Text For Citation: 01 Item/Group: 014 Hazard:

29 CFR 1910.119(f)(1): The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process consistent with the process safety information and shall address at least the following elements. 29 CFR 1910.119(f)(1)(i): Steps for each operating phase: 29 CFR 1910.119(f)(1)(i)(D):Emergency shutdown including the conditions under which emergency shutdown is required, and the assignment of shutdown responsibility to qualified operators to ensure that emergency shutdown is executed in a safe and timely manner. a. On or about and prior to April 8, 2021, employer failed to address emergency shutdown procedures for the unexpected loss of containment in their operating procedures so that shutdown occurred in a safe and timely manner. The procedure did not define when to evacuate. This exposed employees to fire, chemical burns, struck-by/caught-between and other hazards related to explosions. On April 8, 2021, the kettle 3 reactor vessel manway cover to manway failed and released vapor into the kettle 3/kettle 4 room. This catastrophic failure resulted in the explosion event that resulted in a fatality and multiple disabling injuries.