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Occupational Safety and Health Administration OSHA

Inspection Detail



Violation Summary
Serious Willful Repeat Other Unclass Total
Initial Violations 9 9
Current Violations 1 1
Initial Penalty $34,000 $0 $0 $0 $0 $34,000
Current Penalty $2,500 $0 $0 $0 $0 $2,500
FTA Amount $0 $0 $0 $0 $0 $0

Violation Items
# ID Type Standard Issuance Abate Curr$ Init$ Fta$ Contest LastEvent
  1. 01001 Serious 19100119 D03 IB 01/26/2000 02/05/2000 $2,500 $2,500 $0 I - Informal Settlement
Deleted 2. 01002 Serious 19100119 F03 01/26/2000 02/01/2000 $0 $5,000 $0 I - Informal Settlement
Deleted 3. 01003 Serious 19100119 G01 I 01/26/2000 02/01/2000 $0 $5,000 $0 I - Informal Settlement
Deleted 4. 01004 Serious 19100119 J02 01/26/2000 02/05/2000 $0 $2,500 $0 I - Informal Settlement
Deleted 5. 01005A Serious 19100119 J04 I 01/26/2000 02/12/2000 $0 $5,000 $0 I - Informal Settlement
Deleted 6. 01005B Serious 19100119 J04 III 01/26/2000 02/05/2000 $0 $0 $0 I - Informal Settlement
Deleted 7. 01006 Serious 19100119 L01 01/26/2000 02/01/2000 $0 $5,000 $0 I - Informal Settlement
Deleted 8. 01007 Serious 19100119 M04 IV 01/26/2000 02/01/2000 $0 $5,000 $0 I - Informal Settlement
Deleted 9. 01008 Serious 19100119 M06 01/26/2000 02/01/2000 $0 $1,500 $0 I - Informal Settlement
Deleted 10. 01009 Serious 19100145 C02 01/26/2000 02/01/2000 $0 $2,500 $0 I - Informal Settlement

Accident Investigation Summary
Summary Nr: 200210524 Event: 08/09/1999One Killed, One Injured In Refinery Boiler Explosion
Employee #1, an on-shift maintenance technician, and Employee #2, a process technician, were trying to cold-start one of several steam-fired utility boilers at the refinery. The boiler had been down for several days to undergo preventive maintenance. They had tried several times to light-off the main burner when the boiler chamber exploded. Employee #1 was killed instantly and Employee #2 sustained injuries when he was struck by flying pieces of debris. Subsequent investigation revealed that 1) the light-off took several attempts due to a high flow of forced draft air; 2) safety systems, such as flame scanners, had been undergoing repairs over the previous month; and 3) equipment intended for maintenance testing was used during light-off. Neither employee had much experience with the equipment, and it was not well documented in the company's product and identification diagrams and operating procedures. In addition, the employer did not manage for the temporary loss of safety systems. The documentation of maintenance testing of the boiler equipment showed a high reliance on the inspections conducted for state certification and insurance purposes.
Keywords: maintenance, unsecured, work rules, boiler, explosion, inexperience, high pressure, untrained, refinery
Inspection Degree Nature Occupation
1 302101522 Hospitalized injury Puncture Miscellaneous plant and system operators
2 302101522 Fatality Other Electrical and electronic technicians

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