Union Oil Company of California

Read the official release (oshrc.gov)

Plain-English summary

A pressure vessel failed at Union Oil's Chicago refinery, causing an explosion and fire that killed 17 employees and caused lost-worktime injuries to 14 others. OSHA cited pressure-vessel inspection and repair practices, protective equipment for employees performing firefighting duties, fire brigade training, and emergency evacuation planning. The ALJ assessed $22,000 after finding several willful and serious violations. The Seventh Circuit held that the pressure-vessel general duty item and the personal protective equipment item were not willful, and it ruled that the protective equipment requirement covered all employees described in the citation. The court otherwise left the fire brigade and evacuation rulings in place. On remand, the Commission assessed $1,000 each for the two violations reclassified by the court, retained $7,000 for the fire brigade items and $1,000 for the evacuation item, and set the total penalty at $10,000.

Decision snapshot

• Cited standard(s): 29 U.S.C. § 654(a)(1); 29 C.F.R. §§ 1910.132(a) and 1910.156(c)(1)-(4)
• Outcome: Penalties modified after court review from $22,000 to $10,000; the remaining citation findings were left in place.
• Key point: A nonfrivolous interpretation of a protective-equipment standard defeated willfulness, but did not eliminate the underlying violation or its application to the full cited employee group.

Full text (OSHRC public release)

Docket No. 85-0111

SECRETARY OF LABOR,

Complainant,

v.

UNION OIL COMPANY OF CALIFORNIA,

Respondent.

OSHRC Docket No. 85-0111

DECISION

Before: BUCKLEY, Chairman, and AREY, Commissioner.

BY THE COMMISSION:

The United States Court of Appeals for the Seventh Circuit has remanded this case to
us so that we may determine the penalty to be assessed Union Oil Company of California. McLaughlin
v. Union Oil Co. of California , 869 F.2d 1039 (7th Cir. 1989).

The Secretary of Labor issued Union Oil two citations
alleging violations of the Occupational Safety and Health Act of 1970, 29 U.S.C. �� 651 et
seq. ("the Act"). Citation 1 alleged that Union Oil had committed three
willful violations; citation 2 alleged one serious violation. The Secretary proposed the
maximum penalties permitted under the Act, $10,000 for each of the three willful items and
$1,000 for the one serious item. See sections 17(a) and 17(b) of the Act, 29 U.S.C.
�� 666(a) & (b).

Item 1 of citation 1 alleged a willful violation of
section 5(a)(1) of the Act, 29 U.S.C. � 654(a)(1), known as the "general duty
clause." Item 2 alleged a willful violation of 29 C.F.R. � 1910.132(a). Item 3
contained six sub-items alleging violations of various subsections of 29 C.F.R. �
1910.156(c). These sub-items together allegedly constituted one willful violation of
section 1910.156(c). Citation 2 alleged that Union Oil had committed one serious violation
of section 5(a)(1).

The administrative law judge who heard the case found
that Union Oil had committed a willful violation of section 5(a)(1) and affirmed item 1 of
citation 1. He assessed a $10,000 penalty for that item.

Addressing item 2 of citation 1, the administrative
law judge concluded that the requirements of 29 C.F.R. � 1910.132(a) applied to certain
classes of Union Oil's employees but not to others. He consequently found a violation, but
only as to some of the employees covered by item 2 of citation 1. He found that the
violation was willful as to the employees covered, but he reduced the penalty from $10,000
to $4,000.

The judge affirmed five of the six sub-items of item

3. He found that the violations alleged in sub-items 3A, 3C, and 3E were willful and
   assessed a combined penalty of $6,000 for the three. The judge affirmed sub-items 3D and
   3F as serious, rather than willful, violations and assessed a $1,000 penalty for these. He
   vacated the remaining sub-item, 3B.

In citation 2, the judge found that there had been a
serious violation of section 5(a)(1) and assessed the proposed penalty of $1,000. The
penalties assessed totaled $22,000.

The judge's decision was not directed for review by
the Commission, and both parties appealed to the court of appeals.

The court held that the judge had erred in limiting
his finding of a violation of section 1910.132(a) to certain employees. It said that all
the employees described in item 2 of citation 1 had to be provided with protective
equipment under that standard. The court held, however, that the violation of section
1910.132(a) was not willful because Union Oil's interpretation of the standard was not
frivolous. The court also disagreed with the administrative law judge's finding that item
1 of citation 1 was willful.

Although Union Oil challenged on appeal the judge's
findings with regard to the five sub-items in item 3 of citation 1 that were affirmed by
the administrative law judge, the court did not address these items specifically. It found
that the judge committed no clear error in finding that one group of employees was
inadequately trained. The court saw no need to discuss Union Oil's other challenges to the
judge's findings, holding that those challenges had no merit. The court similarly rejected
Union Oil's challenge to the judge's affirmance of citation 2. The judge's disposition of
item 3 of citation 1 and of citation 2 therefore stands.

Under section 17(j) of the Act, 29 U.S.C. � 666(j),
in assessing penalties, the Commission must give due consideration to the size of the
employer, the gravity of the violation, the good faith of the employer, and the employer's
history of previous violations. Having considered those factors, we modify the judge's
decision to assess the following penalties for the violations found non-willful by the
court: $1,000 for item 1 of citation 1 (section 5(a)(1)), and $1,000 for item 2 of
citation 1 (section 1910.132(a)). We affirm the judge's penalty assessments for those
violations not disturbed by the court: $7,000 for item 3 of citation 1 (section
1910.156(c)), and $1,000 for citation 2 (section 5(a)(1)). We therefore assess a total of
$10,000 in penalties.[[1/]]

FOR THE COMMISSION

Ray H. Darling, Jr.

Executive Secretary

DATED: April 26, 1989

SECRETARY OF LABOR,

Complainant,

v.

UNION OIL COMPANY OF CALIFORNIA,

CHICAGO REFINERY,

Respondent,

OIL, CHEMICAL AND ATOMIC WORKERS

INTERNATIONAL UNION, AFL-CIO,

and its Local 7-517,

Authorized Employee Representative.

OSHRC DOCKET NO. 85-0111

DECISION AND ORDER

Child, Judge

APPEARANCES:

For the Complainant:

Richard J. Fiore, Esq., Chicago, Illinois

Lisa R. Williams, Esq., Chicago, Illinois

Mark A. Holbert, Esq., Chicago, Illinois

Peter D. Broitman, Esq., Chicago, Illinois

For the Respondent:

Mark A. Lies, II, Esq., Chicago, Illinois

Robert H. Joyce, Esq., Chicago, Illinois

Robert E. Mann, Esq., Chicago, Illinois

For the Authorized Employee Representative:

Bill Wittig, Lemont, Illinois

Gary Woods, Lemont, Illinois

Robert B. Hattendorf, Lemont, Illinois

Statement of the Case

This matter is before the Occupational Safety and
Health Review Commission (the Commission) pursuant to section 10(c) of the Occupational
Safety and Health Act of 1970, 29 U.S.C. � 651 et seq ., (the Act).
Complainant seeks affirmance of Citation No. 1 issued to respondent January 11, 1985,
charging: one item of willful violation of section 5(a)(1) of the Act[[1/]] for alleged
failure to furnish a place of employment free of the hazard of fire and explosion
resulting from failure to properly repair and adequately inspect for corrosion and
deterioration pressure vessels containing liquefied petroleum products in process of
production, and two items of willful violation of section 5(a)(2) of the Act for alleged
failure of the respondent to comply with various standards adopted by the Secretary of
Labor having to do with personal protective equipment and training to be provided employee
fire fighting personnel. Complainant seeks affirmance of the proposed penalty of
$30,000.00 for these allegedly willful violations.

Complainant also seeks affirmance of Citation No. 2,
issued to respondent January 11, 1985, charging one item of violation of section 5(a)(1)
of the Act for alleged " . . . lack of effective emergency evacuation procedures and
education and training of personnel in said procedures," and of the penalty proposed
thereon in the sum of $1,000.00.

The matter came on regularly for hearing at Chicago,
Illinois, commencing on the 21st day of April 1987, and concluding on the 3rd day of June
1987. The parties were permitted to submit posthearing briefs, proposed findings of fact
and conclusions of law, replies and sur-replies as they desired. Each has submitted
post-hearing briefs. Respondent has submitted proposed findings of fact and conclusions of
law. Complainant and respondent have each submitted replies to the other's post-hearing
brief and sur-replies to the other's reply.

To the extent proposed findings of fact and
conclusions of law submitted by the respondent are consistent with those entered herein
they are accepted; to the extent they are not so consistent they are rejected.

As stated at pages 89-91 of respondent's Post-Trial
memorandum the only "affirmative defenses" claimed by the respondent are: (1)
compliance with the Illinois Boiler and Pressure Vessel Safety Act regarding respondent's
pressure vessel inspection program and the records maintained thereof in effect preempts
an action brought by the Secretary claiming violation of the "general duty
clause" of the Act (Citation No. 1, item 1), and (2) compliance with certain aspects
of the complainant's proposed evacuation program, requiring evacuation of all employees
from the operating units, would create an increased hazard (Citation No. 2, item 1). There
can be no greater hazard affirmative defense to an alleged violation of the general duty
clause. Secretary v. Royal Logging Company , 7 BNA OSHC 1744, 1751 (No. 15169,
1979), affirmed 645 F.2d 822, 830 (Ninth Cir. 1981). See Issue Q, infra .

Jurisdiction of the subject matter and of the parties
has been admitted and is not an issue.

The Issues :

Issues raised by the citations and the pleadings to
be here determined are:

A. Was the respondent in violation of section 5(1)(1) of the Act as alleged in
Citation No. 1, item 1?[[2/]]

B. Would compliance by the respondent with the
Illinois Boiler and Pressure Vessel Safety Act, if compliance there be, constitute a bar
to complainant proceeding under section 5(a)(1) of the Act?

C. If respondent was in violation of section 5(a)(1)
of the Act as set forth in Issue A, was that violation willful?

D. If respondent was in violation of section 5(a)(1)
of the Act as set forth in Issue A what penalty would be appropriate?

E. Was the respondent in violation of 29 C.F.R.
1910.132(a) for failure to provide and require the use of protective fire fighting
equipment as alleged in Citation No. 1, item 2?[[3/]]

F. If respondent was in violation of the standard as
alleged in Issue E, was that violation willful, or failing that, serious?

G. If respondent was in violation of the standard as
alleged in Issue E, what, if any, penalty would be appropriate?

H. Was the respondent in violation of 29 C.F.R.
1910.156(c)(1) as alleged in Citation No. 1, item 3A?[[4/]]

I. Was the respondent in violation of 29 C.F.R.
1910.156(c)(1) as alleged in Citation No. 1, item 3B?[[5/]]

J. Was the respondent in violation of 29 C.F.R.
1910.156(c)(2) as alleged in Citation No. 1, item 3C?[[6/]]

K. Was the respondent in violation of 29 C.F.R.
156(c)(2) as alleged in Citation No. 1, Item 3D?[[7/]]

L. Was the respondent in violation of 29 C.F.R.
156(c)(3) as alleged in Citation No. 1, item 3E?[[8/]]

M. Was the respondent in violation of 29 C.F.R.
1910.156(c)(4) as alleged in Citation No. 1, item 3F?[[9/]]

N. If the respondent was in violation of any or all
of Issues H thru M (items 3A thru 3F), was such violation willful or failing that serious,
in whole or in part?

O. If the respondent was in violation of any or all
of Issues H thru M (items 3A thru 3F) what, if any, penalty or penalties would be
appropriate?

P. Was the respondent in violation of section 5(a)(1)
of the Act as alleged in serious Citation No. 2, item 1?[[10/]]

Q. Would an evacuation plan as proposed by
complainant create a greater hazard to respondent's employees and thus become other than
feasible?

R. If respondent was in violation of section 5(a)(1)
of the Act as set forth in Issue P, above, what penalty would be appropriate?

The Catastrophic Event

During the afternoon shift on July 23, 1984, a vapor
cloud was observed to be coming from the vicinity of a large pressure vessel in the
Unsaturated Gas Plant of respondent's Chicago Refinery.

