OSHA Inspection: ENSIGN-BICKFORD COMPANY (EBCO)

Issued

Aug 13, 1992

Abate by

Aug 18, 1992

Penalty

Initial $3,500 · Current $3,500

Issued

Aug 13, 1992

Abate by

Oct 30, 1992

Penalty

Initial $2,500 · Current $2,500

Issued

Aug 13, 1992

Abate by

Oct 30, 1992

Penalty

Initial $3,500 · Current $3,500

Issued

Aug 13, 1992

Abate by

Oct 30, 1992

Penalty

Initial $3,500 · Current $3,500

Issued

Aug 13, 1992

Abate by

Oct 30, 1992

Penalty

Initial $5,000 · Current $5,000

Issued

Aug 13, 1992

Abate by

Oct 30, 1992

Penalty

Initial $70,000 · Current $70,000

General-duty citation text

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 employees were exposed to
the hazard of explosions (detonations and/or deflagrations) due to runaway
chemical reaction:
BLDG 266:  DUE TO IMPROPER APPLICATION OF CHEMICAL TECHNOLOGY, THE
EMPLOYER ALLOWED CHEMICALS TO REACT SO AS TO CAUSE A RUNAWAY CHEMICAL
REACTION WHICH EXPLODED.
AMONG OTHER METHODS, ONE FEASIBLE AND ACCEPTABLE ABATEMENT METHOD TO
CORRECT THIS HAZARD IS TO ESTABLISH AND IMPLEMENT A CHEMICAL PROCESS
SAFETY MANAGEMENT PROGRAM WHICH WILL INCLUDE, BUT NOT NECESSARILY BE
LIMITED TO THE ELEMENTS OF 29 CFR 1910.119 AND THE FOLLOWING POLICY
ELEMENTS.
A.  QUALITY CONTROL POLICY
1.  ESTABLISH A CHEMICAL ANALYSIS PROGRAM WHEREBY ALL REAGENTS,
SOLVENTS (NEW, RECYCLED OR RECYCLABLE) AND IN-HOUSE SYNTHESIZED
INTERMEDIATES ARE CHECKED FOR CHEMICAL PURITY TO ENSURE
EXPLOSIONS ARE NOT INITIATED BY CONTAMINANTS.
B.  SAFE PRACTICES POLICY
1.  CONDUCT HEAT TRANSFER CALCULATIONS FOR REACTIONS AND EQUIPMENT
TO ENSURE THAT REACTIONS CAN BE HELD WITHIN THE REQUIRED PARAMETERS
TO PREVENT RUNAWAY REACTIONS WHICH COULD CAUSE EXPLOSIONS.
2.  CONDUCT MASS BALANCE CALCULATIONS TO ENSURE THAT AN ACCOUNTING
IS PROVIDED FOR ALL REACTANTS USED IN THE CHEMICAL REACTIONS.
3.  COMPARE MASS BALANCE CALCULATIONS WITH ACTUAL INVENTORY DEPLETIONS
TO ENSURE THAT REACTANTS ARE BEING USED IN PROPER RATIOS TO
PREVENT REACTANTS FROM CONCENTRATING IN SOLVENT SYSTEMS AND
INITIALLY UNANTICIPATED EXPLOSIONS
C.  HAZARD ANALYSIS/OPERATING PROCEDURE POLICY
1.  OPERATING PROCEDURES SHALL INCLUDE METHODS FOR ELIMINATING THE
CHEMICAL HAZARDS WHICH ARE CAPABLE OF CAUSING UNANTICIPATED
EXPLOSIONS AND WERE IDENTIFIED IN THE HAZARD ANALYSIS OF THE
CHEMICAL PROCESS.
D.  SCALE UP POLICY
1.  CHANGES TO THE EXPERIMENTAL EXPLOSIVE MANUFACTURING PROCESS SHALL
BE SCALED UP STEP WISE FROM TEST TUBE QUANTITIES, TO BENCH SCALE
QUANTITIES, TO PILOT PLANT SCALE QUANTITY, TO ENSURE THAT CHEMICAL
REACTIONS CAN BE CONTROLLED AND DO NOT RUN AWAY AND INITIATE
EXPLOSIONS AND/OR EMIT HAZARDOUS VAPORS.
E.  REACTOR VESSEL DECONTAMINATION POLICY
1.  BEFORE ANY REACTANTS ARE CHANGED INTO THE CHEMICAL REACTOR, IT
SHALL BE THOROUGHLY CLEANED AND RINSED.  THE RINSATE SHALL BE
CHEMICALLY ANALYZED AT LEAST QUALITATIVELY WITH A PROPER INDICATOR
(PH PAPER FOR EXAMPLE) TO ENSURE CONTAMINATES CAPABLE OF INITIATING
AN EXPLOSION ARE NOT PRESENT.
F.  INCIDENT INVESTIGATION POLICY
1.  ALL INCIDENTS WHICH COULD HAVE OR DID CAUSE EXPLOSIONS AND/OR
FIRES MUST BE FORMALLY INVESTIGATED.  THE INVESTIGATION MUST
START WITHIN 48 HOURS OF THE OCCURENCE.  THE REPORT MUST BE
MADE BY A COMPETENT PERSON FAMILURE WITH THE PROCESS AND WILL
CONTAIN A FINDING OF THE CAUSE OF THE INCIDENT AND RECOMMENDATIONS
TO PREVENT RECURRENCE.  THE EMPLOYER MUST RESPOND TO THE
RECOMMENDATIONS AND DISCUSS THEM WITH THE AFFECTED EMPLOYEES.
G.  OPERATING EMPLOYEES TRAINING POLICY
1.  ALL EMPLOYEES WHO WILL WORK ON THE DEVELOPMENT AND/OR PRODUCTION
OF EXPLOSIVES WILL BE THOROUGHLY TRAINED ON THE CONTENTS OF
29 CFR 1910.119 AND THE POLICY ELEMENTS.

