Text For Citation: 01 Item/Group: 001 Hazard: LOCKOUT

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 W.G. Abbs was exposed to the recognized hazard of fire and explosion in that: - The employer did not take adequate measures to prevent a hazardous release of flammable materials in that: a) The employer did not conduct internal audits that included items such as a process hazard review, a job safety analysis and a human factor analysis of Polyethylene Plants 4 and 5. This condition could be corrected by addressing safety factors in, for example, a general hazard and operability study (HAZOP), a structured method of systematically investigating each element of a process design, to identify all of the ways in which deviations can occur from intended design parameters to create hazards or operability problems. This condition could also be corrected by addressing conditions which influence the performance of human operators, maintenance staff, technicians, and other personnel in the plant. This review should evaluate mechanical features of the job design that are likely to produce significant human error, the effect of design modification on operator performance, and identify the source of observed human error and identify human factors that could result in accident event sequences. This review should 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. b) Only a single block valve was utilized ot isolate hazardous materials in the polyethylene reactors which operated at elevated degrees of temperature and pressure while maintenance operations were being performed on the settling legs. A failure and/or malfunction of the single block valve system would lead to a catastrophic release of flammable hydrocarbons. This condition could be corrected by the following methods, among others: 1) Redesign the settling legs with the utilization of an additional block valve along with a bleed valve (double block and bleed) in order to contain the reactor contents within the system during maintenance operations; or 2) Utilize a slip blind to provide a barrier after the block valve; or 3) Redesign the settling legs and/or system to reduce or eliminate plugging of settling legs; or 4) Change the operations and maintenance practices to open the settling legs only when the reactors are taken out of operation. c) The employer did not develop, implement and enforce an effective safety permit system (e.g. opening, vehicle entry, hot work and special equipment permit) to communicate the proper safety precaution to be observed prior to and during maintenance operations on reactor settling legs. Additionally, hot work permits with combustible gas monitoring requirements were not used for vehicle entry into the reactor areas. These conditions could be corrected by developing, implementing and enforcing an effective safety permit system and providing training to all appropriate personnel in the purpose and use of that system. At a minimum, such a permit should include a listing of all precautionary requirements or procedures to be observed during the work. A notation should be made on the permit as each procedure is completed, and the permit should be signed by both the issuing person and the receiving person. Furthermore, testing for the presence of flammable vapors must occur whenever an ignition source is introduced into a hazardous area. d) The employer did not utilize adequate lockout/tagout procedures to prepare equipment for maintenance. This condition can be corrected by establishing and enforcing adequate plant lockout/tagout procedures such as that stipulated by ANSI Z244.1-1982, Sections 4 and 5, American Standard of Minimum Safety Requirements for lockout/ tagout of energy sources for personnel protection. Essential elements of the lockout procedure would include each of the following: 1) Open and lock out the main power supply (e.g. air or electrical) for the equipment and bleed off any residual energy; 2) Provide each potentially exposed employee working in the area with separate lock and key to place on the lockout means; 3) Establish a written lockout policy, including procedures to be followed and training for all affected employees, both maintenance and operational crews; 4) Periodically evaluate the program and strictly enforce all of its provisions. e) Critical block valves including, but not necessarily limited to, the 8-inch DEMCO valves located on each of the settling legs on reactors in Polyethylene Plants 4 and 5, were not of the type designed to fail in a safe position in the event of a failure or interruption of service of the energy source controlling the valve. This condition could be corrected by methods such as: 1) Replace the existing valve actuators with air-to-open spring return actuators such as Bettis Model &-420-SR or its equivalent; or 2) Retrofit the existing actuator with a Bettis Type AFS (air fail-safe) system which makes use of an air reservoir to close the actuator should air supply pressure fall below a predetermined level. - The employer did not use or implement adequate methods to minimize the consequences of a flammable materials release in that: a) The Polyethylene Plants 4 and 5 were not provided with combustible gas detectors placed in strategic locations to provide early identification and subsequent mitigation of combustible or flammable gas releases. This