Text For Citation: 01 Item/Group: 002 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 employees were exposed to a fire/explosion hazard as a result of system upset and/or equipment failure due to an uncontrolled over-pressurization of a vessel: a)In the ester reactor room (building 23), reactor operators were exposed to a fire/explosion hazard due to vessel fragmentation from an uncontrolled over- pressurization of a vessel such as the catalyst charge pot (V-146) and/or reactor vessels (V-103, V-104, V-107, and V-108). Among other methods, feasible and acceptable abatement methods to correct this hazard include, but are not limited to, the following: *Provide training and annual refresher training for reactor operators with emphasis on the specific safety and health hazards of the process, emergency operations including shutdown, and safe work practices applicable to the employee's job task such as, but not limited to, the following: **the knowledge, skills, and abilities to safely run ester batches on reactor vessel #8 (V-108); **the knowledge, skills, and abilities to safely charge 35hydrogen peroxide to reactor vessel #8 (V-108); **operating procedures such as emergency operations, emergency shutdown, and peroxide bleaching; **the consequences of charging any chemical or substance other than TPT through the catalyst charge pot (V-146) and that any deviation could potentially result in over-pressurization beyond the capacity of the charge pot; **the reactive properties of TPT and the hazards associated with the mixing of TPT with water/steam and other chemicals such as 35 hydrogen peroxide in the catalyst charge pot (V-146) and TPT charge lines; **the critical limits on each batch and/or reactor vessel (V-103, V- 104, V-107, and V-108), such as maximum temperatures and pressures, and the consequences of deviation; **the limitations and inadequacies of the pressure relief device on the catalyst charge pot (V-146); and **the safety systems and their functions on each of the reactor vessels. *Ascertain and document that the #8 reactor operator involved in the incident in the ester reactor room (building 23) on October 15, 1998, received and understood the training. *Conduct an organized and systematic evaluation (engineering and hazard analysis) of the ester production process at the facility that will effectively identify potential causes and consequences of system upsets or deviations that could cause safety or health hazards to employees, including items such as, but not limited to, the following: **address charging and mixing of a reactive chemical such as 35 hydrogen peroxide with TPT in the catalyst charge pot (V-146) and TPT charge lines; **address addition and mixing of water and/or steam with TPT in the catalyst charge pot (V-146) and TPT charge lines; **address the consequences of engineering control failure such as, but not limited to, the failure of the pressure relief device in the event of an uncontrolled over-pressurization of the catalyst charge pot (V-146) due to a reaction from TPT mixing with another chemical or water/steam; **address facility siting such as, but not limited to, the location of the controls and the location/construction of the break/control room; **address human factors such as, but not limited to, the potential hazards associated with the capability of three ester reactor operators running four reactors in the event of multiple problems and/or alarms on more than one reactor vessel; **evaluate consequences of charging and mixing of a reactive chemical such as 35hydrogen peroxide with TPT in the catalyst charge pot (V-146) and TPT charge lines; **evaluate consequences of addition and mixing of water and/or steam with TPT in the catalyst charge pot (V-146) and TPT charge lines; **evaluate consequences of the relief system's inability to safely handle an event such as an uncontrolled over-pressurization of the catalyst charge pot (V-146); and**identify and evaluate any previous incidents in the ester reactor room (building 23) such as, but not limited to, the following: ***the incident, approximately 17 to 18 years ago, which involved a reaction between residual TPT and hydrogen peroxide resulting in the upper valve of the sample bomb being blown apart on reactor #3; ***the incident, in approximately 1984, which involved an explosion on a reactor, injuring at least 2 employees, due to static electricity; and ***the incident, in approximately 1948-49, which levelled building 23 killing 1 employee. Abatement certification and documentation are required.tion