Text For Citation: 01 Item/Group: 028 Hazard:

29 CFR 1910.119(l)(4): When a change covered by this paragraph resulted in a change in the process safety information required by paragraph (d) of this section, such information was not updated accordingly. a. On or about and prior to April 8, 2021, for the management of change procedure 2191, process safety information was not updated; the employer failed to document, update and compile process safety information material of construction, for the manway gasket; On April 8, 2021, the kettle 3 reactor vessel manway cover to manway flange gasket 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. b. On or about and prior to April 8, 2021, for the management of change procedure 2191, process safety information was not updated; the P&ID (Piping & Instrument Diagram), Drawing RP-KT03, Revision 5 did not reflect the Kettle 3 reactor vessel manway opening. Employees working on and in the vicinity of equipment containing highly hazardous chemicals are exposed to fire, explosion and contact hazards. c. On or about and prior to April 8, 2021, for the management of change procedure 2191, process safety information was not updated; when the employer failed to update the safe upper limits for maximum operating pressure, contained in Yenkin process safety information document, RES-DOC-PLT-03, Operating Parameters Kettle 3. Employees working on and in the vicinity of equipment containing highly hazardous chemicals are exposed to fire, explosion and contact hazards.