The vessel, known as and hereafter referred to as
12D701, was 8� feet in diameter and rose in excess of 53 feet above the ground. Known as
the amine absorber, 12D701 received liquefied propane and butane gas (C3-C4) rich in
hydrogen sulfide (H 2 S) at a port near the bottom of the vessel. The liquefied
propane and butane gas would rise in the vessel through a series of perforated trays,
exiting at the top relatively lean of H 2 S. An amine solution consisting of
monoethanolamine in water (MEA) would enter the vessel at the top and, flowing downward
counter to the flow of the liquefied petroleum product through the perforated trays, would
strip the H 2 S from the liquefied propane and butane gases. The amine solution
would exit the vessel at the bottom having in the process become rich in H 2 S.

The liquefied propane and butane gases would flow to
the next pressure vessel in the process for additional treatment involving removal of
other sulphur compounds. (Tr. 81-83, 330-331; Exhibit C-8)

At approximately 5:30 p.m. on July 23rd personnel at
the Fluid Catalytic Cracking Complex (FCC unit) received warning by telephone from
personnel from an adjacent unit of a possible leak. (Tr. 355) Upon receiving the telephone
warning, outside operator Wayne Kielma and assistant operators Robert Gomer, George Smith
and Robert Haggard left the field shelter, referred to as the unit satellite, and observed
a vapor cloud about 15-20 feet long approximately 12 feet above the ground in the vicinity
of 12D701. (Tr. 354-358, 443-447)

The vapor cloud was observed to be originating from a
horizontal crack at or near a circumferential weld of vessel 12D701. When first observed
the crack appeared to be 6 to 9 inches long. (Tr. 359) The leak at this point was through
the fixed ladder that goes up the side of the vessel to the top of the vessel. It
prevented climbing to the top of the vessel to actuate a mechanically operated pressure
relief valve. (Tr. 383, 384)

Mr. Kielma by means of the portable radio on his
person informed the inside operator on the unit of the leak and its size and location. The
inside operator had a telephone connection with the guard gate from whence a 222 alarm
would be sounded. After Mr. Kielma made his initial report to the inside operator he heard
the 222 alarm sounding. (Tr. 389, 506, 507) He then walked around the tower and determined
there were no other leaks and asked the assistant outside operators to lay out and connect
steam hoses and direct steam at the leak. (Tr. 360, 447) He also asked one of the
assistants to get a ladder.

The purpose of the ladder was to permit access to
some valves elevated on the east side of vessel 12D701. These valves if operated would
permit redirecting the flow of "product" to a different vessel, thus bypassing
12D701. The ladder, when brought, was only about an 8 foot A frame ladder and to reach the
valves Mr. Kielma had to stand on the very top of the ladder. This left him inadequate
"leverage" to open or close the valves. (Tr. 360-362) He was unable to operate
any of the four valves at that location which, had he been successful, would have isolated
the vessel by eliminating the flow in and out. After descending from the ladder he told
one of his assistants they would have to shut the whole unit down. (Tr. 363) By this time
the crack had lengthened to the west and now appeared to him to be 1� to 2 feet in
length. (Tr. 364)

While Mr. Kielma was attempting to thus bypass 12D701
a fire truck arrived at the unit and Mr. Kielma saw Perry Parker, a member of the shift
fire brigade standing next to the truck approximately 12-18 feet southwest of 12D701. Mr.
Parker was wearing no fire fighting equipment at that time. (Tr. 368, 369; Exhibit C-23)
During the attempt to control the escaping vapor by directing steam on it, Chris Watkins,
another member of the shift fire crew was observed to enter the unit wearing only blue
jeans and a flannel shirt, i.e., not wearing turnout gear. (Tr. 452, 2197, 2201, 2216)

Mr. Kielma then told Bill Drury, cracking shift
supervisor, while the two were standing about 25 feet from vessel 12D701 that he was
unable to isolate the vessel and it would be necessary to shut down the entire unit which
would take 30-45 minutes. Mr. Drury approved and said he would get Mr. Kielma some help.
Mr. Drury took a step northeasterly toward the control center and Mr. Kielma took a step
toward the FCC side of the complex. (Tr. 371, 372)

At this point 12D701 failed. Mr. Kielma experienced
an explosion which threw him northerly followed in 2 or 3 seconds by a wall of fire. (Tr.
372-374)

As a result of the explosion the upper portion
consisting of six courses of this seven course tower, vessel 12D701, was propelled through
the air coming to rest 3200 feet from point of origin, spewing its contents as it went.

The explosion and following conflagration resulted in
the deaths of 17 employees and lost worktime injuries to 14 other employees of respondent.
(Exhibit C-23)

The Occupational Safety and Health Administration
(OSHA) conducted an investigation into the causes of failure of vessel 12D701 and the
fire, explosion, deaths and injuries which resulted therefrom which culminated in the
issuance of the citations, subject of this action. (Tr. 3190, 3196)

Metallurgical examination of significant portions of
vessel 12D701 was conducted by the United States National Bureau of Standards after the
incident of July 23, 1984. (Tr. 853, 878, 884; Exhibit C-44) This examination revealed
that pressure vessel 12D701 had fractured along a path adjacent to a circumferential
repair weld joining Course 1 and Course 2 performed in 1974 at the time of the replacement
of Course 2. (Tr. 928, 1031-32) This repair welding had caused a hard microstructure to
form in the area of the metal where the base metal and the weld metal joined. (Tr. 1031,
1032) This area is referred to as the heat-affected zone. (Tr. 930) This hard
microstructure, identified as "martensite," developed as a result of rapid
cooling of the carbon steel creating a region of metal that was more brittle than the
adjacent base metal and therefore more susceptible to both cracking and crack propagation.
(Tr. 1032)

The examination disclosed that at the time of the
catastrophic rupture of pressure vessel 12D701, there existed four pre-existing cracks
adjacent to the weld connecting courses 1 and 2 equal to approximately forty percent of
circumference of the vessel. These cracks, open to the inside surface of the vessel,
extended to depths beyond midthickness of the one inch vessel wall. (Exhibit C-49) The
surfaces of these pre-existing cracks were blackened by deposits of iron sulfide, the
known by-product of the corrosion process produced when steel comes in contact with
hydrogen sulfide. (Tr. 921-926; Exhibit C-48) Exhibit C-49 depicts by hash marks, the
general location of these pre-existing cracks in the vessel wall adjacent to the weld
connecting courses 1 and 2.

The investigation disclosed that when the deepest of
the pre-existing cracks extended through more than ninety (90) percent of the wall
thickness, the remaining 1/10 inch ligament of steel, weakened by the absorbed hydrogen
had insufficient remaining strength to contain the pressurized liquefied propane and
butane gases. This remaining 1/10 inch ligament of vessel wall therefore broke through
causing the initial crack and resulting leak. This crack continued to tear and propagate
along the hydrogen weakened and embrittled vessel until complete separation of the upper
and lower sections of the vessel occurred. (Tr. 960-63)

Discussion

Issue A:

Was the respondent in violation of section 5(a)(1) of
the Act as alleged in Citation No. 1, item 1?

To establish a violation of section 5(a)(1) of the
Act, commonly referred to as the "general duty clause," the Secretary must prove
by a preponderance of the evidence (1) that a condition or activity in the employer's
workplace presented a hazard to employees, (2) the hazard was recognized either by the
employer or generally within the employer's industry, (3) the hazard was likely to cause
death or serious physical harm, and (4) that feasible means existed to eliminate or
materially reduce the hazard. See Inland Steel Co. , 12 BNA OSHC 1968, 1986
CCH OSHD � 27,647 (OSHRC No. 79-3286, 1986); Pelron Corporation , 12 BNA OSHC 1833,
1835 (No. 82-388, 1986); Phillips Petroleum Co. , 11 BNA OSHC 1776, 1984 CCH OSHD �
26,783 (OSHRC No. 78-1816, 1984); Chevron Oil Company , 11 BNA OSHC 1329, 1331 (No.
10799, 1983); National Realty & Construction Co. v. OSHRC , 489 F.2d 1257 (1 BNA
OSHC 1422) (D.C. Cir. 1973).

(1)

Due to the known flammable and explosive properties
of petroleum products, and particularly of liquefied petroleum gases which must be
maintained under pressure, petroleum refineries must necessarily be designed and
maintained in such fashion as to reduce the potential of fire and explosion resulting from
unintended escape of the product in process of refinement. Where that product moves
through vessels under pressure, the integrity of such vessels to support the expected
pressures must be safeguarded.

Fire and explosion can result when liquefied
petroleum gases are allowed to escape into the atmosphere during the process of
refinement.

Leaks of product from pressure vessels occur from
cracks which are allowed to grow. Cracks in the walls of pressure vessels are known to
occur (1) in heat affected zones adjacent to welds where a hard or brittle condition known
as martensite is allowed to occur or remain following welding operations, and (2) where
carbon steel of the type utilized in vessel 12D701 is exposed to H 2 S,
particularly where evidence of corrosion in the form of hydrogen attack is observed.

Failure to apply recognized welding procedures or
post-weld treatment to reduce or eliminate martensite and inadequate inspection to detect
the presence or development of stress cracking or hydrogen induced cracking would permit
cracking to develop to the point of vessel failure and increase the likelihood of fire and
explosion of petroleum product to which hazard operations personnel are exposed. See National
Realty , supra , 1 BNA OSHC at 1427. See also Pelron Corporation , supra ,
12 BNA OSHC at 1835.

(2)

That the increased hazard of fire and explosion of
refinery product was preventable and could be eliminated or could be materially reduced
was recognized by the respondent is established by the existence since 1957 of an
inspection department at respondent's Chicago refinery. This department, sometimes
referred to as the Corrosion and Fouling Department, was responsible for monitoring the
condition of pressure vessels located at the refinery to assure their ability to operate
safely. (Tr. 553-54, 564, 572, 690-93, 1674, 1679, 1680, 1804-05, 3718). Following 1975
the inspection department was intended to qualify under and assure respondent's compliance
with The Illinois Boiler and Pressure Vessel Safety Act (hereinafter "The Illinois
Act"). (Illinois Revised Statutes, Chapter 111�, � 3201 et. seq. , Exhibit
C-59; Respondent's Post Trial memorandum p. 3; Tr. 3607, 3625, 3626; Exhibit R-6)

From the time of its creation in 1957, the inspection
department at respondent's Chicago Refinery was guided by the recommended practices for
inspection of pressure vessels published by the American Petroleum Institute (API). (Tr.
622, 623, 690-692; Exhibits C-61, C-62, C-63, C-64, C-65; and API 510)

In accommodating the inspection requirements of The
Illinois Act after its adoption in 1975, The respondent as an "owner user" under
that act elected to be governed by API 510.[[11/]] (Tr. 3620, 3621; Exhibit R-6)

The Illinois Act contemplated that inspections of
pressure vessels within that state would be performed by the state's Chief Inspector or by
a Deputy Inspector or in the case of qualified owner user situations, i.e., the
respondent, by Special Inspectors.[[12/]]

Section 2.2 of API 510 contains its own set of
requirements for inspector qualifications.[[13/]]

API 510 by its terms applies to vessels after they
have been placed in service. (Exhibit C-60, p.1, section 1.1.1) However, API incorporates
in principle the provisions of the Boiler and Pressure Vessel Code published by the
American Society of Mechanical Engineers (ASME Code). In doing so, the API states that
although the ASME Code is written for new construction, most of its requirements apply to
maintenance inspection, repair and alteration of operating vessels. Where the ASME Code
provisions do not apply, API 510 applies in lieu of strict conformance with the ASME Code.
(Exhibit C-60, p.1&2, sections 1.2.2 and 1.2.3; Tr. 802, 803)

Section V of the ASME Code is specifically referred
to at Section 3.5 of API 510 as a guide to performing many of the non-destructive
examination techniques utilized in inspection; and Section V of the ASME Code adopts the
guidelines for determining qualifications of persons utilizing nondestructive examination
methods as they appear in "Recommended Practice for Nondestructive Testing Personnel
Qualification and Certification" published by the American Society for Nondestructive
Testing. (Exhibit 66, p.8, section T-170, footnote 3; Exhibit C-67)

