Text For Citation: 01 Item/Group: 029 Hazard:

29 CFR 1910.119(m)(1):The employer shall investigate each incident which resulted in, or could reasonably have resulted in a catastrophic release of highly hazardous chemical in the workplace. a. On or about and prior to April 8, 2021, the employer failed to initiate an incident investigation related to the kettle 3 reactor vessel leak from a newly installed manway opening. The leak event happened during the initial startup of production which began on January 3, 2021 and occurred after the December 2020 shutdown installation of the new manway opening into the reactor vessel. 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 the fatality and multiple disabling injuries. b. On or about and prior to April 8, 2021, the employer failed to initiate an incident investigation related to the kettle 3 reactor vessel leak from the manway cover. The leak happened on November 30, 2020 and was documented by a December 1, 2020 work order record. Manway leaks during production activities pose the risk of unconfined vapor cloud release and vapor cloud explosion. c. On or about and prior to April 8, 2021, the employer failed to initiate an incident investigation related to internal pressure buildup in the kettle 3 reactor vessel during fusion processing in the overhead system. The occurrence resulted in a January 29, 2021 shutdown of the equipment and was documented by a January 30, 2021 work order record. Rapid internal pressure increase poses the risk of overpressure, loss of pressure containing capability and an unconfined vapor cloud release resulting in vapor cloud explosion. d. On or about and prior to April 8, 2021, the employer failed to initiate an incident investigation related to a leak from the kettle 3 reactor vessel pressure relief system rupture disk flange. The leak occurred on January 8, 2021 and was documented by a January 8, 2021 work order record. Leaks during production activities pose the risk of unconfined vapor cloud release and vapor cloud explosion.