Text For Citation: 01 Item/Group: 027 Hazard:

29 CFR 1910.119(l)(2): The procedures did not assure that the following considerations were addressed prior to any change: 29 CFR 1910.119(l)(2)(ii):Impact of change on safety and health; a. On or about and prior to April 8, 2021, for the management of change (MOC) procedure tracking number 1556, the employer failed to adequately address potential safety and health impacts of the change made by the MOC procedure. This MOC involved the Kettle 3 Automation (Phase 1), the Bubble Cap Column installation, the Eductor valve change and all kettle 3 changes during the Kettle 3 shutdown completed in December 2018. The MOC failed to address the potential impact on the relief systems of the Kettle 3 reactor vessel and the relief systems for other Kettle 3 system equipment; to include any inlet lines, relief devices, relief discharge lines, relief disposal equipment and safe venting of relief discharge lines. Additionally the MOC failed to address the safety and health impact of the Automation (Phase 1) changes to the agitator kettle 3 operator control screen related to potential "loss of agitation" and removal of the "loss of agitation" lighted alarm from the K3/K4 reactor room. Failure to adequately address the safety and health impacts can lead to improper relief systems exposing employees to loss of containment events, fire, and explosions. b. On or about and prior to April 8, 2021, for the management of change (MOC) procedure tracking number 2178, the employer failed to adequately address potential safety and health impacts of the change made by the MOC procedure. This MOC involved the K3 Condenser installation and failed to address the impact on pressure relief systems to include atmospheric venting of solvent vapor from the condenser, the relief system of the Kettle 3 reactor vessel, the relief systems for other Kettle 3 system equipment and the relief system for K3 Condenser; to include any inlet lines, relief devices, relief discharge lines, relief disposal equipment and safe venting of relief discharge lines. Failure to adequately address the safety and health impacts can lead to improper relief systems exposing employees to loss of containment events, fire, and explosions. c. On or about and prior to April 8, 2021, for the management of change (MOC) procedure tracking number 2191, the employer failed to adequately address potential safety and health impacts of the change made by the MOC procedure. This MOC involved the K3 Hopper Transition and the alteration of an ASME code pressure vessel, the kettle 3 reactor. The MOC failed to address the impact of the alteration on the loss of pressure containing ability related to the installation of a nozzle which penetrated the vessel shell, the installation of a manway opening which penetrated the vessel head and the welding alteration of the existing vessel manway opening to connect to the solid material hopper, to include the use of qualified welding personnel to perform code pressure vessel alterations, the use of qualified organizations to design the alteration, the alteration design performed according to applicable code and the design of inspection and testing plans to address the potential loss of pressure containing ability related to the alteration. On April 8, 2021, the kettle 3 reactor vessel manway cover to manway flange gasket failed and released vapor into the kettle 3/kettle 4 room. This catastrophic failure resulted in the explosion event that resulted in the fatality and multiple disabling injuries. d. On or about and prior to April 8, 2021, for the management of change (MOC) procedure tracking number 2152, the employer failed to adequately address potential safety and health impacts of the change made by the MOC procedure. This MOC involved the Safety Interlock Update and failed to address the potential impact "loss of agitation" on the Kettle 3 reactor vessel pressure safety interlock and the emergency cooling water interlock, to include the agitator interlock preventing cooling water flow into the kettle and the safety and health impact upon the vessel pressure interlock and the emergency cooling water interlock. Failure to adequately address the safety and health impacts can lead to safety system interlock failure exposing employees to loss of containment events, fire, and explosions. e. On or about and prior to April 8, 2021, for the management of change (MOC) procedure tracking number 2088, the employer failed to adequately address potential safety and health impacts of the change made by the MOC procedure. This MOC involved the K4 - Automation Phase 4 and failed to address the potential impact "loss of agitation" on the Kettle 3 reactor vessel pressure safety interlock and the emergency cooling water interlock, to include the agitator interlock preventing cooling water flow into the kettle and the safety and health impact upon the vessel pressure interlock and the emergency cooling water interlock. Failure to adequately address the safety and health impacts can lead to safety system interlock failure exposing employees to loss of containment events, fire, and explosions. f. On or about and prior to April 8, 2021, for the management of change (MOC) procedure tracking number 2044, the employer failed to adequately address potential safety and health impacts of the change made by the MOC procedure. This MOC involved the K5 - Automation Phase 3 and failed to address the potential impact "loss of agitation" on the Kettle 5 reactor vessel pressure safety interlock and the emergency cooling water interlock, to include the agitator interlock preventing cooling water flow into the kettle and the safety and health impact upon the vessel pressure interlock and the emergency cooling water interlock. Failure to adequately address the safety and health impacts can lead to safety system interlock failure exposing employees to loss of containment events, fire, and explosions.