Text For Citation: 01 Item/Group: 008B Hazard: UNAPEQUIP

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 change analysis being performed whenever a change in process procedures occurred that could have an effect on safety. Such change analysis is an element of an effective safety and health program. 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 distillation process procedure, which was the "Plant Operating Standard for OXAD Mother Liquor Distillation in T-644," was deviated from in that the temperature was raised beyond any temperature listed in the procedure (and beyond a safe temperature level). No change analysis was performed when temperatures in the distillation were raised to unsafe levels. 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 perform change analysis whenever a change in facilities, equipment, materials, or processes procedures occurs. ABATEMENT VERIFICATION IS REQUIRED