Text For Citation: 01 Item/Group: 011 Hazard:

29 CFR 1910.119(e)(3): The process hazard analysis did not address: 29 CFR 1910.119(e)(3)(iv):Consequences of failure of engineering and administrative controls; On or about and prior to April 8, 2021, for the PHA Revalidation, PHA High Temp Review 2015; the process hazard analysis revalidation failed to address the consequences of engineering and administrative control failure: a. For the Alcoholysis node, the employer did not address the consequences of engineering and administrative control failure of the listed safeguards "Operator Training," "High pressure alarm on the kettle" and "PLC has safety interlocks. (K8 and K3 furnace off water on. K5 furnace off)" (Lines 5-7) to control rapid pressurization of high temperature kettles and potential catastrophic release of highly hazardous chemicals (HHCs) from covered process equipment. These engineering and administrative controls/safeguards failed to control the identified hazard "Kettle will pressurize upon heating" (Line 5.) On April 8, 2021, the kettle 3 reactor vessel was overpressured in part due to the failure of these engineering and administrative controls to control internal pressure. The vessel overpressurization released vapor in the kettle 3/kettle 4 room resulting in the explosion that resulted in a fatality and multiple disabling injuries. b. For the Alcoholysis node, the employer did not address the consequences of engineering and administrative control failure of the listed safeguards "Operator Training," "High pressure alarm on the kettle" and "PLC has safety interlocks. (K8 and K3 furnace off water on. K5 furnace off)" (Lines 34-36) to control rapid pressurization of high temperature kettles and potential catastrophic release of highly hazardous chemicals (HHCs) from covered process equipment. These engineering and administrative controls/safeguards failed to control the identified hazard "Kettle will pressurize" (Line 34.) On April 8, 2021, the kettle 3 reactor vessel was overpressured in part due to the failure of these engineering and administrative controls to control internal pressure. The vessel overpressurization released vapor in the kettle 3/kettle 4 room resulting in the explosion that resulted in a fatality and multiple disabling injuries. c. For the Alcoholysis node, the employer did not address the consequences of engineering and administrative control failure of the listed safeguards "Operator Training," "High pressure alarm on the kettle" and "PLC has safety interlocks. (K8 and K3 furnace off water on. K5 furnace off)" (Lines 55-57) to control rapid pressurization of high temperature kettles and potential catastrophic release of highly hazardous chemicals (HHCs) from covered process equipment. These engineering and administrative controls/safeguards failed to control the identified hazard "Kettle will pressurize" (Line 55.) On April 8, 2021, the kettle 3 reactor vessel was overpressured in part due to the failure of these engineering and administrative controls to control internal pressure. The vessel overpressurization released vapor in the kettle 3/kettle 4 room resulting in the explosion that resulted in a fatality and multiple disabling injuries. d. For the Alcoholysis node, the employer did not address the consequences of engineering and administrative control failure of the listed safeguards "Operator Training," "High pressure alarm on the kettle" and "PLC has safety interlocks. (K8 and K3 furnace off water on. K5 furnace off)" (Lines 73-75) to control rapid pressurization of high temperature kettles and potential catastrophic release of highly hazardous chemicals (HHCs) from covered process equipment. These engineering and administrative controls/safeguards failed to control the identified hazard "Kettle will pressurize" (Line 73.) On April 8, 2021, the kettle 3 reactor vessel was overpressured in part due to the failure of these engineering and administrative controls to control internal pressure. The vessel overpressurization released vapor in the kettle 3/kettle 4 room resulting in the explosion that resulted in a fatality and multiple disabling injuries. e. For the Alcoholysis node, the employer did not address the consequences of engineering and administrative control failure of the listed safeguards "cooling water fails on when N2 lost" (Line 83) and "Operator Training" (Line 86) to control rapid pressurization of high temperature kettles and potential catastrophic release of highly hazardous chemicals (HHCs) from covered process equipment. These engineering and administrative controls/safeguards failed to control the identified hazard "Potential flash (if exceeding 500F)" (Line 81) and "Potential to build pressure" (Line 83). On April 8, 2021, the kettle 3 reactor vessel was overpressured in part due to the