Issued

Aug 13, 1992

Abate by

Oct 30, 1992

General-duty citation text

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 employees were exposed to
the hazards of runaway chemical reactions which were not controlled by
existing chemical processing equipment:
BLDG 266:  THE EMPLOYER FAILED TO PROVIDE ADEQUATE CHEMICAL PROCESSING
EQUIPMENT AND SAFETY SYSTEMS TO CONTROL A VIOLENT CHEMICAL REACTION
WHICH DETONATED AND/OR DEFLAGRATED WHEN CHEMICALS WERE ALLOWED TO REACT
AND CAUSE A RUNAWAY REACTION WITH THE EVOLUTION OF A TOXIC GAS.
AMONG OTHER METHODS, ONE FEASIBLE AND ACCEPTABLE METHOD TO CORRECT
THIS HAZARD IS TO CONDUCT A CRITICAL REVIEW OF THE CHEMICAL PROCESSING
SAFETY SYSTEMS REQUIRED TO DESIGN AND/OR REDESIGN AND CONSTRUCT AND/OR
RECONSTRUCT AN EXPERIMENTAL EXPLOSIVES MANUFACTURING SYSTEM THAT PROVIDES
MAXIMUM SAFETY FOR EMPLOYEES.  THE REVIEW, DESIGN AND CONSTRUCTION WILL
INCLUDE BUT NOT NECESSARILY BE LIMITED TO THE FOLLOWING:
A.  AN OXIDIZER ADDITION SYSTEM THAT IS CONTROLLED INSTRUMENTALLY AS
WELL AS MANUALLY AND IS
1.  INTERLOCKED WITH THE REACTOR AGITATOR SHAFT TO AUTOMATICALLY
SHUT DOWN THE ADDITION IN THE EVENT OF AGITATION LOSS TO PREVENT
THE CONCENTRATION OF REACTANTS IN ONE AREA OF THE REACTOR, THAT
COULD SUDDENLY AND VIOLENTLY REACT CAUSING A RUNAWAY CHEMICAL
REACTION WHICH COULD DETONATE AND/OR DEFLAGRATE.
2.  INTERLOCKED WITH CHILLING SYSTEM (CITY WATER AND/OR GLYCOL) TO
STOP OR RETARD THE REACTION TO PREVENT DETONATIONS AND
DEFLAGRATIONS CAUSED BY SUDDEN INCREASE IN TEMPERATURE.
3.  INTERLOCKED WITH A PRODUCT HIGH TEMPERATURE SENSOR TO SHUT DOWN
THE ADDITION PROCESS IN THE EVENT OF A RAPID EXOTHERMIC REACTION
THAT IS NOT BEING CONTROLLED BY THE CHILLING SYSTEM.
4.  INTERLOCKED WITH A PRODUCT LOW TEMPERATURE SENSOR TO SHUT DOWN
THE ADDITION SYSTEM IN THE EVENT OF A TEMPORARY (AS ON START UP,
FOR EXAMPLE) ENDOTHERMIC CONDITION TO PREVENT THE CONCENTRATION
OF REACTANTS WHICH COULD SUDDENLY REACT AND DETONATE OR
DEFLAGRATE ONCE THE IDEAL REACTION TEMPERATURE IS ACHIEVED.
5.  INTERLOCKED WITH BUILDING ELECTRICAL AND COMPRESSED AIR SYSTEMS
SO THAT LOSS OF SERVICE WILL SHUT DOWN ADDITION SYSTEM.
