Text For Citation: 01 Item/Group: 005 Hazard:

29 CFR 1910.147(d)(2): Machine or equipment shutdown. The machine or equipment shall be turned off or shut down using the procedures established for the machine or equipment. An orderly shutdown must be utilized to avoid any additional or increased hazard(s) to employees as a result of the equipment stoppage. On June 12, 2018 the employer failed to insure the Lockout/Tagout procedure for work to be performed on the primary water source (well water/demin water blend) for Solvent E cooling tower was suitable and effective. As a result, a valve that should have been closed and locked was left open. As a result, water from the backup water supply (city water) flowed backwards through the non-isolated pipeline and did not go to the cooling tower as intended. The loss of make-up water to the cooling water system caused the cooling tower pan to empty and resulted in a loss of cooling water for the condenser of the anhydrous ammonia cooling system which was a contributing factor in an ammonia release.