equipment such as, but not limited to, heat guns that were not intrinsically safe or designed to be used within a Class I Division II Group B manifold/hood where flammable chemicals and vapors are present while synthesizing Diborane.
c) On or about May 4, 2023, within the H-Space building number 3 in the Mixing 1 Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use equipment such as, but not limited to, heat guns that were not intrinsically safe or designed to be used within a Class I Division II Group B manifold/hood where flammable chemicals and vapors are present while mixing/transfilling Diborane and its mixtures.
d) On or about May 4, 2023, within the H-Space building number 3 in the Mixing 2 Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use equipment such as, but not limited to, heat guns that were not intrinsically safe or designed to be used within a Class I Division II Group B manifold/hood where flammable chemicals and vapors are present while mixing/transfilling Diborane and its mixtures.
e) On or about May 4, 2023, within the H-Space building number 3 in the Mixing 3 Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use equipment such as, but not limited to, heat guns that were not intrinsically safe or designed to be used within a Class I Division II Group B manifold/hood where flammable chemicals and vapors are present while mixing/transfilling Diborane and its mixtures.
f) On or about May 4, 2023, within the H-Space building number 3 in the Purification Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use equipment such as, but not limited to, heat guns that were not intrinsically safe or designed to be used within a
Class I Division II Group B manifold/hood where flammable chemicals and vapors are present while purifying/distilling Diborane.
g) On or about May 4, 2023, within the H-Space building number 3 in the Cryotrap Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use equipment such as, but not limited to, heat guns that were not intrinsically safe or designed to be used within a Class I Division II Group B manifold/hood where flammable chemicals and vapors are present while cryotrapping flammable chemicals.
h) On or about May 4, 2023, within the H-Space building number 3 in the Quality Control Hood/Manifold, the employer exposed employees to fire and explosion hazards in that the employer required employees to use equipment such as, but not limited to, heat guns that were not intrinsically safe or designed to be used within a Class I Division II Group B manifold/hood where flammable chemicals and vapors are present while checking quality of flammable chemicals.
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