condition could be corrected by installing fixed combustible gas detectors in areas where leaks have been known to occur such as, but not necessarily limited to, the reactor settling legs, reactor circulating pump seals, compressors, loading racks, etc. and: 1) Interlock the signal from a tripped combustible gas detector with a separate signal indicative of a process upset condition (i.e., reactor low pressure trip signal) such that the simultaneous presence of both signals could activate a deluge or sprinkler system, and/or activate the closing of critical isolation valves, thereby mitigating the effects of a flammable vapor cloud release; or 2) Interlock separate signals from two or more combustible gas detectors which have been tripped in the same area within a short time span (indicative of a significant vapor cloud release) such that mitigative actions (e.g. activation of deluge, sprinklers and/or closing of valves) are activated. b) The employer located sources of ignition downwind from process units containing large volumes of pressurized flammable liquids/gases. The gas fired catalyst heaters were located northwest of the Polyethylene Plants 4 and 5. The prevailing wind direction for the area is south east to northwest. This condition could be corrected by methods such as: 1) Relocate the catalyst heaters to a position farther removed and/or upwind of the large inventories of flammable materials; or 2) Use fully enclosed electric heaters approved for hazardous service. c) The ventilation system for the Plant 4 and 5 finishing that air intakes faced the Plant 5 reactors at ground level. A flammable hydrocarbon release in the Plant 5 reactor area could be drawn through the air intakes into the finishing building, where it could reach a possible ignition source and could result in a confined vapor cloud explosion. This condition could be corrected by the following methods: 1) Design and construct the ventilation system for critical occupancy buildings so that the air intakes would not draw flammable vapors from a nearby process area should a vapor release occur; or 2) Install flammable gas detectors immediately down stream of the air intakes for the critical occupancy buildings which, when activated, would initiate the shut-down of the air intake system. d) Adequate separation distances were not provided between high hazard process units, as well as between process units and adjacent critical occupancy buildings, so that in the case of a hazardous event (e.g. release of flammable liquids, vapors or gases) at any one unit or area, the other units or areas would not be affected. These would include but are not limited to the finishing building, the control room building, the motor control center, the facility housing the control for major process equipment, and the maintenance shop located in Polyethylene Plants 4 and 5. This condition could be corrected by the following methods: 1) Follow accepted industry guidelines for plant layout and spacing, including but not limited to: a) The Dow Chemical Company, "Fire and Explosion Index Hazard Classification Guide." b) The Industrial Risk Insurer "General Recommendations for Spacing in Refineries, Petrochemical Plants, Gasoline Plants, Terminals, Oil Pump Stations, and Offshore Properties". 2) If adequate spacing cannot be achieved, alternative methods of protection must be implemented. The control room building, a critical work area, shall be afforded protection through explosion-resistant construction or adequate barricading. The process units shall be provided with alternative means such as deluge systems, fire sprinklers, spill containment and/or inventory control. e) The ethylene piping system to Polyethylene Plants 4 and 5 was not provided with emergency isolation valves capable of remote operation or with excess flow sensitive valving, either of which can limit the volume of flammable hydrocarbons continuing to fuel a fire. This condition could be corrected by installing the above valves in each ethylene line between the ethylene header and each individual process unit boundary. - The employer's fire protection system was not maintained in the state of readiness necessary to provide effective fire control in that: Diesel-engine firepumps were not test run weekly. Diesel fuel tank levels were not adequately maintained. Firepumps were removed from service without notification of the plant fire department. The wiring of the electric firewater pumps was not kept independent of other wiring and was not buried or otherwise protected from fire. These conditions can be corrected by the following methods: 1) Assure that a qualified person monitors and records a weekly, 30-minute test run of each diesel-engine drive firepump to ensure their operational readiness. Any problems or maintenance necessary should be corrected and recorded. 2) Coordinate the periodic checking of diesel fuel tank levels with those responsible for fueling the tanks so that proper tank filling is assured as mandated by NFPA-20, Section 8-6.4. Alternatively, increase the frequency for checking of fuel tank levels. 3) Develop and provide training on a standard operating procedure (SOP) for notifying the fire department whenever a firepump is being removed from service. 4) Maintain an independently protected electric power source to the electric firewater pumps.