---

Pressure vessel 12D701 was designed and fabricated in accordance with the ASME Code
which governs the fabrication of pressure vessels. It was constructed of A516-70 carbon
steel, one inch thick consisting of a top and bottom head and seven cylindrical sections
referred to as courses all joined by circumferential welds. Designed to operate at a
maximum operating pressure of 230 psi at a maximum temperature of 140� F, 12D701 was
placed in service in the spring of 1970. (Exhibits C-35, p.00622 and C-44) As operated,
the pressure was maintained at 230 psi measured at the top of the tank with the practical
result that the lower courses exerted greater pressure on the walls of the tank due to the
weight of the product above. (Tr. 100, 105)

Commencing in 1972 and biannually thereafter 12D701
was subjected to a turnaround inspection which involved shutdown of the operation
affecting the vessel, external and internal inspection of the vessel and its components
and repairs where necessary. (Tr. 589-591)

In the course of the 1972 turnaround, inspection
disclosed corrosion defects in the walls of 12D701 resulting from the action of hydrogen
on the A516-70 carbon steel. Hydrogen in its atomic form passes through the steel and
dissipates harmlessly into the atmosphere. However, if hydrogen atoms in passing through
the steel encounter flaws which occur at the time of pouring and/or rolling the steel
during its manufacture consisting of inclusions of foreign material, the atomic hydrogen
there accumulates and converts to molecular hydrogen. In the process tremendous heat and
pressure is exerted causing the inclusion to become a lamination within the steel. Where
these laminations occur near the surface of the steel they appear as blisters. Should
laminations, which generally run parallel to the surface of the steel, be joined by cracks
which tend to run at right angle to the surface, hydrogen step cracking is said to have
occurred. (Exhibits C-51 and C-52) Also, pitting can occur on the interior surface of the
vessel as a result of hydrogen attack. Pitting and blistering were observed to have
occurred on the interior of 12D701. Notes of the inspection disclose: "The second
sheet up has a large area of dirty metal or laminations and some hydrogen blistering has
taken place." A coupon was removed through one of the hydrogen blisters and sent to
respondent's research center in Brea, California, for observation. (Exhibits C-16 and
C-34, pp. 30-31)

The coupon removed came away in two pieces, separated
at the lamination. The inner piece had a thickness of .30 inch. The research center
reported to the inspection department at respondent's Chicago refinery in May of 1972 that
its examination disclosed a large number of "opened laminations," more appearing
on the inner portion of the wall than the outer portion. Also, the steel was found to be
within specifications with hardness ". . .well below the critical hardness at which
point one might expect hydrogen embrittlement." Finally, the report disclosed:

" . . .Most of the laminations which separated were parallel to the walls of the
vessel, although I did find several that had joined in a direction perpendicular to the
wall thickness. . . . joining of the laminations can lower the strength of the wall;"
(Exhibit C-18)

Due to the corrosion deterioration of the 2nd course
of 12D701, that course was scheduled to be replaced during the 1974 turnaround. Using the
same grade of carbon steel, to-wit: A516-70, the new replacement second course was
installed in 1974 in three pieces requiring three vertical and two circumferential welds
accomplished without dismantling the tower and while it remained standing. The first
contractor engaged to do the repair proved unsatisfactory and the repair was cleaned up by
removing welds performed and completed by a second contractor. In addition to the
replacement of the second course, a process change was performed on 12D701 during this
1972 turnaround. The size of the perforations in the 9 trays were enlarged from 5/16"
to 3/8" to permit an increase in the flow or "throughput" of petroleum
product treated. (Exhibits C-15, C-17 and C-34, p.29)

Visual inspection of the balance of 12D701 during the
1974 turnaround disclosed continuing corrosion and attack by hydrogen in the form of
numerous small hydrogen blisters on the interior of the first course of the vessel.

After completion of second course replacement and
tray perforation enlargement the vessel was returned to service.

Ultrasonic thickness examination of the first course
in October of 1975 caused the respondent's inspection department to conclude "dirty
steel bottom ring." (Exhibit C-34, p.29)

Straight beam ultrasonic (Sonoray) examination causes
an ultrasonic beam from the surface to measure the thickness of a wall of steel. An
interruption of that beam caused by meeting a place where a lamination has occurred will
cause the thickness of the wall to appear to be the distance from the surface point of
origin of the beam to the point of the lamination. Thus false readings of wall thickness
would be interpreted as disclosing laminations, sometimes referred to as discontinuities.

In the spring of 1976 a turnaround inspection was
again done on 12D701. This time visual inspection disclosed:

"Small 'raindrop' like blisters on top of #7 and #8 downcomers. . . . Blistering
occurring on second ring southwest side. . . . The entire surface of shell plate, ring #1
had many blisters ranging in size from �" to 1" in diameter. The lamination of
the blister varied from .16" to .38". (Exhibit C-34, p.29)

Courses 3, 4, 5, and 6 are now observed to
"appear to be in good condition except that many areas have dirty metal or
lamination." (Exhibit C-34, p.28)

In order "to arrest the hydrogen attack on the
plate," a monel metal liner was welded orange peel fashion to the bottom head of the
vessel and monel metal liner was welded to the entire interior surface of the first
course, excepting only a distance of ten inches below a portion of the circumferential
weld connecting the first and second courses at which point one of the perforated trays
interfered. The vessel was again returned to service.

By entry dated November 1977, a member of
respondent's inspection department noted on the record of vessel 12D701:

Sonoray coverage on a grid indicated hydrogen evolution to be active. The new plate (1974)
in second ring has two localized spots of subsurface discontinuities. (Exhibit C-34, p.27)

Following the 1982 turnaround the following recommendation was entered in the history
record of 12D701:

Recommend : Do External UT as time permits & check ring #1 & #2 for
laminations (Ref. LWV Grid Survey 11/77). (Exhibit C-34, p.24)

Notes entered following the 1984 turnaround conducted
in or around April 1984 included: "All ultrasonic thickness readings taken on shell
are above nominal thickness" and "Six scattered hydrogen blisters, �"
diameter max., were found in feed tray area, all located within 1 foot of circumferential
weld." (Exhibit C-34, p.24) That the circumferential weld referred to is that joining
course 1 and course 2 is apparent from the additional entry for that turnaround,
"bottom head and shell below feed tray has Monel lining." It will be remembered
that the presence of the tray prevented monel lining from being placed over a portion of
course 1 to a point 10 inches below the circumferential weld.

Inspection of vessel 12D701 during the 1984
turnaround was performed by one of respondent's trainee inspectors, who nonetheless held
the title of "Inspection Supervisor". (Tr. 1682, 1687; Exhibit C-71, p.1)
Respondent's "Inspection Supervisor" was assisted in this inspection by an
independent inspector supplied to respondent under a contract entered into between
respondent and an independent inspection contracting company.

The head of respondent's inspection department
testified that respondent's "Inspection Supervisor" was not the "team
leader" of the two-man team that inspected 12D701 during the 1984 turnaround, (Tr.
1683) that he was in fact receiving training in inspecting 12D701 at that time, (Tr. 1688)
and that he was receiving the "expert guidance" of the independent inspector who
was working with him. (Tr. 1689) This position on part of the respondent belies the facts.

The independent inspector who participated in the
inspection of 12D701 during the 1984 turnaround was supplied under a contract which
provided:

The contractor will provide experienced personnel qualified to perform inspection of
Petroleum Refinery process equipment and other field inspection as directed by Union
Oil Company Representative. . . . This work is to be done under the supervision of the
Company Inspection Supervisors . (Emphasis added) (Exhibit C-75, p.1)

Also the independent inspector who participated in the inspection of vessel 12D701
testified: that in the 1984 turnaround Mr. Granot, head of respondent's inspection
department, assigned him to work with respondent's inspection supervisor in question; that
he knew nothing of the inspection supervisor's background or credentials; that he was told
that he was to do inspection work with respondent's inspection supervisor; that he
performed no training activities; that the inspection supervisor would inform him what
they had to do on a daily basis; that the inspection supervisor was his contact with Mr.
Granot; that he took no notes, they were rather taken by the inspection supervisor; that
he made no recommendations with respect to repair or alterations of any vessels; that
during the three weeks he was there he neither certified nor decertified any vessel; that
they would inspect from two to five vessels each day; and that he initialed no documents
during the turnaround. (Tr. 1878-1885)

This independent inspector has for many years been
licensed by the State of Indiana, pursuant to examination, as an Unfired Pressure Vessel
Inspector. Before retiring in 1981 he worked for Amoco Oil Refinery where he inspected
pressure vessels from 1961 until retirement. He holds no other certifications and has
taken no courses given by the American Society of Nondestructive Testing. He considered
the interior inspections of vessels they inspected during the turnaround to be in
accordance with his understanding of good industry inspection practices. (Tr. 1889-1891,
1902; Exhibit C-67 p.5)

Neither member of the two-man team that inspected
vessel 12D701 was a Special Inspector as that term is defined in the Illinois Act which
provides:

The inspections herein required shall be made by . . . a Special Inspector provided
for in this Act. (Exhibit C-59, sec. 10(7))

Notwithstanding the foregoing, Mr. Granot, head of
respondent's inspection department, who made no inspection of vessel 12D701 certified to
the State of Illinois as required in the Illinois Act that 12D701 was inspected in 1984 as
required by the Act. Mr. Granot was himself a qualified Special Inspector under the
Illinois Act. This procedure of certifying to the State without having seen the vessel had
also been followed in the course of the turnaround inspections since Mr. Granot headed up
the inspection department at respondent's Chicago Refinery in 1977. (Tr. 1802-1804, 3441,
3442)

---

Following the repair of vessel 12D701 in 1974 respondent tested the quality of the
repair in three particulars: (1) it submitted the welds to visual inspection, (2) it
subjected the repair welds to radiography, and (3) the vessel was hydrostatically pressure
tested to 345 psi. (Exhibits C-34 p.29, C-16 p.30061) Respondent's engineer in charge of
the inspection department at the time of the replacement of the second course of 12D701 in
1974 has known since the 1960's that if welds in an environment where atomic hydrogen can
be generated have a Brinelle hardness over 220, the likelihood of cracking is a
possibility. (Tr. 677, 682) In the course of the 1974 repair the turnaround was delayed by
poor productivity and welding performed by the contractor first hired. That welding was
removed and re performed by a second contractor. Also respondent's records disclose that
"Very poor cuts on plates in D701 caused excessive rewelding." Notwithstanding
these problems no hardness tests were performed on the repair welds after their completion
in 1974 or at any time thereafter. (Exhibits C-22 p.2, C-34 pp.24-30) Likewise respondent
appears to have given no consideration to the likelihood that hardening of the base metal
in the heat affected zone adjacent to the extensive repair welds might have resulted from
this torturously performed field welding. No attempt was made in 1974 or at any time
thereafter to rule out the presence of "martensite."

The literature of the American Petroleum Institute as
well as Chapters V and VIII of the ASME Boiler and Pressure Vessel Code bear abundant
witness that the petroleum refinery industry recognized the potential for hydrogen induced
cracking and pressure vessel failure where hard welds or martensite were allowed to be
present as a result of field or repair welding. Also the literature warned of permitting
unrelieved residual stresses to remain as a product of repair welds. The literature warned
that such conditions could give rise to Hydrogen Stress Cracking where allowed to exist in
an environment exposed to H 2 S and advised methods both of avoiding the
conditions and inspecting for the existence, development or growth of hydrogen cracking.
(Exhibit C-62 pp.35, 36, 47, 48; Exhibit C-63 p.4; Exhibit C-64 p.5, 6; Exhibit C-66 p.7;
Appendix A, attached to Complainant's Post Trial Brief, pp.10, 12 of the 1958 Edition and
pp.10, 12 of the 1970 Edition)

Particularly useful for the detection of cracks
formed or in process in the shells of pressure vessels were Magnetic Particle Testing and
Liquid Dye Penetrant Testing. Also Ultrasonic Testing was useful in detecting cracks if
angle beam, also referred to as shear beam ultrasonic testing method, was utilized. The
respondent utilized the straight beam method of ultrasonic testing which serves only to
measure wall thickness or the depth of discontinuities or laminations. (Tr. 689)

Respondent had on hand a portable Telebrineller
hardness measuring instrument and actually measured the hardness of welds at the second
course of 12D701 in 1972. (Exhibit C-34, p.30) Respondent also had on hand the equipment
for performing the ultrasonic testing, the magnetic particle testing and the liquid dye
penetrant testing for cracks. Notwithstanding such capability and awareness of ongoing
hydrogen attack respondent did nothing following the repair welds of 12D701 in 1974 to
either measure the hardness of the repair welds or the base metal in the heat affected
zone adjacent to those welds; nor did respondent conduct any tests to rule out the
presence of cracking in pressure vessel 12D701.

