OSHA found multiple safety violations at an ethanol refinery expansion project after a 38-year-old pipefitter suffered fatal burn injuries when ethanol spilled from a process pipe he was working on and was ignited by flames from nearby welding operations. On Nov. 1, 2016, OSHA issued five serious safety violations to the worker’s employer, the project’s construction contractor. Inspectors determined the contractor allowed welding work to occur without verifying that the area was free of flammable liquids. OSHA cited the refinery operator and owner for three serious violations of OSHA’s process safety management standards including failing to ensure the process pipe being removed did not contain ethanol. Investigators determined the pipefitter was removing a vent line on the sixth floor of the refinery’s distillation building on May 6, 2016, when the incident occurred. As he detached a nine-foot segment of this line, 190-proof ethanol spilled onto him, flowed through the grated flooring, and ignited on the fourth floor due to the welding operations occurring there. The resulting fire engulfed the worker, causing fatal injuries that led to his death the following day. Here are the citations:
NOTE: this is the first 1926.64 Citations (Construction PSM Standard) that I am aware of being issued in 24 years!
Contractor Employer Citations
Citation 1 Item 1
Type of Violation: Serious; $ 12,471
29 CFR 1910.1200(h)(1) : Employers shall provide employees with effective information and training on hazardous chemicals in their work area at the time of their initial assignment, and whenever a new chemical hazard the employees have not previously been trained about is introduced into their work area. Information and training may be designed to cover categories of hazards (e.g., flammability, carcinogenicity) or specific chemicals. Chemical-specific information must always be available through labels and safety data sheets.
(a) On and prior to May 6, 2016, the exposing employer did not provide employees with effective information and training on hazardous chemicals in their work area at the time of their initial assignment and whenever a new physical or health hazard the employees have not previously been trained about is introduced into their work area such as but not limited to the 190-proof ethyl-alcohol. This condition exposed employees to a fire hazard.
Abatement Note:
(a) Employees shall be informed of:
(1) Any operation in their work area where hazardous chemicals are present; and,
(2) The location and availability of the written hazard communication program, including the required list(s) of hazardous chemicals, and material safety data sheets required by this section.
(b) Employee training shall include at least:
(1) Methods and observations that may be used to detect the presence or release of a hazardous chemical in the work area (such as monitoring conducted by the employer, continuous monitoring devices, visual appearance or odor of hazardous chemicals when being released, etc.);
(2) The physical and health hazards of the chemicals in the work area;
(3) The measures employees can take to protect themselves from these hazards, including specific procedures the employer has implemented to protect employees from exposure to hazardous chemicals, such as appropriate work practices, emergency procedures, and personal protective equipment to be used;
(4) The details of the hazardous communication program developed by the employer, including an explanation of the labeling system and the material safety data sheet, and how employees can obtain and use the appropriate hazard information.
Citation 1 Item 2
Type of Violation: Serious; $12,471
29 CFR 1926.95(a): Protective equipment, including personal protective equipment for eyes, face, head, and extremities, protective clothing, respiratory devices, and protective shields and barriers, shall be provided, used, and maintained in a sanitary and reliable condition wherever it is 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) On and prior to May 6, 20 16, the exposing employer failed to provide and ensure that each employee was provided with appropriate Personal Protective Equipment (PPE) such as flame-retardant treated clothing (FRC) necessary to protect employees from burns due to potential flash fires. Two pipefitters engaged in a line break and removal of a carbon steel four- inch vent line connected to the rectifier (T402), containing highly flammable 190-proof ethyl-alcohol, were not wearing flame resistant clothing.
On May 6th, 2016, a pipefitter involved in the removal of the vent line was severely burned and later died as a result of a flash fire that occurred after the contents spilled out and traveled down through grated flooring to the fourth floor, where the material ignited as a result of welding work being conducted. This condition exposed employees to fire hazards.
Citation 1 Item 3
Type of Violation: Serious; $12,471
29 CFR 1926.64(h)(3)(ii): The contract employer shall assure that each contract employee is instructed in the known potential fire, explosion, or toxic release hazards related to his/her job and the process, and the applicable provisions of the emergency action plan:
On and prior to May 6, 2016, the contract employer did not ensure that employees were instructed concerning fire hazards related to the opening of a vent line off the top of vessel T-402. also known as the rectifier, which had the potential to contain 190-proof ethyl-alcohol.
On May 6th, 2016, a pipefitter involved in the removal of the vent line was severely burned and later died as a result of a flash fire that occurred after the contents spilled out and traveled down through grated flooring to the fourth floor, where the material ignited as a result of welding work being conducted. This condition exposed employees to fire hazards.
Citation 1 Item 4
Type of Violation: Serious; $12,471
29 CFR 1926.64(h)(3)(iii): The contract employer shall document that each contract employee has received and understood the training required by this paragraph. The contract employer shall prepare a record which contains the identity of the contract employee, the date of training, and the means used to verify that the employee understood the training:
(a) On and prior to May 6, 2016, the contract employer did not document that employees required to open a vent line off the top of vessel T-402, also known as the rectifier, which had the potential to contain 190-proof ethyl alcohol, had received training on line breaking permit procedures, hot work permit procedures, and ignition sources.
