Text For Citation: 01 Item/Group: 012 Hazard:

29 CFR 1910.119(f)(4): The employer did not develop and implement safe work practices to provide for the control of hazards during operations such as lockout/tagout; confined space entry; opening process equipment or piping: a) On or about May 12, 2021, at Limetree Bay Refining, LLC., Delayed Coker Unit (DCU) - The employer failed to implement the safe work practice 35-0044 "Walk the Line (WTL) Guidance" to isolate and return equipment to service when Operations along with designated personnel (Maintenance, Engineering, SME, etc.) did not walk down the Coke Drum quench water system following a piping repair where the quench water 3" bypass valve was opened to drain the water lines. On May 12, 2021, an excessive amount of quench water, due to unsecured and open quench water 3" bypass valve and spectacle blind, entered Coke Drum D-8504, resulting in an overpressure event, release to flare, and a fire at the flare stack. b) On or about May 12, 2021 at Limetree Bay Refining, LLC., Delayed Coker Unit (DCU) - The employer failed to develop and implement safe work practices to ensure the position of car seals was verified to prevent inadvertent valve opening or closure (i.e. deviating from normal operating conditions). Car seal inspections were not performed when equipment was returned to service following maintenance activities where a car sealed valve's normal state/condition was changed.