PRCS Fatality in a railcar (HAZ ATM & $131K)

At 2:00 p.m. on May 20, 2014, Employee #1 was in a tank railcar confined space containing residual sweet crude oil without prior entry assessment and without wearing a harness with stand-by extraction equipment. While Employee #1 was shoveling crude oil inside a permit-required confined space tank railcar. Employee #1 was wearing a full-face supplied-air respirator (SAR), MSA Type-C Ultraview, attached to shop air and filter pot with no carbon monoxide filtration.

One of Employee #1′ s co-workers was acting as the entry supervisor and remained outside of the tank. After Employee #1 had been working inside the tank for 40 minutes, he informed his co-worker that he wanted to exit at which point his co-worker lowered a ladder into the tank. Employee #1 collapsed against the ladder. In-house employees attempted entry rescue three times before 911 was called, 65 minutes after Employee #1 had collapsed. Fire and rescue service was able to extract the Employee #1 two hours after the employee collapse. An autopsy determined Employee #1’s cause of death as a cardiac arrhythmia which was caused by difluoroethane intoxication.

Violation Summary
  Serious Willful Repeat Other Total
Initial Violations 14 7     21
Current Violations 14 7     21
Initial Penalty $34,400 $154,000 $0 $0 $188,400
Current Penalty $24,080 $107,800 $0 $0 $131,880

 

Violation Items
# ID Type Standard Issuance Abate Curr$ Init$ Contest LastEvent
1. 01001A Serious

19100023 C01 – Rungs and steps of portable metal

ladders are corrugated, knurled, dimpled, coated

with skid-resistant material, or otherwise treated

to minimize the possibility of slipping;

11/18/2014 04/17/2015 $1,400 $2,000 12/10/2014 F – Formal Settlement
2. 01001B Serious

19100132 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.

11/18/2014 04/17/2015 $0 $0 12/10/2014 F – Formal Settlement
3. 01002 Serious

19100134 D02 I B – A combination full facepiece pressure

demand supplied-air respirator (SAR) with auxiliary

self-contained air supply.

11/18/2014 04/17/2015 $1,960 $2,800 12/10/2014 F – Formal Settlement
4. 01003 Serious

19100134 E01 – The employer shall provide a medical

evaluation to determine the employee’s ability to use

a respirator, before the employee is fit tested or required

to use the respirator in the workplace. The employer may

discontinue an employee’s medical evaluations when the

employee is no longer required to use a respirator.

11/18/2014 04/17/2015 $1,960 $2,800 12/10/2014 F – Formal Settlement
5. 01004 Serious

19100134 F01 – The employer shall ensure that employees

using a tight-fitting facepiece respirator pass an appropriate

qualitative fit test (QLFT) or quantitative fit test (QNFT) as

stated in this paragraph.

11/18/2014 04/17/2015 $1,960 $2,800 12/10/2014 F – Formal Settlement
6. 01005 Serious

19100134 I07 – For oil-lubricated compressors, the

employer shall use a high-temperature or carbon monoxide

alarm, or both, to monitor carbon monoxide levels. If only

high-temperature alarms are used, the air supply shall be

monitored at intervals sufficient to prevent carbon monoxide

in the breathing air from exceeding 10 ppm.

11/18/2014 04/17/2015 $1,960 $2,800 12/10/2014 F – Formal Settlement
7. 01006 Serious 19100146 D03 I – Specifying acceptable entry conditions 11/18/2014 04/17/2015 $1,400 $2,000 12/10/2014 F – Formal Settlement
8. 01007A Serious

19100146 D03 IV – Purging, inerting, flushing, or ventilating

the permit space as necessary to eliminate or control

atmospheric hazards

11/18/2014 04/17/2015 $1,960 $2,800 12/10/2014 F – Formal Settlement
9. 01007B Serious

19100146 D04 II – Ventilating equipment needed to obtain

acceptable entry conditions;

11/18/2014 04/17/2015 $0 $0 12/10/2014 F – Formal Settlement
10. 01008 Serious

19100146 D04 VIII – Rescue and emergency equipment

needed to comply with paragraph (d)(9) of this section,

except to the extent that the equipment is provided by

rescue services; and

11/18/2014 04/17/2015 $1,960 $2,800 12/10/2014 F – Formal Settlement
11. 01009A Serious

19100146 D09 – Develop and implement procedures for

summoning rescue and emergency services, for rescuing

entrants from permit spaces, for providing necessary

emergency services to rescued employees, and for

preventing unauthorized personnel from attempting a

rescue

11/18/2014 04/17/2015 $1,960 $2,800 12/10/2014 F – Formal Settlement
12. 01009B Serious

19100146 I07 – Summon rescue and other emergency

services as soon as the attendant determines that

authorized entrants may need assistance to escape

from permit space hazards;

11/18/2014 04/17/2015 $0 $0 12/10/2014 F – Formal Settlement
13. 01010 Serious

19100146 D14 – Review the permit space program,

using the canceled permits retained under paragraph

(e)(6) of this section within 1 year after each entry

and revise the program as necessary, to ensure that

employees participating in entry operations are

protected from permit space hazards.