---

Respondent expresses a defense to be that it should not be responsible for failure to
detect a "microscopic" crack among 700 pressure vessels. There is no evidence
the cracks found to be present in vessel 12D701 were "microscopic." The evidence
is that four cracks covering some 40% of the circumference of the vessel in the vicinity
of the horizontal weld joining courses one and two occurred in the
"microstructure" of the metal in the weld heat affected zone which
microstructure took on the properties of martensite as a result of the welding procedures
followed in 1974. (Tr. 1032, 1044, 1055; Exhibit (C-49)

(3)

That fire or explosion and the increased likelihood
thereof resulting from undetected cracks would likely cause death or serious physical harm
is amply born out by the events at respondent's Chicago Refinery on July 23, 1984.
Seventeen employees died and fourteen received injuries resulting in lost work time as a
result of the ignition of refinery product which began its escape from an undetected crack
in pressure vessel 12D701 and which crack rapidly connected with others around the
circumference of the corrosion weakened wall.

(4)

Respondent had the feasible means of detecting cracks
in the welds or base metal of pressure vessels at its refinery from prior to 1974 and
through the time of the catastrophe on July 23, 1984. The timely detection of hydrogen
stress cracks in pressure vessel 12D701 could have eliminated or materially reduced the
likelihood of the leak of product which resulted in the fire and explosion of July 23,
1964.

Complainant has met its burden of proof of Issue A.

Issue B:

Would compliance by the respondent with the Illinois
Act, if compliance there be, constitute a bar to complainant proceeding under section
5(a)(1) of the Act?

Section 18(a) of the Act addresses State jurisdiction
over occupational safety and health issues with respect to which no standard is in effect
under section 6 of the Act. In effect section 18(a) makes no interference with the right
of any State agency or court to assert concurrent jurisdiction over occupational safety
and health issues where the Secretary of Labor acting through OSHA has promulgated no
specific regulation.

In the case before us respondent may have failed to
comply with the requirement of the Illinois Act that inspection of its pressure vessels be
performed by "Special Inspectors" commissioned by the State of Illinois. Should
the State of Illinois desire to assert jurisdiction and proceed against the respondent for
that alleged failure, section 18(a) provides that "nothing in this Act shall prevent.
. ." it from doing so.

There is nothing in the language of the Act or the
legislative history to suggest that Congress intended compliance with the standards of
applicable state law to create an exemption from the Act's general duty clause. See Puffers
Hardware, Inc. v. Donovan , 742 F.2d 12, 16-17 (1st. Cir. 1984), OSHRC No. 83- 1863.

The existence of the Illinois Act or compliance
therewith would not act as a bar to the Secretary proceeding under the general duty clause
of the Act as set forth in Citation No. 1, item 1.

Issue C :

If respondent was in violation of section 5(a)(1) of
the Act as set forth in Issue A, was that violation willful?

In order to show a violation of section 5(a)(1) of
the Act to have been willful, the Secretary has the burden of demonstrating by a
preponderance of the evidence the employer's disregard of or plain indifference to its
statutory duty to furnish a workplace free from recognized hazards. The evidence produced
must be such that it convincingly establishes that the employer intentionally disregarded
or was indifferent to employee safety. The Secretary may satisfy his burden by showing
aggravating circumstances such as: the employers failure to remedy a visibly dangerous
condition actually known to the employer or its supervisory personnel, ( Central Soya De
Puerto Rico v. Secretary of Labor , 653 F.2d 38 (1st Cir. 1981); Kus-tum Builders,
Inc. , 10 BNA OSHC 1128, 1131 (No. 76-2644, 1981); Babcock & Wilcox Company ,
7 BNA OSHC 1194 (No. 77-3575-A, 1979); St. Joe Mineral Corp. v. OSHRC , 647 F.2d
840, 848 (8th Cir. 1981)) or the employer's deliberate disregard of known safety
requirements, ( Ensign-Bickford Co. v. OSHA , 10 BNA OSHC 1639 (No. 78-4945, 1982),
aff'd., 717 F.2d 1419 (D.C. Cir. 1983).

Respondent suggests that this case should be governed
by the Commission's reasoning in United States Steel Corporation , 12 BNA OSHC 1693
(No. 79-1998, 1986) which ruled the employer not guilty of a willful violation where it
had developed a strategy for dealing with the hazard based on the judgment of its managers
as to the existence of conditions that could give rise to an explosion hazard. Here,
however, no such strategy was developed for the detection or elimination of cracks.

The record establishes that there were applicable
industry safety standards including the API Pressure Vessel Inspection Code and Inspection
Guides and that respondent had knowledge of those standards. Respondent had in fact
obligated itself to observe the API standards by electing, as permitted by the Illinois
Act, to conduct its own inspection program in accordance with API rules and regulations
utilizing "Special Inspectors" qualified under the Illinois Act, rather than to
submit to state inspection of its pressure vessels.

Notwithstanding continued observations of ongoing
hydrogen attack on pressure vessel 12D701 over the ten year period between 1974 to 1984,
respondent failed to utilize recommended and available repair methods to avoid the
potential for cracking, or testing techniques to determine the presence or absence of
cracks in the vessel walls or welds. Furthermore, respondent followed a course of conduct
which certified to the State of Illinois on a continuing basis that inspection of pressure
vessels was accomplished by inspectors qualified under the Illinois Act when such was
contrary to the fact. Respondent's repeated failure to test for cracks and its
misrepresentation of the quality of the inspections performed is convincing evidence of
plain indifference to employee safety and the statutory duty to furnish a workplace free
from the recognized hazard of fire or explosion which could result from leak of product
from undetected cracks allowed to form in pressure vessels.

Complainant has met its burden of proof with respect
to the willful nature of the 5(a)(1) violation set forth in Issue A.

Issue D

If respondent was in violation of section 5(a)(1) of
the Act as set forth in Issue A, what penalty would be appropriate?

Giving due consideration to the factors set forth at
Section 17(j) of the Act and by reason of the disregard shown by the respondent of the
known safety requirements of the Illinois Act, and of the various American Petroleum
Institute recommendations regarding welding repairs, inspecting for cracks and inspections
conducted by qualified inspectors, it is here determined that the proposed penalty of
$10,000 for this willful violation is appropriate.

Issue E

Was the respondent in violation of 29 C.F.R.
1910.132(a) for failure to provide and require the use of protective fire fighting
equipment as alleged in Citation No. 1, item 2?

To prove a violation of section 5(a)(2) of the Act,
the complainant must prove by a preponderance of the evidence an employer's noncompliance
with an applicable standard and employee exposure to the hazard created by the violative
condition. Otis Elevator Co. , 6 BNA OSHC 2048, 1978 CCH OSHD � 23,135 (No. 16057,
1978) The standard at 29 C.F.R. 1910.132(a) has been held to apply to the facts of a case
if a reasonable person familiar with the circumstances, including facts unique to an
industry, would recognize a hazardous condition requiring the use of personal protective
equipment. Tube-Lok Products , 9 BNA OSHC 1369, 1981 CCH OSHD � 25,235 (No. 16200,
1981); General Electric Co. , 7 BNA OSHC 2183, 1980 CCH OSHD � 24,268 (No. 15037,
1980); Lukins Steel Company , 10 BNA OSHC 1115, 1123 (No. 76-1053, 1981); Puffers
Hardware, Inc . dba Beacon Hardware , 11 BNA OSHC 1701 (83-267, 1983).

Evidence presented supports findings of both
constructive and actual knowledge of a hazardous condition warranting the use of fire
protective clothing by all members of the shift fire crews and operating personnel
required to contain fires and potential fires in the operations areas of the refinery.

Complainant's expert, Mr. Lawrence Watrous, a
licensed Fire Protection Engineer, testified that because of the large amounts of fuel
involved, an oil refinery fire may develop from the incipient or small stage into a major
fire within a very short period. Thus operating personnel and the Shift Fire Crew may
necessarily be required to confront major emergencies before the Day Fire Crew can be
called in. (Tr. 2868, 2879; Exhibit C-92) Mr. Watrous further testified that protective
gear should be provided to all personnel who may be thus faced with possible vapor
ignition. (Tr. 2871-72, 2893-95) Internal memoranda clearly demonstrate that respondent's
Fire Chief and other supervisory personnel recognized that refinery fires were
unpredictable and that the possibility of encountering a hazardous situation always
existed. (Exhibit C-86, pp.18452, 18458-59; Tr. 2595-97)

At the time of the 1984 explosion and prior thereto,
respondent had written emergency procedures. (Exhibit C-9; Tr. 2630) Under its policies:
(1) All operating personnel at the refinery were expected to extinguish or contain minor
fires located in their work areas as part of their regular duties. (Exhibit C-9, p.30012;
Tr. 2516); (2) Fires and potential fires beyond the capabilities of the operating
personnel were to be handled by the Day Fire Crew, volunteers trained to become
"proficient" in firefighting. (Exhibit C-9, pp. 29988, 30013; Tr. 2517, 2520);
(3) Members of the Shift Fire Crew, refinery employees filling designated refinery
positions and trained to "adequately" perform firefighting duties (Exhibit C-9,
29988; Tr. 2590), were to respond at times when the Day Fire Crew was not present.
(Exhibit C-9, pp. 29988, 29991; Tr. 2520); (4) The Shift Fire Crew was to call in the Day
Fire Crew from their homes should a fire develop beyond their capabilities. (Exhibit C-9,
p. 29991; Tr. 2524)

No protective clothing was provided for or required
to be worn by regular operating personnel. (Tr. 2519) All members of the fire crews were
required under standing orders to obtain fire protective turnout gear consisting of boots,
helmet, coat and gloves before reporting to a fire or potential fire scene. (Exhibit C-9,
pp.29989, 29991; Tr. 2525-26) However, Shift Fire Crew personnel testified that the crew
regularly responded to fire scenes without the required turnout gear. (Tr. 2248-9, 2287,
2351, 2413, 2425-26, 2430) Respondent's records disclose that this practice was known to
respondent's Fire Chief, who expressed concern over the likelihood of serious injury
resulting therefrom in January 1984. (Exhibit C-86, p.18458; Tr. 2794-99) On the day of
the explosion giving rise to this action, Shift Fire Crew members who died in the ensuing
events were seen to arrive at the scene of the potential fire without turnout gear. (Tr.
368, 369, 452, 2000-01, 2197, 2201, 2216; Exhibit C-23)

---

At page 64 of its Post-Trial Memorandum respondent raises the following defense:

Initially, this citation is legally unenforceable relating to personnel who are
assigned to the shift fire brigade, since 29 C.F.R. 1910.156, relating to fire brigade,
does not require the use of personal protective equipment for shift fire brigades
who are required to respond to "incipient" stage fires. Further, since the shift
fire brigade was only required to respond to incipient stage fires, there is no factual
basis for asserting a more general regulation (1910.132) than that which is specifically
applicable to the shift fire brigade.

Other than refuting respondent's indefensible claim
that its fire brigades were " . . .only required to respond to incipient stage
fires," complainant makes no reply to this defense. Neither party cites any cases or
authorities in support of their respective positions. 29 C.F.R. 1910, Subpart L - Fire
Protection, in pertinent part reads:

Subpart L - Fire Protection

� 1910.155 Scope, application and definitions applicable to this subpart.

(a) Scope . This subpart contains requirements for fire brigades, and all portable
and fixed fire suppression equipment, fire detection systems, and fire or employee alarm
systems installed to meet the fire protection requirements of 29 C.F.R. Part 1910.

(b) Application . This subpart applies to all employments except for maritime,
construction and agriculture.

*             *
             *

� 1910.156 Fire Brigades.

(a) Scope and application --(1) Scope . This section contains requirements for
the organization, training, and personal protective equipment of fire brigades whenever
they are established by an employer.

