Text For Citation: 01 Item/Group: 007B Hazard: EXPLOSION

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 causing or likely to cause death or serious physical harm to employees, in that employees were exposed to fire and explosion from use of flammable liquids in an OXAD Mother Liquor (ML) distillation process on August 2 and 3, 2006, without effective safety change analysis of the newly-developed process, including its operating procedures, before the distillation process was conducted. Such change analysis for new processes would be a necessary sub-element of an effective safety and health program's hazard anticipation and detection element. On August 2 and 3, 2006, the employer ran an OXAD Mother Liquor (ML) distillation process in tank T-644, in line 3 of building 6. (OXAD was 3-(4-nitrophenyl)-5-(2-oxo-3,3-dimethyl butyl)-1,2,4-oxadiazole.) There was a reported 3,451 pounds of flammable liquid (methanol) in tank T-644 at the beginning of the distillation. (There were more flammable liquids in tanks in the same line and in the building that could have also been involved in a fire or explosion.) The written work practice for the distillation, which was the "Plant Operating Standard for OXAD Mother Liquor Distillation in T-644," was not effectively safe. For example, no safe upper temperature limit for the OXAD ML was provided in the procedure for the last phase of the distillation. The OXAD ML distillation procedure was reportedly composed on 7/31/06, signed for approval on 8/1/06, and used on 8/2/06. No effective safety change analysis of the newly-developed process, including its operating procedures, was conducted before the distillation process was performed. Employees such as Operators, Shift Leaders, a Process Engineer, and an Operations Manager, were potentially exposed to a fire and/or explosion when working on the process. An explosion and fire did occur on 8/3/06. This hazard was reasonably foreseeable in that it was recognized by employer representatives, the industry, and common sense. Among other methods, one feasible and acceptable abatement method for correcting this hazard is to conduct effective safety change analysis of a newly-developed process, including its operating procedures, before the process is performed. ABATEMENT VERIFICATION IS REQUIRED