11/18/2014 04/17/2015 $1,400 $2,000 12/10/2014 F – Formal Settlement
14. 01011 Serious

19100146 E05 I – The entry operations covered by the

entry permit have been completed

11/18/2014 04/17/2015 $1,120 $1,600 12/10/2014 F – Formal Settlement
15. 01012 Serious

19100146 G02 IV – Whenever the employer has reason

to believe either that there are deviations from the

permit space entry procedures required by paragraph

(d)(3) of this section or that there are inadequacies

in the employee’s knowledge or use of these procedures.

11/18/2014 04/17/2015 $1,120 $1,600 12/10/2014 F – Formal Settlement
16. 01013A Serious

19100146 K01 I – Evaluate a prospective rescuer’s ability

to respond to a rescue summons in a timely manner,

considering the hazard(s) identified

11/18/2014 04/17/2015 $1,960 $2,800 12/10/2014 F – Formal Settlement
17. 01013B Serious

19100146 K01 II – Evaluate a prospective rescue

service’s ability, in terms of proficiency with rescue-related

tasks and equipment, to function appropriately while rescuing

entrants from the particular permit space or types of permit

spaces identified

11/18/2014 04/17/2015 $0 $0 12/10/2014 F – Formal Settlement
18. 01014A Serious

19100146 K01 IV – Inform each rescue team or service

of the hazards they may confront when called on to

perform rescue at the site

11/18/2014 04/17/2015 $1,960 $2,800 12/10/2014 F – Formal Settlement
19. 01014B Serious

19100146 K01 V – Provide the rescue team or service

selected with access to all permit spaces from which rescue

may be necessary so that the rescue service can develop

appropriate rescue plans and practice rescue operations

11/18/2014 04/17/2015 $0 $0 12/10/2014 F – Formal Settlement
20. 02001A Willful

19100134 G03 VI A – Pressure demand or other positive

pressure SCBAs, or a pressure demand or other positive

pressure supplied-air respirator with auxiliary SCBA;

and either

11/18/2014 04/17/2015 $9,800 $14,000 12/10/2014 F – Formal Settlement
21. 02001B Willful

19100146 K02 I – An employer whose employees have

been designated to provide permit space rescue and

emergency services shall take the following measures

11/18/2014 04/17/2015 $0 $0 12/10/2014 F – Formal Settlement
22. 02002 Willful

19100134 H04 – The employer shall ensure that respirators

that fail an inspection or are otherwise found to be

defective are removed from service, and are discarded or

repaired or adjusted in accordance with the following

procedures:

11/18/2014 04/17/2015 $9,800 $14,000 12/10/2014 F – Formal Settlement
23. 02003 Willful

19100146 D05 I – Test conditions in the permit space to

determine if acceptable entry conditions exist before entry

is authorized to begin, except that, if isolation of the space

is infeasible because the space is large or is part of a

continuous system (such as a sewer), pre-entry testing

shall be performed to the extent feasible before entry is

authorized and, if entry is authorized, entry conditions

shall be continuously monitored in the areas where

authorized entrants are working;

11/18/2014 04/17/2015 $9,800 $14,000 12/10/2014 F – Formal Settlement
24. 02004 Willful

19100146 D05 II – Test or monitor the permit space as

necessary to determine if acceptable entry conditions

are being maintained during the course of entry

operations; and

11/18/2014 04/17/2015 $9,800 $14,000 12/10/2014 F – Formal Settlement
25. 02005A Willful

19100146 E01 – Before entry is authorized, the employer

shall document the completion of measures required by

paragraph (d)(3) of this section by preparing an

entry permit.

11/18/2014 04/17/2015 $9,800 $14,000 12/10/2014 F – Formal Settlement
26. 02005B Willful

19100146 J02 – Verifies, by checking that the appropriate

entries have been made on the permit, that all tests

specified by the permit have been conducted and that

all procedures and equipment specified by the permit

are in place before endorsing the permit and allowing

entry to begin

11/18/2014 04/17/2015 $0 $0 12/10/2014 F – Formal Settlement
27. 02006 Willful

19100146 K02 IV – Ensure that affected employees

practice making permit space rescues at least once

every 12 months, by means of simulated rescue

operations in which they remove dummies,

manikins, or actual persons from the actual

permit spaces or from representative permit

spaces. Representative permit spaces shall,

with respect to opening size, configuration,

and accessibility, simulate the types of permit

spaces from which rescue is to be performed

11/18/2014 04/17/2015 $9,800 $14,000 12/10/2014 F – Formal Settlement
28. 02007 Willful

19100146 K03 – To facilitate non-entry rescue, retrieval

systems or methods shall be used whenever an

authorized entrant enters a permit space, unless the

retrieval equipment would increase the overall risk of

entry or would not contribute to the rescue of the

entrant. Retrieval systems shall meet the following

requirements

11/18/2014 04/17/2015 $49,000 $70,000 12/10/2014 F – Formal Settlement

 

OSHA Case File

 

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