(2) Application . The requirements of this section apply to fire brigades,
industrial fire departments and private or contractual type fire departments. Personal
protective equipment, requirements apply only to members of fire brigades performing
interior structural fire fighting. The requirements of this section do not apply to
airport crash rescue or forest fire fighting operations.

*             *
             *

(e) Protective clothing . The following requirements apply to those employees who
perform interior structural fire fighting. The requirements do not apply to employees who
use fire extinguishers or standpipe systems to control or extinguish fires only in the
incipient stage.

*             *
             *

Under "protective clothing" the standard lists foot and leg protection, body
protection, hand protection, head, eye and face protection. Said protective clothing is
also referred to therein as "equipment." The reference to "incipient
stage" fires in � 1910.156(e) is viewed as applying only to employees performing
"interior structural fire fighting" referred to also in that paragraph.

Nevertheless, the Secretary has, perhaps unwittingly,
managed to give notice in this Subpart L that in all employments except maritime,
construction and agriculture, personal protective equipment need not be furnished to or
worn by members of employer established fire brigades unless said brigades are engaged in
interior structural fire fighting and then only if the fire is beyond the incipient stage.

Subpart L, dealing as it does specifically with fire
protection and the need for fire protective clothing for employer established fire
brigades in industries including the oil refining industry, we are constrained to follow
the Commission's reasoning in Williams Enterprises of Georgia, Inc. , 12 BNA OSHC
2097 (No. 79-4618, 1986), reversed Brock v. Williams Enterprises of Georgia, Inc .
832 F.2d 560 (11th Cir. 1987)

The general standard at 29 C.F.R. 1910.132(a) is held
not to apply to the members of respondent's fire brigades to whom respondent furnished
protective clothing. Nevertheless the standard does apply to respondent's operation
personnel who are required to handle the fire or potential fire until allowed to evacuate
by the Chief of the responding fire crew. Respondent furnished no protective clothing to
these operations employees. Just as Scott Air Pack respirators hung on the walls at the
respective satellites, so also could have hung protective clothing.

The complainant has met its burden of proving a
violation of 29 C.F.R. 1910.132(a) with respect to operating personnel, but not with
respect to respondent's fire brigade members.

Issue F :

If respondent was in violation of the standard as
alleged in Issue E, was that violation willful, or failing that, serious?

In order to show a violation of a standard or
regulation under 5(a)(2) of the Act to have been willful the Secretary has the burden of
proving by a preponderance of the evidence the respondent's violative conduct to have been
voluntarily done with intentional or careless disregard for the requirements of the Act or
with plain indifference to employee safety. See Williams Enterprises v. Donovan ,
744 F.2d 170, 179-180 (D.C. Cir. 1984) 13 BNA OSHC 1249 (No. 85-355, 1987); Asbestos
Textile Company, Inc. , 12 BNA OSHC 1062, 1063 (No. 79-3831, 1984); D.A.&L.
Caruso, Inc. , 11 BNA OSHC 2138, 2142 (No. 79-5675, 1984); Daniel International
Corporation v. Donovan , 705 F.2d 382 (10th Cir. 1983), 11 BNA OSHC 1305 (No. 81-1714,
1983). Thus, no showing of malicious intent or of obstinate refusal to comply with the
requirements of the Act need be shown to establish a willful violation. In Tri-City
Construction Co. , 8 BNA OSHC 1567 (No. 77-3668, 1980) the Commission stated:

While we agree. . . "that a willful violation is established when. . . the
respondent. . . made a conscious and deliberate decision not to comply" with a known
requirement of the Act, we would also find a willful violation when the respondent's
conduct is properly characterized as showing a careless disregard of the requirements
of the Act or an indifference to employee safety . (8 BNA OSHC at 1571) (emphasis
added).

A violation is said to be "serious" under
the Act ". . . if there is a substantial probability that death or serious physical
harm could result. . ." (Section 17 (k))

Applying the foregoing principles to respondent's
failure to provide fire protective clothing to its operations personnel who were first to
handle fires or potential fire emergencies on respondent's production units and who were
expected to remain at the scene until allowed to evacuate by the chief of the responding
fire crew, (Tr. 2745) we are compelled to find that said violation on the part of the
respondent was at the least serious.

The hazard presented employees dealing with escaping
flammable liquids or gases is that in a very brief time the situation can change from a
very small fire or potential for fire to a major conflagration.

That respondent recognized this situation is apparent
from its providing its shift fire crews with fire protective clothing and training them in
the use of 2� inch and 3 inch hoses and 2� inch nozzles, notwithstanding respondent's
claim that its shift fire crews were expected to handle only "incipient stage
fires."

Respondent's training of operations personnel to
handle incipient stage fires and its failure to provide fire protective clothing to
personnel in the production units who might be faced with controlling escaping flammable
liquids or gases while it provided the fire crew members expected to come to the scene
with such protective clothing must be viewed as conduct voluntarily done with careless
disregard for the requirements of the Act and with plain indifference to the safety of
operations personnel.

Complainant has proved respondent's violation of item
2 of Citation No. 1 to have been willful.

Issue G:

If respondent was in violation of the standard as
alleged in Issue E, what, if any, penalty would be appropriate?

Giving due consideration to the factors set forth at
section 17(j) of the Act and the fact that whereas complainant charged this violation to
have affected shift fire brigade members and unit operating personnel, whereas it has been
here found that the regulation violated was applicable only to the unit operations
personnel; it is here determined that the sum of $4,000.00 is an appropriate penalty to be
assessed against respondent for the willful violation of item 2 of Citation No. 1.

Issue H :

Was the respondent in violation of 29 C.F.R.
1910.156(c)(1) as alleged in Citation No. 1, item 3A?

The complainant must prove by a preponderance of the
evidence that 1910.156(c)(1) was applicable to the facts of this case, that respondent
failed to comply with the standard by failing to provide adequate training to fire
brigade members and employee exposure to the hazard created by the violative condition. Otis
Elevator Co., supra ., Issue E, p.44.

General knowledge and the evidence presented at the
hearing compel an awareness of the rapidity with which an incipient stage fire or even a
potential fire not yet ignited can become a major conflagration in an oil refinery
environment. (Tr. 2865-67) Flammable vapors emitted from a leaking vessel, given a source
of ignition, can ignite in an instant enveloping personnel in the vicinity. Respondent's
knowledge of the flammable properties of its various products is beyond dispute.

Notwithstanding the foregoing, respondent claims to
have required its shift fire brigades to respond only to incipient stage fires and to have
trained them accordingly. (Tr. 4742; Respondent's Post-Trial Memorandum, pp. 26, 64, 67,
Respondent's Post-Trial Reply Memorandum p.35)

As of March 17, 1982, the Fire Protection Department
at respondent's Chicago Refinery considered its "fire suppression force" to be
organized and trained as follows:

A. PERSONNEL

1. All Refinery Employees

Each employee is expected to fight fires in his or
her work area and to be proficient in the use of the fire fighting equipment provided.
This includes portable hand held fire extinguishers, hose reels and monitors. All
employees will attempt to safely extinguish minor fires using the above equipment or
contain the fire until additional fire fighting personnel and equipment have arrived.

2. Shift Fire Crew

The Shift Fire Crew shall provide initial control and
suppression measures during nights, weekends and holidays. The Shift Fire Crew shall be
composed of the Laboratory Personnel, Coke Handlers, Pumpers and Shift-fitters. Training
for these personnel shall be held on a bi-monthly basis to ensure familiarity with the
equipment available to them.

3. Day Fire Crew of The Fire Department

The Fire Department is composed of members who, on a
voluntary basis, have agreed to attend monthly training sessions to become proficient in
the handling of in-plant emergencies. Members of the Fire Department will also, after a
given period of membership (usually 2 years) and with the individual's consent, attend a
second monthly class to learn the proper method of operation of all mobile firefighting
equipment.

The Shift Fire Crew and Day Fire Crew and their
training were further defined:

SHIFT FIRE CREW

The purpose of the Shift Fire Crew is to provide fire
protection when the Day Fire Crew is not present. The Shift Fire Crew is headed by the
Petrochemical Department Shift Supervisor unless the incident involves the Petrochemical
Operating Area. In this case, the Blending and Transfer Shift Supervisor shall assume the
responsibilities as head of the Shift Fire Crew. Whenever possible, both the Petrochemical
and Blending and Transfer Shift Supervisor shall respond, with the Blending and Transfer
Shift Supervisor assisting the Petrochemical Shift Supervisor when both are present. The
acting coordinator of the Shift Fire Crew shall hereafter be referred to as the Shift Fire
Chief.

The Shift Fire Crew is comprised of the following job classifications:

1. Pumpers

2. Laboratory Personnel

3. Coke Handlers

4. Shift Pipefitters

Training sessions for Shift Fire Crew personnel are held on a bi-monthly basis. Classes
consist of practical and classroom instruction to enable members to adequately perform
fire fighting duties.

DAY (VOLUNTEER) FIRE CREW

The Day Fire Crew provides fire protection during
weekdays, between 7:30 A.M. and 4:00 P.M. and assists the Shift Fire Crew upon request.
Membership consists of both salaried and hourly personnel who normally work straight days
and who have volunteered for membership.

Training sessions for the Day Fire Crew are held on a monthly basis. Additional half-day
classes will be held monthly for members classified as apparatus engineers. Apparatus
engineers will be certified after passing a comprehensive written and practical
examination.

(Exhibit C-9, pp. 23988, 30012, 30013 see also pp. 30017, 30018)

It will thus be seen that the Shift Fire Crew, who were assigned as firefighters along
with their Shift Fire Crew Chiefs as part of their refinery job description, received less
and inferior training than the Day Fire Crew, who volunteered to serve and agreed to
attend monthly training session. (Tr. 2748-49)

That respondent actually expected its Shift Fire
Crews to respond to and handle fires greater than incipient stage is manifest by
respondent's furnishing fire protective clothing to be worn by the members of said crews.
(Tr. 4825)

Respondent had a written rule in its emergency
procedures plan that protective clothing would be put on by members of the fire crews
before reporting to the scene of a fire or potential fire. (Exhibit C-9, pp. 29989, 29991,
30014; Tr. 2525-26) Respondent's Fire Chief expressed his concern when the rule requiring
the wearing of turnout gear was not obeyed by fire crew members. (Exhibit C-86, p.18458;
Tr. 2794-99)

That respondent knew its Shift Fire Crews would in
all likelihood be facing major fires rather than "incipient stage fires" is
further apparent from a review of respondent's Shift Fire Crew training records which
reveal that at eleven training sessions in 1983 alone, training involved use of 3 inch
hose, 2� inch hose and 2� inch nozzles. (Exhibit C-89, 17708, 17718, 17721, 17722,
17728, 17729, 17730, 17731, 17732, 17735 and 17737)

Respondent argues:

". . . it should be noted that all employees in the refinery who worked out in
the operating units (regardless of job classification) were to receive annual fire-
fighting training, consisting of hands-on training at the respondent's fire field at the
refinery, as well as classroom instruction in the use of handheld fire extinguishers, one
and one-half inch hoselines and fixed monitors."

(Tr. 4850-4853) (Respondent's Post-Trial Memorandum p.70)

Section 1910.155(26) defines incipient stage fires:

(26) "Incipient stage fire" means a fire which is in the initial or beginning
stage and which can be controlled or extinguished by portable fire extinguishers, Class II
standpipe or small hose systems without the need for protective clothing of breathing
apparatus.

Thus the general production employee population at respondent's Chicago refinery, was
trained to respond to "incipient stage fires."

