Four workers were killed by a lethal dose of methyl mercaptan gas in November 2014. OSHA has cited the company for 11 safety violations and identified scores of safety upgrades the company must undertake to prevent future accidents at its manufacturing building. The company employs 313 workers who manufacture crop protection materials and chemicals there. The fatal incident occurred as one worker was overwhelmed when methyl mercaptan gas was unexpectedly released when she opened a drain on a methyl mercaptan vent line. Two co-workers who came to her aid were also overcome. None of the three wore protective respirators. A fourth co-worker — the brother of one of the fallen men — attempted a rescue, but was unsuccessful. All four people died in the building. The company was cited for one repeat, nine serious and one other than serious OSHA violations. The repeat violation was assessed for not training employees on using the building’s ventilation system and other safety procedures, such as how to respond if the fans stopped working. In July 2010, the company was cited for a similar violation in a fatality involving Phosgene gas. Here is a breakdown of the citations…
Citation 1 Item 1
Type of Violation: Serious; $7,000
29 CPR 1910.119(d)(3)(i)(B): Process safety information pertaining to the equipment in the process did not include the piping and instrument diagrams (P&IDs):
On November 15, 2015 and at times prior thereto, Piping and instrument diagrams such as, but not limited to the following, were inaccurate or incomplete:
- Piping and Instrument Diagram (P&ID) W363900 Railcar Spot 1A2, the Nitrogen Rupture Disc (RD) set pressures differ in the field from what is reflected on the P&ID.
- Piping and Instrument Diagram (P&ID) W117396 Railcar Spot 1A4, the Nitrogen Rupture Disc (RD) set pressures differ in the field from what is reflected on the P&ID.
- Piping and Instrument Diagram (P&ID) W1173976, line 11965 reflects that it vents to the MIC Incinerator instead of the NRS.
- Piping and Instrument Diagram (P&ID) W363888, line 2822 reflects G82K as being plugged, but it has been modified.
- Piping and Instrument Diagram (P&ID) W363888, line 2817 reflects G32K with a blind flange, but it has been modified.
Citation 1 Item 2a
Type of Violation: Serious; $7,000
29 CFR 1910.119(e)(1): The process hazard analysis was not appropriate to the complexity of the process and did not identify, evaluate, and control the hazards involved in the process:
On November 15, 2015 and at times prior thereto, the employer:
- Did not identify, evaluate and control hazards that workers are exposed to when engineering controls such as the ventilation fans of the Lannate/ API manufacturing building are out of service.
- Did not identify, evaluate and control the hazards that could lead to loss of containment and or process upset, resulting from draining low point bleeds on the MeSH vent header to atmosphere, on the 3rd floor of the Lannate Building.
Citation 1 Item 2b
Type of Violation: Serious; Grouped
29 CFR 1910.119(e)(3)(iii): The process hazards analysis did not address Engineering and administrative controls applicable to the hazards and their interrelationships such as appropriate application of detection methodologies to provide early warning of releases. (Acceptable detection methods might include process monitoring and control instrumentation with alarms, and detection
hardware such as hydrocarbon sensors.)
- On November 15, 2015 and at times prior thereto and times subsequent thereto, the employer did not have a MeSH alarm detection system located at or on the 3rd floor of the Lannate/API Manufacturing Building that would provide employees with an early warning of a release.
Citation 1 Item 3
Type of Violation: Serious; $7,000
29 CFR 1910.119(f)(1)(ii)(B): The employers written operating procedures covering operating limits did not address the steps required to correct deviations:
-In the Alternative-
29 CFR 191O.ll9(J)(2): The employer did not establish and implement written procedures to maintain the on-going integrity of process equipment as required.
- On November 15, 2015 and at times prior thereto, the employer did not develop and implement written procedures to correct/address pluggage in the lines of the Mesna system.
- On November 15, 2015 and at times prior thereto, the employer did not develop and implement written procedures to correct/address pluggage in the lines of the MeSH system.
Citation 1 Item 4
Type of Violation: Serious; $7,000
29 CFR 1910.119(f)(4): The employer did not develop and implement safe work practices to provide for the control of hazards during operations such as lockout/tagout; confined space entry; opening process equipment or piping; and control over entrance into a facility by maintenance, contractor, laboratory, or other support personnel. These safe work practices shall apply to employees and contractor employees.
On November 15, 2015 and at times prior thereto, the employer did not implement safe work practices to provide for the control of hazards during the opening of process equipment or piping in the following instances:
- Opening the drain lines on vent header at or near 18HV
- Swapping and draining the flame arrestors on the NOx Reduction System (NRS)
Citation 1 Item 5
Type of Violation: Serious; $7,000
29 CFR 1910.119(j)(5): Equipment deficiencies. The employer did not correct deficiencies in equipment that are outside acceptable limits (defined by the process safety information in paragraph (d) of this section) before further use or in a safe and timely manner when necessary means are taken to assure safe operation.
On November 15, 2015 and at times prior thereto, in the Lannate/API building of the facility, the employer did not repair the ventilation fans in a timely manner and did not implement measures to ensure safe entry and operation of processes in the building that rely on the ventilation for safety:
- Wet end ventilation fan was out of service and the affected section of the building was not restricted – chemicals continued to be brought into the building, operation of processes continued, line openings in the building continued, and adjustments were not made to ensure it would be safe for personnel entry.