failure of these engineering and administrative controls to control internal pressure. The vessel overpressurization released vapor in the kettle 3/kettle 4 room resulting in the explosion that resulted in a fatality and multiple disabling injuries. f. For the Alcoholysis node, the employer did not address the consequences of engineering and administrative control failure of the listed safeguards "cooling water fails on when N2 lost" (Line 100) and "Operator Training" (Line 104) to control rapid pressurization of high temperature kettles and potential catastrophic release of highly hazardous chemicals (HHCs) from covered process equipment. These engineering and administrative controls/safeguards failed to control the identified hazard "Potential flash (if exceeding 500F)" (Line 98) and "Potential to build pressure" (Line 100). On April 8, 2021, the kettle 3 reactor vessel was overpressured in part due to the failure of these engineering and administrative controls to control internal pressure. The vessel overpressurization released vapor in the kettle 3/kettle 4 room resulting in the explosion that resulted in a fatality and multiple disabling injuries. g. for the Alcoholysis node, the employer failed to address the failure of the engineering and administrative controls for the safeguards listed as "Operator Training," "High pressure alarm on the kettle" and "PLC has safety interlocks" (K8 and K3 furnace off water on. K5 furnace off)" (Lines 107-109) to control rapid pressurization of high temperature kettles and potential catastrophic release of highly hazardous chemicals (HHCs) from covered process equipment. These engineering and administrative controls/safeguards failed to control the identified hazard "Kettle will pressurize" (Line 107). On April 8, 2021, the kettle 3 reactor vessel was overpressured in part due to the failure of these engineering and administrative controls to control internal pressure. The vessel overpressurization released vapor in the kettle 3/kettle 4 room resulting in the explosion that resulted in a fatality and multiple disabling injuries. h. For the Alcoholysis node, the employer did not address the consequences of engineering and administrative control failure of the listed safeguards "Operator Training," "High pressure alarm on the kettle" and "PLC has safety interlocks. (K8 and K3 furnace off water on. K5 furnace off)" (Lines 63-65) to control rapid pressurization of high temperature kettles and potential catastrophic release of highly hazardous chemicals (HHCs) from covered process equipment. These engineering and administrative controls/safeguards failed to control the identified hazard "Kettle will pressurize" (Line 63.) On April 8, 2021, the kettle 3 reactor vessel was overpressured in part due to the failure of these engineering and administrative controls to control internal pressure. The vessel overpressurization released vapor in the kettle 3/kettle 4 room resulting in the explosion that resulted in a fatality and multiple disabling injuries. i. For the Esterification node, the employer did not address the consequences of engineering and administrative control failure of the listed safeguards "Pressure gauges/switches" and "Operator training" (Lines 32-33) to control increased internal pressures and the rapid pressurization and potential catastrophic release of highly hazardous chemicals (HHCs) from covered process equipment. These engineering and administrative controls/safeguards failed to control the identified hazard "Build pressure in the kettle" (Line 32). On April 8, 2021, the kettle 3 reactor vessel was overpressured in part due to the failure of these engineering and administrative controls to control internal pressure. The vessel overpressurization released vapor in the kettle 3/kettle 4 room resulting in the explosion that resulted in a fatality and multiple disabling injuries. j. For the Esterification node, the employer did not address the consequences of engineering and administrative control failure of the listed safeguards "Automatic water interlocked with high temp alarm (k3, 5 and 8)" and "Operator training" (Lines 108 and 109) to control increased internal pressures and the potential catastrophic release of highly hazardous chemicals (HHCs) from covered process equipment. These engineering and administrative controls/safeguards failed to control the identified hazard "Temperature higher than expected" and the listed consequence "Reactor could overheat" (Line 107). On April 8, 2021, the kettle 3 reactor vessel was overpressured in part due to the failure of these engineering and administrative controls to control internal pressure. The vessel overpressurization released vapor in the kettle 3/kettle 4 room resulting in the explosion that resulted in a fatality and multiple disabling injuries.