Apart from that minimal training afforded all
employees, respondent established two classifications of Fire Brigade. The Day Fire Crew
sometimes referred to as The Fire Department was made up of volunteers who were trained to
be ". . .proficient in the handling of in-plant emergencies." The members agreed
to and were expected to attend, at minimum, monthly training sessions. Some were expected
to attend two monthly sessions ". . .to learn the proper method of operation of all
mobile firefighting equipment." The members of this Day Fire Crew were issued their
own personal protective clothing which was kept on the Fire Department Mobile Command
Center truck. Fire Department Officers were to be appointed by the Chief based on
experience and ability. The Day Fire Crew members were divided into squads directed by
lieutenants. Respondent's Fire Chief and Deputy Fire Chief worked the day shift. (Exhibit
C-9)

Finally, the second Fire Brigade classification
established by the respondent was the Shift Fire Crew. Although turnout gear of various
sizes was placed in the back of the pickup truck assigned to the Shift Fire Crew Chief and
members of the Shift Fire Crew were instructed to put on turnout gear before reporting to
the scene of a fire or potential fire, these members were not assigned or furnished
protective clothing for their individual use. (Tr. 2824) Certain job descriptions, to-wit:
Pumpers, Laboratory personnel, Coke Handlers and Shift Pipefitters carried with them the
incidental requirement that the person awarded the job would be automatically a member of
the Shift Fire Crew and required to respond to the scene of fire or potential fire when
the alarm sounded. (Tr. 2822) By job description the Petrochemical Department Shift
Supervisor became automatically the Shift Fire Crew Chief unless the emergency was in his
operating area in which event the Blending and Transfer Shift Supervisor, who was
otherwise to act as Assistant Chief, was to assume the responsibility of head of the Shift
Fire Crew. The Shift Fire Crew was ". . .to provide fire protection when the Day Fire
Crew is not present." Training was to be bimonthly consisting of practical and
classroom instruction to enable members to "adequately" perform fire fighting
duties. (Exhibit C-9, p. 29988) Elsewhere training for Shift Fire Crew is described "
. . .to ensure familiarity with the equipment available to them." (Exhibit C-9, p.
33012)

The refinery operated 24 hours a day, 7 days each
week. A serious fire emergency could occur during any shift at any time of the day. There
was no reason to assume that the hazard of fire or potential fire would be greater at any
given point in time be it day or night. (Tr. 2525, 2820)

Realistically, the respondent trained its Day Fire
Crew to meet fire emergencies which could arise in its Chicago refinery plant.
Unrealistically, respondent trained its Shift Fire Crew to respond only to incipient stage
fires (Tr. 4742) and then changed it with the responsibility to ". . . provide fire
protection when the Day Fire Crew is not present." The hazards they were to face were
identical. If the Shift Fire Crew could not handle the problem, it was required to summon
the off-duty Day Fire Crew and then, in effect, hold the fort until help arrived. That
help was intended to be not merely more manpower, but better trained personnel. (Tr. 2524)

Such a plan and strategy on the part of the
respondent merely put untrained personnel in harm's way.

Respondent failed to train and educate members of its
Shift Fire Crews commensurate with those duties and functions they were expected to
perform.

Complainant met its burden of proof with respect to Issue H.

Issue I :

Was the respondent in violation of C.F.R.
1910.156(c)(1) as alleged in Citation No. 1, item 3B?

The standard requires that fire brigade leaders be
provided with training and education which is more comprehensive than that provided the
general membership of the fire brigade.

Complainant alleges that in reference to the Shift
Fire Crew Chiefs, this was not done.

Respondent made an attempt to provide additional
training to its Shift Fire Crew Chiefs over and above what they would receive in attending
the bimonthly Shift Fire Crew classes.

As of 1979, all Shift Fire Crew Chiefs had attended
an out-of-refinery training class at either the Industrial Fire Training School at Texas A
and M or the Western Oil and Gas Association facility in Reno, Nevada. There were ten
Shift Fire Crew Chiefs and as of 1979 respondent had a program to send two of these chiefs
to the above mentioned outside fire training schools each year. Thus each Fire Crew Chief
was anticipated to attend an outside training school each five years. (Tr. 4896, 4897)

One Shift Fire Crew Chief attended the Union Oil
sponsored Fire Training School at Reno the year of its inception in 1981. (Tr. 4898) In
1982 the respondent effected a reorganization which interfered with the Fire Department's
training plans and five Shift Fire Crew Chiefs were sent to the Reno Fire Training School
that year. (Tr. 4899) Shift Crew Chiefs from the Chicago refinery attended the Reno Fire
Training School in 1983. (Tr. 4899) By the fall of 1983 every new Shift Fire Chief was to
have attended a week long out of state fire training school. (Exhibit C-86, p. 018449)
Early in 1984 the Fire Department of the respondent commenced Shift Fire Chief classes on
Monday afternoons. Each class was repeated on four consecutive Mondays in order to allow
these shift workers each the opportunity of attending the given class. (Tr. 4894-4896) In
these classes incidents which had occurred in the refinery would be discussed and how they
may have been handled differently. (Tr. 4894)

In view of the foregoing it can hardly be said that
respondent's Fire Brigade leaders were not provided training and education more
comprehensive than that provided the general Shift Fire Crew membership.

The testimony of Mr. Watrous, respondent's witness,
was convincing and established the need for more concern on the part of the respondent for
more adequate fire training. (Tr. 2892-2897) Nevertheless the facts are that the
respondent provided training to its Shift Fire Crew Chiefs which was more comprehensive
than that given the crew members. The result may have been that the poorly trained were
being led by the less poorly trained, but complainant failed to meet its burden of proving
a violation of Issue I.

Issue J :

Was the respondent in violation of 29 C.F.R.
1910.156(c)(2) as alleged in Citation No. 1, item 3C?

The standard requires that fire brigade members be
provided training frequently enough to assure that each member is able to perform assigned
duties and functions satisfactorily and in a safe manner so as not to endanger fire
brigade members or other employees.

After becoming Fire Safety Supervisor for the
respondent in 1975, Dale T. Pirc, by letter dated May 29, 1979, called attention of his
corporate superiors to difficulties in getting Shift Fire Crew personnel to attend fire
training sessions. He pointed out that the problem had existed for many years, and stated:
". . . The lack of attendance at trainings and response to off-shift emergencies
cannot be ignored any longer. The potential of the loss of life and property without an
efficient off-shift fire and rescue squad is too great." (Exhibit C-86, p. 018431;
Tr. 4739)

Again, by letter dated August 7, 1979, Chief Pirc
complained to his corporate superiors, ". . . In the past we have managed to slip by
with the few capable people we have on shift and merely turning our heads the other way
with those who choose not to participate. Needless to say, some day our luck will run out
and we will suffer the consequences. . ." (Exhibit C-86, p. 018433)

In May of 1981, Chief Pirc reported that Shift Fire
Crew attendance at training classes was up to an "acceptable" 70%. He reported
that attending personnel had for the first time been subjected to "live fire" at
the fire training field. He noted that whereas the Shift Fire Crew Chief's had a 60%
attendance, it should be 100% since they have ". . .overall responsibility of shift
fire emergencies." (Exhibit C-86, p. 018438)

Incidentally, in the above report of May 14, 1981,
Chief Pirc noted that all personnel at the training field ". . .used full protective
clothing," and that in the upcoming Shift Fire Crew classes for July there would be a
review of ". . . 2� handline operations." (emphasis added)

By letter to his corporate superiors dated December
23, 1981, Chief Pirc expressed disappointment in the attendance of Shift Fire Crew
personnel at training sessions throughout 1981. The Shift Fire Crew Chiefs had only a 66%
attendance. Chief Pirc there noted: ". . . We have determined that if each
classification in the Shift Fire Crew achieves an 80% attendance in each of the six annual
classes, they should be able to maintain the basic skills required for that job. . . . We
believe that attendance below this minimum greatly increases the risk of property damage
and personal injury to the members themselves." (Exhibit C-86, p.018440)

By letter to his corporate superior dated March 25,
1983, Chief Pirc noted that the Shift Fire Chiefs from the "North Plant" had a
0% attendance at the March 1983 training classes. Chief Pirc noted: "The problem is
now to the point that not only I seriously question the Shift Fire Chief's ability, but
many members of the Shift Crew. . . have also begun to ask the same question. . . . Such a
lack of confidence would prove disastrous to any progress we have made with the Shift Fire
Crew over the past few years." (Exhibit C-86, p. 018444)

Continuing neglect of training by the Shift Fire Crew
Chiefs is noted by Chief Pirc in a letter to his corporate superior, dated June 22, 1983.
(Exhibit C-86, p. 018448)

Chief Pirc's concerns were forwarded up the corporate
ladder in a letter dated June 28, 1983, wherein it was noted: ". . . Since the
Operating Department reorganization in September (1982), attendance of the Shift Fire
Chiefs as a group has averaged 33%. The last time a Shift Supervisor from the
Petrochemical Department attended a shift fire training class was January 1983." The
writer also notes: "Thus far, our request for recommendations from the Operating
Division have not provided any significant solutions. We are putting a select group of
individuals into nonroutine, unpredictable and hazardous situations for which training
plays a major part in both effectiveness and safety of the entire Shift Fire Crew."
(Exhibit C-86, p. 018452)

By January 18, 1984, Chief Pirc noted in a letter to
his superior the attendance of Shift Fire Chiefs at training sessions had risen to less
than 50%. Shift Crew member attendance had improved and was observed to be
"marginally acceptable." (Exhibit C-86, p. 018457)

Perhaps the biggest flaw in respondent's Shift Fire
Crew concept was that although membership was mandated by job description including the
positions of Chief, participation in training or even appearance at a sounded emergency
alarm was not enforced. Chief Pirc, who had no input in the selection of shift crew
members or chiefs, (Tr. 2588) on at least two occasions suggested that Shift Fire Crew
members should be replaced in their job classifications if they failed to have
satisfactory attendance at training sessions or failed a written competence test. He
didn't venture so bold as to suggest the same requirement of Chiefs who held supervisory
positions in operations. (Tr. 4938-40, 2442-44, 2451-53, 2590; Exhibit C-86, pp. 018454,
018456) There is no evidence in the record that management took Chief Pirc's suggestions
seriously.

That respondent gave production priority over safety
fire training is demonstrated in the closure of the Fire Training Field in 1983.
Respondent without first providing an alternative fire training site preempted the space
and constructed a new production facility thereon. From May of 1983 until around the first
of July 1984 the respondent's Fire Department was without a live training field where it
could provide hands-on training in putting out actual fires to its fire fighting
personnel. Chief Pirc considered live firefighting drills to be a necessary part of the
training. (Tr. 2630-32)

Respondent's failure to respond effectively to the
importuning of its Fire Department Chief that more frequent attendance at fire training
sessions be required of Shift Fire Crew members and Chiefs and respondent's disabling of
the live fire training field without providing an alternative for a period exceeding one
year constituted a failure to provide fire training to its Shift Fire Crew ". .
.frequently enough to assure that each member of the fire brigade was able to perform his
or her assigned duties and functions satisfactorily and in a safe manner so as not to
endanger fire brigade members or other employees."

Complainant has met its burden of proof with respect
to Issue J.

Issue K :

Was the respondent in violation of 29 C.F.R.
1910.156(c)(2) as alleged in Citation No. 1, item 3D?

The standard requires in addition to sufficient
frequency of training that "all fire brigade members shall be provided with training
at least annually."

As of July 23, 1984, the respondent had 10 Shift Fire
Crew Chiefs or Assistant Chiefs and 65 Shift Fire Crew members. (Exhibit C-85)

Review of the training history of the 8 Shift Fire
Crew members and Shift Fire Crew Chief and Assistant Shift Fire Crew Chief who died in the
fire of July 23, 1984, discloses that one crew member had no fire training within the year
preceding the fire. (Exhibit C-10)

Complainant has thus proved that not "all"
fire brigade members were provided training "at least annually." To confront
such an untrained employee with a fire or potential fire in an oil refinery environment
where fire can escalate rapidly is to expose that employee to a substantial probability
that death or serious physical harm could result.

Issue L :

Was the respondent in violation of 29 C.F.R.
1910.156(c)(3) as alleged In Citation No. 1, item 3E?

The standard requires that the training and education
program for oil refinery fire brigade members be similar to those conducted by Texas A and
M University, Lamar University, Reno Fire School or the Delaware State Fire School.

Each of the recommended fire schools, as an essential
part of its fire training program, had a live fire field where the trainees wearing
turnout gear would get hands-on experience extinguishing fires involving flammable liquids
and flammable gases. Approximately one-half of the time of the trainees at these schools
was devoted to this practical, hands-on training. (Tr. 4749-4757)

Respondent's Fire Chief Pirc considered live fire
fighting drills to be a necessary part of fire brigade training. Yet the respondent
preempted the live fire field to construct a production facility and left its Fire
Department without the means of offering to its Fire Crew members live, hands-on
experience in extinguishing fires for more than a year, i.e., between May 1983, and July
1984. (Tr. 2630-32)

Respondent thus expressed a lack of concern for
safety and fire training and rendered its fire brigade training program dissimilar to
those recommended in the standard in a major and essential respect.