On May 6th, 2016, a pipefitter involved in the removal of the vent line was severely burned and later died as a result of a fl ash fire that occurred after the contents spilled out and traveled down through grated flooring to the fourth floor, where the material ignited as a result of welding work being conducted. This condition exposed employees to fire hazards.
Citation 1 Item 5
Type of Violation: Serious; $12,471 29
CFR 1926.64(h)(3)(iv): The contract employer did not ensure that each contract employee follows the safety rules of the facility including the safe work practices required by paragraph (f)(4) of this section:
(a) On and prior to May 6, 2016, the contract employer did not ensure that all employees involved in the welding of a 30-inch pipe joint and the opening of a vent line off the top of vessel T-402, followed the hot work permit procedures and line break permit procedures established on May 3, 2016.
On May 6th, 2016, a pipefitter involved in the removal of the vent line was severely burned and later died as a result of a flash fire that occurred after the contents spilled out and traveled down through grated flooring to the fourth floor, where the material ignited as a result of welding work being conducted. This condition exposed employees to fire hazards.
Refinery Citations
Citation 1 Item 1
Type of Violation: Serious; $12,471
29 CFR 1926.64(f)(1)(i)(F): The employer did not implement written operating procedures that provide clear instructions for safely conducting normal shutdown activities: (a) On and prior to May 6, 2016, the controlling employer did not ensure contract employees were protected from the hazards, in that, pipefitters opened a four-inch vent line off the top of vessel T-402, also known as the rectifier, which the employer had previously shutdown, but not adequately purged of 190-proof ethyl-alcohol.
(a) On and prior to May 6, 2016, the controlling employer did not ensure contract employees were protected from the hazards, in that, pipefitters opened a four-inch vent line off the top of vessel T-402, also known as the rectifier, which the employer had previously shutdown, but not adequately purged of 190-proof ethyl-alcohol.
On May 6, 2016 a contractor pipefitter involved in the removal of the vent line on the sixth floor of distillation, was severely burned and later died as a result of a flash fire. While removing the four-inch vent line the flammable contents of the pipe (190-proof alcohol) spilled onto the contractor and through the grating beneath the contractor. A flash fire occurred when the flammable material was ignited as a result of welding work that was being conducted on the fourth floor. This condition exposed employees to fire and burn hazards.
Citation 1 Item 2
Type of Violation: Serious; $12,471
29 CFR 1926.64(h)(2)(ii): The employer shall inform contract employers of the known potential fire, explosion, or toxic release hazards related to the contractor’s work and the process.
(a) On and prior to May 6, 2016, the controlling employer did not inform a contract employer of the potential fire hazards related to opening a vent line off the top of vessel T-402, also known as the rectifier, which had the potential to contain 190-proof ethyl alcohol.
On May 6, 2016, a contract pipefitter involved in the removal of the vent line on the sixth floor of distillation building, was severely burned and later died as a result of a flash fire. Two contract pipefitters were involved in a line break of a four inch vent line pipe that contained flammable liquid (190-proof alcohol) that spilled from the line, covered one employee, and travelled through the grated flooring to the fourth floor, where the material ignited as a result of the welding work that was being conducted. This condition exposed contract employees to fire and burn hazards. Citation 1 Item 3
On May 6, 2016, a contract pipefitter involved in the removal of the vent line on the sixth floor of distillation building, was severely burned and later died as a result of a flash fire. Two contract pipefitters were involved in a line break of a four inch vent line pipe that contained flammable liquid (190-proof alcohol) that spilled from the line, covered one employee, and travelled through the grated flooring to the fourth floor, where the material ignited as a result of the welding work that was being conducted. This condition exposed contract employees to fire and burn hazards.
Citation 1 Item 3
Type of Violation: Serious; $12,471
29 CFR 1926.64(h)(2)(iv): The employer shall develop and implement safe work practices consistent with paragraph (f)(4) of this section, to control the entrance, presence and exit of contract employers and contract employees in covered process areas.
(a) On and prior to May 6, 2016, the controlling employer did not implement a line breaking permit process which prohibited the issuance of a line break permit to a contractor performing a line break on a line potentially containing 190-proof ethyl alcohol while hot work was being performed directly below.
On May 6, 2016, a contractor pipefitter involved in the removal of the vent line on the sixth floor of distillation, was severely burned and later died as a result of a flash fire. Two subcontractor pipefitters were involved in a line break of a four-inch vent line pipe that contained flammable liquid (190-proof alcohol) that spilled from the line, covered one employee, and traveled through the grated flooring to the fourth floor, where the material ignited as a result of welding work that was being conducted. This condition exposed contractor employees to fire and burn hazards.
CLICK HERE for the Contractor citations
CLICK HERE for the Refinery citations