B.  INSTRUMENTATION AND RECORDING SYSTEM THAT WILL SENSE AND PERMANENTLY
RECORD TIME AND CRITICAL PARAMETERS INCLUDING BUT NOT LIMITED TO:
1.  PRODUCT TEMPERATURE
2.  COOLING JACKET INLET AND OUTLET TEMPERATURES
3.  REACTOR PRESSURE (POSITIVE AND NEGATIVE)
4.  AGITATOR REVOLUTIONS PER MINUTE
5.  OXIDIZER ADDITION RATE
6.  CITY WATER LINE PRESSURE
7.  GLYCOL LINE PRESSURE
8.  OPENING AND CLOSING OF DROWN VALVE
9.  AIR LINE PRESSURE
10.  GAS EVOLUTION IN THE REACTOR
C.  A MULTIPHASED EMERGENCY RELIEF SYSTEM SIZED AND DESIGNED ACCORDING
TO RECOGNIZED CURRENT TECHNOLOGY SUCH AS THAT PUBLISHED BY THE
DESIGN INSTITUTE OF EMERGENCY RELIEF SYSTEMS (DIERS) OF THE AMERICAN
INSTITUTE OF CHEMICAL ENGINEERS.
D.  AN AUTOMATIC AND MANUAL DROWN SYSTEM BASED UPON CRITICAL TEMPERATURES
AND PRESSURES.  THE VALVING SHALL BE "FAIL SAFE" IN THAT THE VALVE
IS NORMALLY OPEN AND IF FAILURE OF THE CONTROL SYSTEM SHOULD OCCUR
THE VALVE WILL FAIL IN THE OPEN POSITION ALLOWING THE CONTENTS OF THE
REACTOR TO DUMP AND THE REACTION BE QUENCHED.  THE AUTOMATIC VALVE
SHALL BE SO DESIGNED THAT IT CANNOT BE EASILY MANUALLY OVERRIDDEN.
E.  ALL CRITICAL PARAMETERS WILL BE ALARMED WITH VISUAL OR AUDIBLE
ALARMS TO WARN EMPLOYEES OF IMPENDING DANGER AND ALLOW THEM SUFFICIENT
TIME TO TAKE APPROPRIATE ACTION TO PROTECT THEMSELVES.
F.  REMOTE OPERATION.  ALL CRITICAL OPERATIONS (OXIDIZER ADDITION FOR
EXAMPLE) MUST BE AUTOMATED AND CAPABLE OF BEING OPERATED FROM A
REMOTE, SAFE LOCATION.  MONITORING OF THE REMOTE OPERATION SHALL
BE DONE BY CLOSED CIRCUIT TELEVISION.  THE REMOTE SYSTEM MUST BE
UTILIZED WHENEVER A NEW OR REVISED PROCESS IS ATTEMPTED AND MUST
BE CONTINUALLY USED UNTIL THE EMPLOYER CAN DEMONSTRATE THAT THE
CHEMICAL REACTIONS INVOLVED IN THE PROCESS CAN BE CONTROLLED BY THE
EXISTING SAFETY SYSTEMS.
G.  ALL INSTRUMENTS, RECORDERS, ALARMS AND CONTROLLERS WILL BE CALIBRATED
QUARTERLY.  IN THE EVENT THE SAFETY SYSTEM IS DISRUPTED, ALL COMPONENTS
WILL BE CALIBRATED BEFORE THE PROCESSING SYSTEM IS USED AGAIN.
H.  A BACK-UP AGITATION SYSTEM SHOULD BE DEVELOPED, WHEREBY IF THERE IS
LOSS OF ONE AGITATION SYSTEM, THE OTHER WOULD CONTINUE TO OPERATE TO
PRESENT BUILD UP OF REACTANTS WHICH COULD CAUSE DETONATION.