Issue M :

Was the respondent in violation of 29 C.F.R.
1910.156(c)(4) as alleged in Citation No. 1, item 3F?

In addition to informing fire brigade members about
special hazards such as storage and use of flammable liquids and gases, the standard
requires the employer to develop and make available for inspection by fire brigade members
written procedures that describe the actions to be taken in situations involving the
special hazards and to include these in the training and education program.

Although the properties of the flammable liquids and
gases members of respondent's fire brigades would be coping with were undoubtedly
discussed at training sessions, respondent's Fire Chief testified that respondent had no
written preplan manual that described actions to be taken by a fire brigade when fighting
a fire at the refinery's processing units. (Tr. 2738)

Complainant met its burden of proof with respect to
Issue M.

Issue N :

If the respondent was in violation of any or all of
Issues H thru M (Citation No. 1, items 3A thru 3F), was such violation willful or failing
that serious, in whole or in part?

For the elements which must be proved to make a
violation of section 5(a)(2) of the Act to be either "Willful" or
"Serious" and cases so holding see the discussion under Issue F, supra at
pp. 49-51.

Applying said principles to the facts of items 3A thru 3F of Citation No. 1, which items
were grouped for the purpose of fixing a single penalty based on a charge of willfulness,
we determine the following:

Item 3A : Respondent's position that it made the determination to require its
Shift Fire Crews to respond to "incipient stage fires" and to train them
accordingly does it no credit. The facts are at variance with respondent's position held
at the hearing and through its briefing. Indeed, respondent's position seems to have been
adopted, at least in part, in order to justify a claim that it was not required to furnish
or require the wearing of protective clothing. In fact, respondent did furnish both Day
and Shift Fire Crews protective clothing. Respondent did instruct the members of the Shift
Fire Crews to wear protective clothing. Unfortunately, it tolerated failure of the crew
members to heed its instructions. In fact, respondent did train its Shift Fire Crews in
the use of 2 � and 3 inch hoses and 2 � inch nozzles. Thus
respondent acknowledged that its Shift Fire Crew members may be confronted with
emergencies involving major fires, but it did not provide training commensurate with such
likelihood.

Nevertheless, respondent required of its Shift Fire
Crew that it remain at the scene and attempt to control a fire emergency beyond its
training ability until better trained help should arrive. Such a policy manifests a plain
indifference to the safety of the members of the Shift Fire Crew. This violation was
willful under the Act.

Item 3B : Since the training of respondent's
Shift Fire Crew leaders was here found to have been more comprehensive than that given the
members of the Shift Fire Crew, no violation was found with regard to item 3B.

Item 3C : Respondent failed to adequately
respond to the continued urging of its Fire Chief and to develop a method of enforcing
attendance of Shift Fire Crew members and Chiefs at training sessions prepared and offered
by its Fire Department. Although respondent justifiably expresses pride in the expertise
and qualifications of its Fire Chief (Respondent's Post-Trial Reply Memorandum, pp.41,
42), it nonetheless undermined his training efforts by denying him or the fire fighting
personnel a live Fire Field for hands-on fire extinguishing for over one year from May
1983, to early in July 1984.

Such failure to respond to the persistent urging of
its Fire Chief and deliberate removal of his essential training facility amounts to an
intentional disregard for the requirements of the Act and manifests a plain indifference
to employee safety, this violative conduct was willful within the meaning of that term
under the Act.

Item 3D : Although at least one of respondent's
Shift Fire Crew members did not receive at least annual training, it was clear from the
evidence presented at the hearing that respondent made a concerted effort to give all of
its production employees annual training and in addition to give bi-monthly training to
its Shift Fire Crew members. Though it failed to accomplish the frequency of training its
Fire Chief held to be essential, it nonetheless would appear that failure of all Shift
Fire Crew members to receive at least annual training was more the exception than the
rule.

Respondent's conduct in this regard cannot be held to
be willful. That the violation was serious, however, is established by the fact that the
one Shift Fire Crew member who had received no training for more than one year, upon which
this finding of violation is based, perished in the fire of July 23, 1984.

Item 3E : Respondent's violative conduct which
made out a violation of item 3E was the removal of the live fire field as a fire fighting
training facility for a period exceeding one year. Respondent thus accommodated its
production department at the expense of employee safety. Such conduct cannot be viewed
other than manifesting careless disregard for the requirements of the Act and plain
indifference to employee safety. The violation of item 3E was willful as that term is used
in the Act.

Item 3F : Although respondent failed to develop
written procedures and make them available for the inspection of fire brigade members
describing the actions to be taken in situations involving the special hazards of
flammable liquids and gases or to include same in its fire brigade training and education
program, that fact only establishes a violation of the standard at 29 C.F.R.
1910.156(c)(4).

Facts necessary to show that failure to have been
willful are lacking.

Respondent's omission of this mandated requirement of
the Act when taken in conjunction with respondent's other failures found in meeting the
requirements of the various subsections of 29 C.F.R. 1910.156 compels a finding that this
violation was serious.

Respondent is thus held to be in willful violation of
items 3A, 3C and 3E. Violations of items 3D and 3F are held to be serious. Item 3B should
be vacated.

Issue O :

What, if any, penalty or penalties would be
appropriate for the willful violations of items 3A, 3C and 3E and the serious violations
of items 3D and 3F.

Giving due consideration to the factors affecting the
appropriateness of penalties to be assessed as set forth at section 17(j) of the Act, it
is here determined that the combined sum of $6,000.00 is an appropriate penalty to be
assessed for the willful violation of items 3A, 3C and 3E and the combined sum of
$1,000.00 is an appropriate penalty to be assessed for the serious violations of items 3D
and 3F.

Issue P :

Was the respondent in violation of section 5(a)(1) of
the Act as alleged in serious Citation No. 2, item 1?

For the elements which must be proved to make out a
violation of section 5(a)(1) of the Act and cases so holding, see the discussion under
Issue A, supra at pp. 23-24.

The citation charges respondent with ". . . the
lack of effective emergency evacuation procedures and education and training of personnel
in said procedures." In the citation the Secretary proposes the establishment and
implementation of a refinery "emergency action plan" which would include some
twelve itemized elements as a minimum, all having to do with evacuation of employees.

That the failure to institute emergency evacuation
procedures constitutes a hazard which was present in respondent's refinery and recognized
by respondent and the petroleum refining industry is clear from the evidence presented at
hearing. It is axiomatic that the processing of petroleum products involves inherent
potential dangers. Harry McAninch, an engineering consultant for the Secretary, testified
that the failure of pressure vessels to contain hydrocarbons can result in fires and
explosions as the escaping contents mix with oxygen in the air. (Tr. 1972-75) David White,
a consultant in petrochemical refining fire protection testifying for respondent,
recognized that a refinery vessel leak may result in the release of rapidly expanding
petroleum gases forming an invisible, flammable vapor. (Tr. 5186-90) Mr. White,
respondent's Fire Chief, and the Secretary's expert, Lawrence Watrous, all agreed that the
possibility of ignition of such vapors poses a hazard to personnel who may be exposed to
the gases. (Tr. 2911, 5026-27, 5189) Mr. Watrous testified that a preplanned evacuation
procedure for getting personnel safely out of an endangered area is a necessity to avoid
jeopardizing the lives and safety of personnel at the emergency site and to later rescue
personnel. (Tr. 2909-2912) Mr. Pirc agreed that evacuation of personnel downwind of an
unignited leak was a necessity. (Tr. 5027) Both he and Mr. White testified that any sound
emergency response program should contain preplanned provisions for evacuation of
personnel. (Tr. 2724-25, 2734-40, 2743-44)

It is clear that the failure to preplan evacuation
procedures may result in death or serious bodily harm and that evacuation measures would
materially reduce the risk of serious bodily harm. Refinery fires involving large
quantities of flammable liquids and gases subject employees to the dangers of
asphyxiation, serious burns or death due to the presence of those employees in areas of
high gas concentrations. (Tr. 2911-12) A procedure by which refinery employees may execute
an orderly evacuation from fire and explosion sites without confusion and resulting loss
of time clearly would increase such employees' chances of escaping bodily harm. (Tr.
2915-2916)

Respondent argues that it is impossible to plan in
advance for each and every possible emergency which may arise in a petroleum refinery.
However, under the language of the Act, a safety measure need not completely eliminate a
recognized hazard; if such measure will materially reduce the hazard, it may be required
under 5(a)(1). See Litton Systems, Inc. , Ingalls Shipbuilding Division , 10
BNA OSHC 1179, 1182 (No. 79-900, 1981). The diversity of possible emergencies does not
prevent a refinery from developing the rudiments of an evacuation plan, including
designation of personnel to determine the need to begin evacuation, setting of a
preassigned signal to report to such personnel and a system for accounting for all
personnel.

That evacuation preplanning is feasible is
demonstrated by the testimony. Mr. Watrous testified to the institution of evacuation
plans by numerous other refineries. (Tr. 2907-09, 2855-57, 2914) Mr. White testified that
as part of his consulting business, he assisted Saudi Arabian refineries develop their own
evacuation programs. (Tr. 5158-59) The Secretary also introduced published guidelines
outlining possible evacuation procedures. See, Fire Protection Manual For Hydrocarbon
Processing Plants, 2d ed., 1973, Exhibit C-95, p. 455. Moreover, respondent admits the
feasibility of an evacuation plan in its Surreply Memorandum stating that it developed
such a plan in 1986 to comply with new state law. (Respondent's Surreply Memorandum at
p.11)

Respondent defends, stating that even if the
Secretary has established a duty to implement an evacuation plan, he has failed to prove
that respondent's emergency procedures were inadequate to meet the requirements of the
Act.

Prior to and at the time of the July 1984 fire,
respondent's methods for dealing with fire and explosion emergencies were contained in its
Emergency Procedures (Exhibit C-9), containing respondent's 222 Alarm System. Any employee
sighting fire or potential fire was to dial 222 on the refinery phone system. (Tr.
4869-70) A plant guard would receive the employee's information and sound the appropriate
alarm, followed by an announcement on the public address system and the fire frequencies
giving the location and the nature of the emergency. (Tr. 4871, 4874-75) On the sounding
of the alarm, vehicle traffic and work which might provide an ignition source was to cease
(Tr. 4871-72), and nonessential personnel, i.e., maintenance workers or independent
contractors, were to leave the battery limits of the endangered unit. (Tr. 4874) Operating
personnel were to remain and attempt to control the operations and contain the emergency
on the unit. (Tr. 4875-77) Shift operating personnel were to remain and be under the
supervision of the responding Shift Fire Chief, who had the ultimate responsibility for
determining the necessity and manner of removing personnel from the area on an ad hoc
basis. (Tr. 2745- 47) Respondent asserts that over and above the foregoing. "All of
respondent's outside operators . . . are instructed . . . that in any circumstance when
such individual feels that he is in a life threatening situation, that he is immediately
to leave such area." Such reliance on the instinct for self preservation is no
substitute for an emergency evacuation preplan.

