Text For Citation: 02 Item/Group: 001 Hazard: ELECTRIC

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 Blaine A. Reese was exposed to the recognized hazard of fire and explosion. Specifically: Adequate precautions were not taken to prevent an explosive atmosphere/explosion within the vapor space of tank TK68720 in the utilities wastewater area: a) Internal audits for the utilities wastewater area did not inlcude a human factor analysis. This condition could be corrected by evaluating conditions which influence the performance of operators, maintenance staff, technicians, and other personnel in the plant. These reviews should: evaluate mechanical features of the job that are likely to produce significant human error; evaluate the effect of design modifications on operator performance; identify the source of observed human error; and identify human factors that could result in a systematic listing of the (1) types of errors likely to be encountered during normal or emergency operation, (2) factors contributing to such errors, and (3) proposed system modifications to reduce the likelihood of such errors. The reviews should also result in the implementation of operations and maintenance training programs that include initial and refresher training to provide operations and maintenance personnel with an understanding of the hazards created by process reactions, recognition of instrumentation failure, and the actions necessary to reduce the hazards. b) On or about June 15, 1990, the nitrogen purge to the vapor space of tank TK68720 was reduced to an ineffective level, and on July 4, 1990 was further reduced to its minimum flow, where it remained until a few minutes before tank TK68720 exploded on July 5, 1990. This condition could be corrected by modifying the nitrogen purge system to tank TK68720 to prevent operator reduction of nitrogen flow below the amount necessary to maintain an inert atmosphere within the vapor space of tank TK 68720. c) On or about June 15, 1990, through the time of the fire and explosion on July 5, 1990, the oxygen analyzer for the vapor space of tank TK68720 did not furnction in a reliable manner and an alternate method of monitoring the oxygen content of the vapor space of tank TK68720 was not employed. This condition could be corrected by the implementation of a redundant system of testing to verify the readings taken from the oxygen analyzer for the vapor space of tank TK68720. d) Excessive liquid hydrocarbons were allowed to accumulate in the tank. This condition could be corrected by modifying the liquid hydrocarbon removal system for tank TK68720 to continually remove excess liquid hydrocarbons to a safe storage facility. e) The C6801 vent compressor was available for use or used to compress the explosive vapor in the vapor space of the tank, and was a source of ignition in light of the characteristics of the vapors space on July 5, 1990. This condition could be corrected by maintaining an inert atmosphere in the vapor space of tank TK68720. f) Activities involving the use of potential ignition sources, such as unapproved electrical lights and cord sets, internal combustion engine vehicles, and an impact wrench, were performed in the utilities wastewater area. This condition could be corrected by enforcing an effective safety permit system which required initial and periodic hydrocarbon monitoring of the atmosphere in the work area during any operations involving ignition sources, and by observing the precautions required by 20 CFR 1910.106(b)(6) and 29 CFR 1910.307(b).