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Inspection Detail
Inspection: 123807828 - Ashland Inc #2 Refinery
Inspection Information - Office: Ky Labor Cabinet Division Of Osh Compliance
Site Address:
Ashland Inc #2 Refinery
U.S. 23
Cattlettsburg, KY 41129
Mailing Address:
P. O. Box 150, Catlettsburg, KY 41114
Union Status: Union
SIC:2911
NAICS: 0
Inspection Type: Accident
Scope: Partial
Advanced Notice: N
Ownership: Private
Safety/Health: Health
Close Conference: 11/12/1993
Emphasis:
Case Closed: 10/28/1996
| Type | Activity Nr | Safety | Health |
|---|---|---|---|
| Accident | 360208920 |
| Violations/Penalties | Serious | Willful | Repeat | Other | Unclass | Total |
|---|---|---|---|---|---|---|
| Initial Violations | 11 | 1 | 12 | |||
| Current Violations | 10 | 1 | 11 | |||
| Initial Penalty | $55,000 | $0 | $0 | $0 | $0 | $55,000 |
| Current Penalty | $50,000 | $0 | $0 | $0 | $0 | $50,000 |
| FTA Penalty | $0 | $0 | $0 | $0 | $0 | $0 |
| # | Citation ID | Citaton Type | Standard Cited | Issuance Date | Abatement Due Date | Current Penalty | Initial Penalty | FTA Penalty | Contest | Latest Event | Note |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. | 01001 | Serious | 19100119 D03 IH | 11/18/1993 | 12/15/1993 | $5,000 | $5,000 | $0 | 12/14/1993 | F - Formal Settlement | Citation has been deleted. |
| 2. | 01002 | Serious | 19100119 E03 I | 11/18/1993 | 12/15/1993 | $5,000 | $5,000 | $0 | 12/14/1993 | F - Formal Settlement | |
| 3. | 01003 | Serious | 19100119 E03 III | 11/18/1993 | 12/15/1993 | $5,000 | $5,000 | $0 | 12/14/1993 | F - Formal Settlement | |
| 4. | 01004 | Serious | 19100119 E03 V | 11/18/1993 | 12/15/1993 | $5,000 | $5,000 | $0 | 12/14/1993 | F - Formal Settlement | |
| 5. | 01005 | Serious | 19100119 E03 VI | 11/18/1993 | 12/15/1993 | $5,000 | $5,000 | $0 | 12/14/1993 | F - Formal Settlement | |
| 6. | 01006 | Serious | 19100119 F01 IG | 11/18/1993 | 07/23/1996 | $5,000 | $5,000 | $0 | 12/14/1993 | P - Petition to Mod Abatement | |
| 7. | 01007A | Serious | 19100119 F01 IIA | 11/18/1993 | 07/23/1996 | $5,000 | $5,000 | $0 | 12/14/1993 | P - Petition to Mod Abatement | |
| 8. | 01007B | Serious | 19100119 F01 IIB | 11/18/1993 | 07/23/1996 | $0 | $0 | $0 | 12/14/1993 | P - Petition to Mod Abatement | |
| 9. | 01008A | Serious | 19100119 F01 IIIA | 11/18/1993 | 07/23/1996 | $5,000 | $5,000 | $0 | 12/14/1993 | P - Petition to Mod Abatement | |
| 10. | 01008B | Serious | 19100119 F01 IIIB | 11/18/1993 | 07/23/1996 | $0 | $0 | $0 | 12/14/1993 | P - Petition to Mod Abatement | |
| 11. | 01009 | Serious | 19100119 F01 IV | 11/18/1993 | 07/23/1996 | $5,000 | $5,000 | $0 | 12/14/1993 | P - Petition to Mod Abatement | |
| 12. | 01010A | Serious | 19100119 G01 I | 11/18/1993 | 12/15/1993 | $5,000 | $5,000 | $0 | 12/14/1993 | F - Formal Settlement | |
| 13. | 01010B | Serious | 19100119 L03 | 11/18/1993 | 12/15/1993 | $0 | $0 | $0 | 12/14/1993 | F - Formal Settlement | |
| 14. | 01010C | Serious | 19100119 G03 | 11/18/1993 | 12/15/1993 | $0 | $0 | $0 | 12/14/1993 | F - Formal Settlement | |
| 15. | 01011 | Serious | 19100119 J04 IV | 11/18/1993 | 12/15/1993 | $5,000 | $5,000 | $0 | 12/14/1993 | F - Formal Settlement | |
| 16. | 02001 | Other | 19100020 D01 II | 11/18/1993 | 11/24/1993 | $0 | $0 | $0 | 12/14/1993 | F - Formal Settlement |
Investigation Summary
Several operators were preparing to ignite a 2-B-3 crude heater after a two week turnaround. The lead operator had two very inexperienced workers helping him light the heater. Due to the lack of precise and clearly written procedures and proper training, a large concentration of fuel gas was allowed to enter the heater before the pilot light was ignited. The resulting explosion killed Employee #1, who received fatal injuries to the back of his head. The operators bypassed safety shutdown features and did not do a visual check of the emergency shutdown system to ensure that the features were closed. In addition, they did not check the firebox to ensure that it was gas-free before lighting the heater.
Keywords: PILOT LIGHT, HEAD, HEATER, WORK RULES, GAS, LOCKOUT, EXPLOSION, INEXPERIENCE, UNTRAINED
| # | Inspection | Age | Sex | Degree of Injury | Nature of Injury | Occupation |
|---|---|---|---|---|---|---|
| 1 | 123807828 | Fatality | Fracture | Miscellaneous plant and system operators |