Text For Citation: 02 Item/Group: 002 Hazard:

29 CFR 1910.119(l): Management of change. 29 CFR 1910.119(l)(1):The employer shall establish and implement written procedures to manage changes (except for "replacements in kind") to process chemicals, technology, equipment, and procedures; and, changes to facilities that affect a covered process. The employer does not protect employees from hazards associated with the catastrophic release of hazardous chemicals from the kettle 3 reactor vessel covered process by failing to comply with the OSHA PSM standard for management of change procedures. a. This most recently occurred on April 8, 2021, the employer failed to implement the company management of change (MOC) procedure for equipment in the covered process. An MOC procedure was not developed/implemented for a gasket change that was made on the Kettle 3 reactor vessel (K3) manway opening and manway cover. The material and style of gasket were changed and put in-service/implemented before the employer evaluated the change under its MOC procedure. This gasket material of construction change was involved in a K3 manway leak; that manway leak occurred during the initial startup of production on January 3, 2021 and followed the December 2020 shutdown installation of the new manway opening into the reactor vessel. The gasket replacement was completed on January 4, 2021 and was completed without developing/implementing an MOC. 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.