Issued

Aug 13, 1992

Abate by

Oct 30, 1992

General-duty citation text

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 employees were exposed to
the hazards of explosion (detonations and/or deflagrations) due to
runaway chemical reactions an event for which the employer had not
adequately trained his employees in methods of prevention and/or
controlling:
BLDG 266:  THE EMPLOYER FAILED TO ADEQUATELY TRAIN HIS EMPLOYEES IN METHODS
OF PREVENTING AND/OR CONTROLLING A VIOLENT CHEMICAL REACTION WHICH
DETONATED AND/OR DEFLAGRATED DURING THE EXPERIMENTAL MANUFACTURE OF
EXPLOSIVES WHEN AN INAPPROPRIATE QUANTITY OF OXIDIZER WAS ADDED TOO QUICKLY
TO A NITRATABLE BASE.
AMONG OTHER METHODS, ONE FEASIBLE AND ACCEPTABLE ABATEMENT METHOD TO
CORRECT THIS HAZARD IS TO ESTABLISH A WRITTEN TRAINING PROGRAM AND TO
ADEQUATELY TRAIN EMPLOYEES WITH THE PROGRAM.  THE PROGRAM AND TRAINING
WILL INCLUDE BUT NOT NECESSARILY BE LIMITED TO:
A.  PREPARATION OF PROCESS FLOW SHEETS, THAT IDENTIFY POTENTIAL
EMERGENCIES WHICH COULD DEVELOP DURING START-UP, SHUT DOWN AND
NORMAL OPERATING CONDITIONS AND METHODS WHEREBY EMPLOYEES WILL BE
PROTECTED.
B.  PREPARATION OF PIPING AND INSTRUMENTATION DIAGRAMS (P& ID) TO
IDENTIFY CONTROLLERS, SENSORS, INSTRUMENTS, VALVES AND RECORDERS THAT
WILL DETECT PROCESS SYSTEM ANOMALIES TO ENSURE THAT EMPLOYEES ARE
AWARE OF THE LOCATION AND SIGNIFICANCE OF ALL ELEMENTS OF THE SAFETY
SYSTEM AND ARE TRAINED IN METHODS THEY ARE TO USE TO PROTECT THEMSELVES
INCLUDING BUT NOT LIMITED TO ANOMALY ATTENUATION AND/OR EVACUATION.
C.  OBTAIN AND/OR PREPARE MATERIAL SAFETY DATA SHEETS FOR ALL REACTANTS
AND INTERMEDIATE CHEMICALS TO ENSURE THAT EMPLOYEES ARE AWARE OF THE
DANGERS OF THESE CHEMICALS AND ARE TRAINED IN THE METHODS OF PROTECTING
THEMSELVES IN THE EVENT OF EXPOSURE.
D.  PREPARE DETAILED PROCESS EQUIPMENT OPERATING PROCEDURES AND TRAIN
EMPLOYEES TO ENSURE THEY CAN SAFELY OPERATE ALL EQUIPMENT.
E.  PREPARE DETAILED CHEMICAL TECHNOLOGY OPERATING PROCEDURES AND TRAIN
EMPLOYEES TO ENSURE THEY CAN SAFELY MIX/ADD REACTANTS WHICH ARE CAPABLE
OF INITIATING DETONATIONS AND DEFLAGRATIONS.
F.  SUPPLY AND TRAIN EMPLOYEES IN THE USE OF APPROPRIATE PERSONAL
PROTECTIVE EQUIPMENT.
G.  DEVELOP AND IMPLEMENT AN EMERGENCY EVACUATION PLAN FOR BLDG 266.