Text For Citation: 02 Item/Group: 063 Hazard: CRUSHING

Section 5(a)(1) of the Occupational Safety and Health Act of 1970: The %% employer did not furnish employment and a place of employment to Debra Miller which was free from recognized hazards that were causing or likely to cause serious physical harm to employees in that there was a catastrophic failure/explosion in a pressure vessel containing liquified Carbon Dioxide (CO2), Ammonia (NH3), Ammonium Carbamate, and urea, under 2850 psig of pressure at a temperature of 370 degrees Fahrenheit, exposing them to; being crushed/struck by flying/falling debris and/or, heat/chemical burns and/or, asphyxiation/toxic gases. The following conditions contributed to the existence of this hazard: (a) On or about July 28, 1992, the urea manufacturing operation utilizing a pressure vessel was not shut down upon previous detection of leaks in the liner. Feasible abatement methods to correct this condition may include, but are not limited to, shut the reactor down immediately upon detection of a leak and radiographically check for corrosion. (b) On or about July 28, 1992, management had not developed an adequate inspection program to insure that each leak detection system (weep holes and leak detection holes) was inspected properly for detection of decomposition gases (carbon dioxide and ammonia) or leaking product (ammonia carbamate). 1. Inconsistent recordkeeping and review practices of leak detection system (weep holes and leak detection holes) inspection programs and procedures were used. 2. Means to thoroughly inspect each leak detection system (weep holes and leak detection holes) for the possibility of escaping gases (carbon dioxide and ammonia), or leaking product (ammonia carbamate) had not been provided. Feasible abatement methods to correct this condition may include, but are not limited to, installing manometers on each weep hole to detect if gas is being released or construct platforms around the reactor to provide accessibility to the weep hole, drilling out weep holes if badly clogged or rodded out if the clogging is not too hard. Steam injection for periods long enough to dissolve the hardened urea may also be done. Numerous checks by ammonia detection techniques are required to maintain assured continuous operation, creating and establishing appropriate and/or adequate administrative controls to insure that operators inspect each weep hole every hour on the hour for conditions indicating possible leaks in the liner and document these conditions by having a check-off column on the inspection form for each of the twenty-four (24) weep holes. Management must conduct follow-up inspections to assure compliance. (c) On or about July 28, 1992, the Arcadian Corporation operated a pressure vessel (R-2 Reactor) with a stainless steel liner that had been inadequately/improperly repaired, inspected, and maintained in a manner which did not assure an optimum degree of integrity. Feasible abatement methods to correct this condition may include, but are limited to, complying with API 510, ASME, etc., to make repairs and test welds prior to operating the reactor.