Text For Citation: 01 Item/Group: 001 Hazard: CHEMICAL

Section 5(a)(1) of the Occupational Safety and Health Act of 1970: The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that on June 6, 1991 employees in the area of the MRC feed tank were exposed to fire/explos- ion and toxic inhalation hazards due to chemical release from the Methylamines synthesis process, amines MRC Feed tank in which during the incident, the alert level was raised from minor event to standby notification by the employer and caused the freeway into the plant shut off. The following conditions contributed to the potential exposure: a. Maintenance and operating did not ensure control of leakage, accidental escape, and employer exposure to toxic flammable gas/liquid in that through lack of maintenance, the automatic steam control valve to the MRC feed tank heater failed to fully close off the steam due to a wron indentation or groove in the seat of the valve. Both of which could have been recognized during maintenance. b. The recycle tank level instrument device did not have its span properly set therefore causing the tank to read 85% when the tank was 100% full. c. The employee while closing the manual steam valve subsequent to the chemical release was not equipped with respiratory protection appropriate for the location and the atmosphere was not tested in the immediate area for air contaminants prior to this action. d. Due to inadequate training, operators could not recognize that the automatic steam control valve was still leaking when the pressure in the MRC Feed tank did not decrease promptly, after instrumentation showed the valve to be 0% closed. e. Written procedures do not address in a worse case scenario, at what point during an emergency the process should be shut down. Feasible abatement methods, among others, include but are not limited to: 1. Appropriate preventive maintenance on automatic and other valves to recognize in advance potential breakdowns of the valves. 2. Selection of a valve which would ensure a tighter shut-off and which is fail safe. 3. Appropriate training of area personnel in recognition of potential problems with the system. For example when the automatic steam control valve signaled 0%, the pressure in the MRC Feed tank continued to rise, it was not recognized that steam was more than likely still getting to the process and to shut off the manual steam control valve. 4. Revise emergency shut down procedures to indicate those instances during an emergency situation when the system should be shut down. 5. Set the span on the recycle tank level device so that it reads accurately.