- Damp end ventilation fan was out of service and the affected section of the building was not restricted – chemicals continued to be brought into the building, operation of processes continued and adjustments were not made to ensure it would be safe for personnel entry.
Citation 1 Item 6a
Type of Violation: Serious; $7,000
29 CPR 1910.119(1)(1): The employer did not establish and implement written procedures to manage changes to process chemicals, technology, equipment, and procedures; and, changes to facilities that affect a covered process.
On or about November 15, 2014 and at times prior to, at the facility, the employer did not implement its change of design (COD) procedure to manage changes when:
- Changes were made to the Mercaptan vent piping on the third floor of the Lannate/API Building
- The 1A2 railcar spot was used to route liquid Mercaptan from the storage tank to the vent and nitrogen header system.
- The 1A4 railcar spot was used to route liquid Mercaptan from the storage tank to the vent and nitrogen header system.
- Operation of the process changed and the Low points around the 18HV were used to drain fluids from the Mercaptan vent header while process is running and the vent is not isolated from the process.
- Did not follow the ventilation fan operating procedure to restrict access to the Lannate/ API building when the wet end ventilation fan was not operating.
- Did not follow the ventilation fan operating procedure to restrict access to the Lannate/ API building when the dry end ventilation fan was not operating.
- The safety interlock at the 1185HV was bypassed.
- The safety interlock at the 1152FV was bypassed.
Citation 1 Item 6b
Type of Violation: Serious; Grouped
29 CFR 1910.119(1)( 4): Process safety information required by paragraph (d) of this section was not updated when a change covered by this paragraph resulted in a change in the process safety information.
On or about November 15, 2014 and at times prior to, the employer did not update its piping and instrumentation diagram WI722137 to show the piping modification for the Change of Design (TCOD 2011-51) when piping was modified to route a drain line from the AAO vent header to the MIC Caustic Scrubber.
Citation 1 Item 7
Type of Violation: Serious; $7,000
29 CFR 1910.134(c)(1)(vii) The employer failed to train employees in the respiratory hazards to which they are potentially exposed during routine situations.
On November 15, 2015 and at times prior thereto, the employer did not ensure employees were trained to recognize the respiratory hazards they were exposed to while opening low point drains on the NRS/ Mesh vent header.
Citation 1 Item 8
Type of Violation: Serious; $7,000
29 CFR 1910.165(b)(1): The employee alarm system did not provide warning for reaction time for safe escape of employees from the workplace or the immediate work area, or both.
On November 15, 2015 and at times prior thereto, the employer did not ensure that the employee alarm system provided warning for reaction time for safe escape from the Lannate/ API Manufacturing Building.
Citation 1 Item 9a
Type of Violation: Serious; $7,000
29 CFR 1910.1OOO(a)(1): Employee(s) were exposed to an airborne concentration of Methyl Mercaptan listed in Table Z-1 in excess of the ceiling concentration of 10 ppm:
On or about November 15, 2015 and at times prior thereto, in the Lannate/API building, employees were exposed to airborne concentrations of Methyl Mercaptan while opening bleed valves on a relief header.
Citation 1 Item 9b
Type of Violation: Serious; Grouped
29 CFR 1910.1000(e): Administrative or engineering controls were not used and implemented to achieve compliance with the limits prescribed in 29 CFR 1910.lOOO(a) through (d). When such controls were not feasible/available to achieve full compliance, protective equipment or any other protective measures were not used to keep the exposure of employees to air contaminants within the limits prescribed:
On or about November 15, 2015 and at times prior thereto, in the Lannate/API building, the employer failed to implement adequate engineering and administrative measures and/or take any other protective measures to keep the exposure of employees to air contaminants within the limits prescribed.
Citation 2 Item 1
Type of Violation: Repeat; $35,000
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 (t) of this section. The training shall include emphasis on the specific safety and health hazards, emergency operations including shutdown, and safe work practices applicable to the employee’s job tasks.
- On November 15, 2015 and at times prior thereto, the employer did not train employees on the written operating procedure for the Lannate/ API/MIC building ventilation fans (“Building Ventilation System Function of Operation”) and all safe work practices that needed to be employed in the event they were not operational.
- On November 15, 2015 and at times prior thereto, the employer failed to train employees on the safe work practices for draining Low Point Drains located near the 18HV, and did not ensure employees followed line opening and MSS procedures.
Company was previously cited for a violation of this Occupational Safety and Health Standard or its equivalent standard 29 CFR 1910.119(g)(l)(i) which is contained in OSHA Inspection Number 313371924, Citation Number 1Item5, issued on July 19, 2010 with respect to a workplace located in Belle, WV. This file became Final Order on August 24, 2010.
Citation 3 Item 1
Type of Violation: Other-than-Serious; $1,000
29 CPR 1910.119(h)(2)(vi): The employer shall maintain a contract employee injury and illness log related to the contractor’s work in process areas.
On or about November 15, 2014, the employer did not provide copies of the Injury and Illness Logs for their contractors.
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