Text For Citation: 01 Item/Group: 017 Hazard:

29 CFR 1910.119(f)(1): Operating procedures. 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)(ii): Operating limits: 29 CFR 1910.119(f)(1)(ii)(B):Steps required to correct or avoid deviation. a. On or about and prior to April 8, 2021, the written operating procedure, K3, K4, K5 Agitator Operation, RES-PRO-KO-007, failed to address the steps to correct the loss of cooling water deviation and to correct the loss of agitation deviation in covered process operations. On April 8, 2021, the kettle 3 reactor vessel manway failed and released vapor into the kettle 3/kettle 4 room. Just prior to the vapor release, agitation loss was discovered and was restored to operation at normal speed. This catastrophic failure resulted in the explosion event that resulted in a fatality and multiple disabling injuries. b. On or about and prior to April 8, 2021, the written operating procedure, Kettle 3 Overhead Processing Procedure, RES-PRO-KO-022, failed to address the steps to correct the disruption of flow (or blockage of equipment) deviation in the overhead system, failed to address the steps to correct the return of water into the reactor vessel deviation that can result in "foaming," failed to address the steps to correct the loss of cooling water deviation and failed to address the loss of agitation deviation in the reactor vessel. On April 8, 2021, the kettle 3 reactor vessel manway failed and released vapor into the kettle 3/kettle 4 room. Just prior to the vapor release, agitation loss was discovered and was restored to operation at normal speed. This catastrophic failure resulted in the explosion event that resulted in a fatality and multiple disabling injuries. c. On or about and prior to April 8, 2021, the written operating procedure, Solvent Manifold Operation, RES-PRO-KO-031, failed to address the steps to correct the disruption of flow (or blockage of equipment) deviation in the overhead system, failed to address the steps to correct the return of water into the reactor vessel deviation that can result in "foaming," failed to address the steps to correct the loss of cooling water deviation and failed to address the loss of agitation deviation in the reactor vessel. On April 8, 2021, the kettle 3 reactor vessel manway failed and released vapor into the kettle 3/kettle 4 room. Just prior to the vapor release, agitation loss was discovered and was restored to operation at normal speed. This catastrophic failure resulted in the explosion event that resulted in a fatality and multiple disabling injuries. d. On or about and prior to April 8, 2021, the written operating procedure, K3 and K4 Eductor Operation, RES-PRO-KO-005, failed to address the steps to correct the disruption of flow (or blockage of equipment) deviation in the overhead system, failed to address the steps to correct the return of water into the reactor vessel deviation that can result in "foaming," failed to address the steps to correct the loss of cooling water deviation and failed to address the loss of agitation deviation in the reactor vessel. On April 8, 2021, the kettle 3 reactor vessel manway failed and released vapor into the kettle 3/kettle 4 room. Just prior to the vapor release, agitation loss was discovered and was restored to operation at normal speed. This catastrophic failure resulted in the explosion event that resulted in a fatality and multiple disabling injuries. e. On or about and prior to April 8, 2021, the written operating procedure, OPC Emergency Shutdown Procedure, RES-PRO-PLT-009, failed to address the steps to correct the loss of cooling water deviation and to correct the loss of agitation deviation in covered process operations. On April 8, 2021, the kettle 3 reactor vessel manway failed and released vapor into the kettle 3/kettle 4 room. Just prior to the vapor release, agitation loss was discovered and was restored to operation at normal speed. This catastrophic failure resulted in the explosion event that resulted in a fatality and multiple disabling injuries.