Text For Citation: 01 Item/Group: 015 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)(E):Emergency Operations; a. On or about and prior to April 8, 2021, employer failed to address loss of agitation and the unexpected loss of containment in their operating procedures for emergency operations. This exposed employees to fire, chemical burns, struck-by/caught-between and other hazards related to explosions. b. On or about and prior to April 8, 2021, employer failed to address loss of agitation in their operating procedures for emergency operations. 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 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.