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

T.C.A. 50-3-105(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were likely to cause death or serious physical harm to employees, in that employees were exposed to fire and explosion from use of contaminated rare earth raw materials in their dissolving process in the rare earth main processing building on 2/9/07 and 2/11/07, without: a.Adequate safe work practice procedures and/or without adhering to procedures necessary for safe operation in existing work practice procedures, with respect to: 1.Work practice procedures to control unsafe raw material acquisition and use; 2.Effective isolation of hazardous areas from employee exposure, due to lack of adherence to an existing safe work practice procedure on "Barricading Hazardous Areas"; and 3.An effective safe work practice procedure to transfer information concerning incidents and hazards between the 2nd shift (after which the process was shut down) Friday night and the 3rd shift (which restarts the process) Sunday night; and b.Performing an effective change and/or hazard analysis of the new flammable/explosive materials introduced (inadvertently) to the rare earth dissolving process in tank PRE-138. An effective, thorough change and/or hazard analysis was necessary after the flammability/explosivity hazard was evident on 2/9/07. Safe work practice procedures, enforcement to ensure adherence to such procedures, and thorough change/hazard analysis (where new hazards have been introduced in the workplace) are all elements of an effective safety and health program. Employers are expected, with reasonable diligence, to have such elements in an effective safety program. In August of 2006, the employer took steps to receive 52 drums (55 gallon) of rare earth raw material (also termed Malaysian Chloride, Lanthanum Chloride, or Chinese Cast) from another company (Remacor), free of charge (except shipping costs). Drums of this material were mixed in batches of the employer's rare earth + water solutions. On 2/9/07, the Remacor material, when added to the batch in tank PRE-138, caused sparking, flames, and possible explosion. Yellow barricade tape was installed, and left over the weekend, around the tank area. After finding no reason for the yellow barricade tape, it was removed at the beginning of the 3rd shift Sunday night, 2/11/09. Upon beginning transfer of the batch in tank PRE-138 to tank PRE-149 on the third shift on Sunday night, 2/11/07, another explosion occurred, with flames emanating from the tank PRE-138 feed opening. Chemical Operators and a Supervisor were exposed to the fire/explosion hazards. The following were findings, with respect to the above-listed safety program deficiencies: a.1.Although this particular raw material acquisition (at least one drum of which was contaminated with material that was flammable and explosive) was unusual for the employer, his "Raw Material Supplier List - Standard Procedure," Document No. PU-SP-001, was predominantly not followed (although receipt and analysis of a trial sample, one part of the procedure, wasfollowed). The procedure was not safe, as written, due to the non-specific requirements listed. An example was paragraph 6.2: "[The Purchasing Process Owner (PPO)] selects the appropriate method for supplier assessment based on the nature of the raw material and GRACE Davison's end-use quality requirements." Of the methods listed from which to select, some that were not selected (such as 6.2.1: "On-site quality audit of the supplier") could have stopped the acquisition; 2.The hazardous area, including tank PRE-138, was barricaded with yellow tape on 2/9/07, and it remained in place until the beginning of the 3rd shift on 2/11/07, when it was taken down. Examples of where the employer's work practice procedure on "Barricading Hazardous Areas," was not followed were: i."Yellow tape will be used to give notice of hazards that can be seen by personnel coming into the area. These hazards are not to be considered life threatening or disabling. Yellow tape shall be used to denote "Caution""; ii."Red barricade tape will be used to give notice of areas where the hazard is not readily apparent or where the situation could be life threatening or disabling. Red tape shall be used to denote "Danger""; iii."A plastic tag will be attached to each taped area identifying the person who hung the tape, the date and the hazard in the taped area"; iv."When a hazardous situation is identified, the appropriate supervisor shall be contacted and everyone working in the area shall be informed." 3rd shift personnel reopening the operation on 2/11/07 were not so contacted or informed; v."If a person needs to go into a yellow barricaded area, they will do this only if necessary. They must determine the reason for the barricade before entering." 3rd shift personnel entered the yellow barricaded area without adhering to the preconditions; and vi."The employee(s) responsible for barricading an area or piece of equipment shall make sure the barricade tape is removed after the hazard has been corrected." Management personnel installed the yellow barricade tape on 2/9/07 and indicated that they felt "there was no significant hazard remaining" (which was incorrect) by the end of the 2nd shift on 2/9/07, but they did not then remove the barricade tape; 3.Whereas there was an unwritten procedure (use of log books and e-mail between shift foremen) for transferring hazard and incident information between the two shifts, it was not followed during this incident. One complicating factor was that responsibilities were not clearly understood, after management personnel became involved in the handling of the incident; and b.An effective change analysis and/or hazard analysis was not conducted after it was evident that there was a flammable/explosive contaminant introduced into the rare earth batch in PRE-138 on 2/9/07. These hazards were reasonably foreseeable in that they were recognized by employer representatives, the industry, and common sense.Among other methods, feasible and acceptable abatement methods for correcting these hazards are to: a.1.Develop and implement a safe work practice procedure for handling all raw material acquisitions, including those that may be unusual. Such a procedure could include: i.Researching a potential raw material supplier company's historical record. In the above-mentioned case: A.Brief internet research yielded information that Remacor had several major explosions and/or fires in its 20 plus years of production. The last was in 2005, and it affected the bulk of its operation; B.The employer also found, after its fire/explosion incidents, that Remacor was under an EPA-forced (ordered) cleanup of the worksite, and that may presumably be why they were getting rid of the rare earth materials; C.The employer also found, after their incidents, that Remacor was going out of business (and no longer existed after the employer received the rare earth from them); D.Internet research also found that Remacor made: magnesium (a flammable solid) products from magnesium turnings (shavings); and misch metals (flammable solids that are pyrophoric - they ignite spontaneously in air or spark when slight friction is applied), that are use in production of lighter flints) from rare earth chlorides; ii."On-site quality audit of the supplier," which was one of the potential methods of supplier assessment in the employer's "Approved Raw Material Supplier List - Standard Procedure." When they received the rare earth "lanthanum chlorides"-labeled materials from Remacor (the tags on some of the 1992-labeled drums said the name of the company was "Reactive Metals and Alloys Corp."), they came in rusty 55 gallon drums that had dates of 4/18/92, 5/31/92, and 7/31/97 (10 to 15 years old); iii."Completion of self-assessment questionnaire by the supplier," which was also one of the potential methods of supplier assessment in the employer's "Approved Raw Material Supplier List - Standard Procedure"; and iv."Registration to ISO 9001/9002 Standard," which was also one of the potential methods of supplier assessment in the employer's "Approved Raw Material Supplier List - Standard Procedure"; 2.Ensure adherence to the employer's "Barricading Hazardous Areas" Operating Procedure. Such adherence can be ensured through consistent monitoring and enforcement of safe work practice procedures; 3.Develop an effective shift change information transfer procedure, with clearly defined responsibilities, and ensure its consistent implementation through monitoring and enforcement; andb.Conduct a thorough change analysis when a new material, with potential hazards, is added (inadvertently or not) to an operation. Such a change analysis may be incorporated into a hazard analysis and/or a pre-startup safety review. ABATEMENT VERIFICATION IS REQUIRED