Refinery personnel were trained in the function of
the 222 system at their initial orientation; the various alarm codes were tested weekly
but only during the day shift. (Tr. 4876) Several of respondent's employees and Shift Fire
Crew members testified that they were unaware of the existence of any evacuation plan and
had received no training in that regard. (Tr. 348, 527, 2202-03, 2251-52, 2300-01, 2350,
2414-15, 2431-32) Two of the victims caught in the explosion were listed as contract
guards, non-essential personnel who under the respondent's stated policy should have left
the endangered area. (Exhibit C-23)

On the day of the explosion, there was no attempt to
institute evacuation procedures. (Tr. 120) Operating personnel on an adjacent unit did not
know whether to remain on the unit or head for the nearest exit. (Tr. 2296-2301) Seven
employees in the FCC unit control room remained at their posts following the initial
explosion while a number of supervisory personnel entered and left; finally a day process
supervisor and a shift supervisor conferred and ordered the room cleared approximately 45
minutes later. (Tr. 519-27)

Mr. Watrous testified that an effective evacuation
plan contains education of supervisory personnel as to when evacuation procedures should
be implemented, provisions for notifying personnel of the necessity of evacuation, route
planning for evacuation and a method of "counting heads" to determine whether
all personnel are accounted for. (Tr. 2907-08) Respondent's Fire Chief admitted that
respondent's Emergency Procedures (Exhibit C-9) contained none of these basic
requirements. (Tr. 5032-33)

Whatever elements respondent's emergency response
program did contain, it was silent respecting evacuation other than requiring maintenance
personnel and independent contractors to leave the battery limits of the endangered unit.
Respondent's delegation of evacuation duties to the Shift Fire Chief, who must of
necessity be otherwise occupied in his fire fighting activities at a time when the need
for evacuation arises, seems manifestly unreasonable. Such a "plan" is no plan
at all and does nothing to advance the purposes of preplanning, i.e. avoiding confusion
and delay. Moreover, it is clear that even those so called "procedures"
contained in respondent's emergency plan were inadequately communicated to personnel, many
of whom had no understanding regarding the possibility of evacuation, how it would be
carried out, or from whom instructions would come.

Complainant met its burden of proof with respect to
item 1 of Serious Citation No. 2.

Issue Q :

Would an evacuation plan as proposed by complainant
create a greater hazard to respondent's employees and thus become other than feasible?

In addition to generally denying the alleged
violation, set forth in item 1 of Serious Citation No. 2, respondent raises the
affirmative defense of Greater Hazard by way of specific exception to the second element
of the Secretary's proposed emergency evacuation plan which reads:

"A feasible emergency action plan which includes
. . .

*             *
             *

(b) Procedures to be followed by employees who remain to operate critical plant operations
before they evacuate.

Respondent claims that an evacuation plan mandating
the evacuation of all personnel from a fire or potential fire site would leave the site
unattended, allowing the emergency situation to develop uncontrolled, thus increasing the
hazard for all refinery personnel.

Respondent's Fire Chief, Dale Pirc, testified that
during a fire or potential fire emergency, operating personnel are to remain on their unit
to isolate or block in the unit in order to contain the emergency. (Tr. 4877) Mr.
McAninch, testifying for the Secretary, agreed that in the event of a leakage of
hydrocarbons, operating personnel must be present to segregate and depressurize a leaking
vessel and disperse escaping vapors. (Tr. 1989-91) However, as Mr. McAninch further
testified, where a situation progresses beyond the operators' control, those operators
must leave for their own safety. (Tr. 1978, 1991)

Respondent assumes that the Secretary's abatement
plan calls for essential operating personnel to abandon their posts during critical
periods as an emergency develops. The Secretary's plan calls for no such measure. All
that, is required under item (b) of the suggested plan is the development of
"[p]rocedures to be followed by employees who remain to operate critical plant
operations before they evacuate."

Respondent's Contention that because of this element
an evacuation preplan would result in an increased hazard is without merit. See Brown
& Root, Inc. , 8 BNA OSHC 2140, 2144 (No. 76-1296, 1980); Cerro Metal Products
Division, Marmon Group, Inc. , 12 BNA OSHC 1821 (No. 78-5159, 1986).

Issue R :

If the respondent was in violation of section 5(a)(1)
of the Act as set forth in Issue P above, what penalty would be appropriate?

Again, giving due consideration to the statutory
requirements set forth at section 17(j) of the Act, the penalty proposed by the Secretary
in the sum of $1,000.00 for this violation of section 5(a)(1) of the Act is found to be
appropriate.

---

Now, having observed the demeanor of the witnesses and having weighed the credibility
thereof, there are here entered the following:

Findings of Fact

1. Respondent is, and at all times pertinent hereto
   was, a corporation, with an office and place of business at 135th Street and New Avenue,
   Lemont, Illinois, where, at all times herein mentioned, it was engaged in the business of
   refining raw petroleum into fuels and lubricants.

2. Respondent at all times pertinent hereto was
   engaged in a business affecting interstate commerce in that respondent was engaged in
   producing goods a substantial portion of which were being produced for interstate commerce
   and were being shipped or delivered or sold to persons or firms in states other than the
   state wherein so produced and in that respondent was engaged in handling goods which had
   been moved in interstate commerce.

3. Respondent at times pertinent hereto employed
   approximately 680 to 700 employees at the above described workplace, known as the Chicago
   Refinery, and was an employer within the meaning of the Act.

4. Facts set forth under The Catastrophic Event
   portion of this decision and elsewhere herein are here incorporated by reference as though
   specifically again set forth at this point.

5. Vessel 12D7016 was fabricated from A516-Grade 70
   carbon steel and in accordance with Section VIII of the ASME Boiler and Pressure Vessel
   Code. (Tr. 718)

6. The respondent's inspection department conducted
   periodic inspections of pressure vessels in the refinery, including vessel 12D701, during
   regularly scheduled refinery shutdown periods,known as turnarounds as well as on-stream
   inspections. (Tr. 3530)

7. Pressure vessel 12D701 was inspected internally at
   the time of initial installation and during turnarounds in 1972, 1974, 1976, 1978, 1980,
   1982 and 1984. (Tr. 667, 1897, 3578; Exhibits C-27 thru C-33)

8. During each turnaround inspection of vessel 12D701
   straight beam ultrasound thickness tests were performed on the vessel. (Tr. 3615, 3616;
   Exhibit C-16)

9. Scheduled refinery shutdown for inspections is a
   practice recognized throughout the petroleum and oil refinery industry. (Tr. 4524, 4692)

10. Respondent maintained records of the various
    inspections which were conducted of each of its pressure vessels, including pressure
    vessel 12D701. (Tr. 599, 614; Exhibits C-27 thru C-33)

11. Respondent conducted training of the members of
    its inspection department in the conducting of inspection of its pressure vessels. (Tr.
    3450, 3466, 3472-73, 3529, 3583-85; Exhibit C-71)

12. During turnaround inspections, respondent on
    occasion employed inspectors from outside companies to supplement respondent's inspection
    department. (Tr. 3475-3477)

13. Prior to the April 1984 turnaround inspection
    respondent engaged B. Ostrofsky Associates, Inc. to provide inspectors to supplement
    respondent's inspection personnel in conducting pressure vessel inspections including
    vessel 12D701. (Tr. 3475-3477, 3638)

14. Mr. P. J. Krol, an inspector supplied respondent
    by B. Ostrofsky Associates, Inc., conducted an internal inspection of vessel 12D701 with
    and under the supervision of Mr. J. Gallagher, a member of respondent's inspection
    department during the 1984 turnaround inspection. (Tr. 1801, 1897, 3862-3872)

15. The results of the inspection of vessel 12D701
    during the 1984 turnaround were recorded in the file maintained by the respondent for said
    vessel. (Tr. 1881; Exhibit C-34)

16. Failure to adequately inspect for the presence of
    cracking or cracks in or about, field welds performed at respondent's refinery, or in the
    walls of pressure vessels exposed to hydrogen environment, increased the likelihood of
    fire or explosion to which respondent's employees would be exposed.

17. The increased likelihood of fire or explosion at
    respondent's Chicago Refinery from undetected cracks in pressure vessels was recognized by
    the respondent and by the oil refinery industry.

18. Fire and/or explosion, if they occur, are likely
    to cause death or serious physical harm to employees exposed thereto.

19. Cracks which may escape visual inspection can be
    detected by Magnetic Particle Testing, Liquid Dye Penetrant Testing, or Angle Beam
    Ultrasonic Testing, all. of which methods were recommended and accepted by the industry of
    which respondent was a part and known to the respondent, and respondent had the means of
    performing said tests.

20. Other than visual inspection respondent did
    nothing to detect cracks in vessel 12D701 and respondent was in violation of item 1 of
    Citation No. 1. (Issue A)

21. Respondent's violation of Citation No. 1, item 1
    was willful as that term is used in the Act. (Issue C)

22. The sum of $10,000.00 is an appropriate penalty
    to be assessed for respondent's willful violation of the Act as set forth in Citation No.
    1, item 1. (Issue D)

23. The respondent did not provide fire protective
    clothing to operating personnel on respondent's various production units nor require use
    thereof by said personnel.

24. Respondent's operations personnel were required
    to handle fires or potential fires occurring in the production units of respondent's
    Chicago refinery from the initial stages and until said operations personnel were allowed
    to evacuate the unit by the chief of the fire crew which responded to the fire or
    potential fire alarm. (Tr. 2745) In such situations operations personnel were exposed to
    the same hazard of fire or explosion as the members of respondent's fire crews who were
    furnished and required to wear fire protective clothing.

25. Respondent was in violation of item 2 of Citation
    No. 1. (Issue E)

26. Respondent's violation of item 2 of Citation No.
    1 was willful as that term is used in the Act. (Issue F)

27. The sum of $4,000.00 is an appropriate penalty to
    be assessed for respondent's willful violation of the Act as set forth in item 2 of
    Citation No. 1. (Issue G)

28. Members of respondent's shift fire crews were
    exposed to the hazards of fire or explosion without being provided training and education
    commensurate with the duties and functions they were expected to perform.

29. Respondent was in violation of the standard at 29
    C.F.R. 1910.156(c)(1) with respect to its shift fire brigades (crews) as charged in item
    3A of citation No. 1. (Issue H)

30. Respondent's fire brigade leaders and instructors
    were provided training and education more comprehensive than that provided the fire
    brigade members.

31. Respondent was not in violation of the standard
    at 29 C.F.R. 1910.156(c)(1) with respect to its fire brigade leaders and instructors as
    charged in item 3B, Citation No. 1. (Issue I)

32. Respondent failed to assure that training and
    education of members of its shift fire crews was conducted frequently enough to assure
    that each member was able to perform assigned functions satisfactorily and in a manner not
    to endanger fire brigade members or other employees.

33. Respondent was in violation of the regulation at
    29 C.F.R. 1910.156(c)(2) as charged in item 3C, Citation No. 1. (Issue J)

34. Not all fire brigade members were provided
    training at least annually.

35. Respondent was in violation of the regulation at
    29 C.F.R. 1910.156(c)(2) as charged in item 3D, Citation No. 1. (Issue K)

36. The training and education program for
    respondent's fire brigade members was not similar to a substantial degree to that
    conducted by Texas A and M University, Lamar University, Reno Fire School or the Delaware
    State Fire School.

37. Respondent was in violation of the regulation at
    29 C.F.R. 1910.156(c)(3) as charged in item 3E, Citation No. 1. (Issue L)

38. Respondent failed to develop and make available
    for inspection by fire brigade members written procedures that described the actions to be
    taken in situations involving flammable liquids and gases and to include these in the
    training and education program.

39. Respondent was in violation of the regulation at
    29 C.F.R. 1910.156(c)(4) as charged in item 3F, Citation No. 1. (Issue M)

40. Respondent's violations of items 3A, 3C and 3E of
    Citation No. 1 were willful as that term is used in the Act and a combined penalty of
    $6,000.00 is appropriate for said violations. (Issue N and Issue O)

41. Respondent's violations of items 3D and 3F of
    Citation No. 1 were serious as that term is defined at section 17(k) of the Act and a
    combined penalty of $1,000.00 is appropriate for said violations. (Issue N and issue O)

42. Failure to preplan and assign suitable
    responsibility for evacuation of personnel of oil refineries handling massive quantities
    of flammable liquids and liquefied petroleum gases under pressure exposes said employees
    to the increased risk of serious physical harm or death from fire or explosion which may
    occur.

43. The hazard of potential fire or explosion in an
    oil refinery and the fact that it may occur is recognized by the respondent.

44. The need for evacuation preplanning is recognized
    by the oil refinery industry of which respondent is a part.

45. Respondent on July 23, 1984, had no effective
    evacuation preplan covering operations unit personnel at its Chicago Refinery.

46. Respondent's operations units personnel were
    exposed on July 23, 1984, to the hazard of fire and explosion and there was no preplan for
    evacuation including such rudiments as an evacuation signal, assignment of suitable
    individual or individuals to initiate evacuation and a system for accounting for
    personnel.

47. Development and installing of an evacuation
    preplan is feasible and has been accomplished by other oil refineries.

48. The consideration and inclusion of procedures to
    be followed by employees who remain to operate critical plant operations before evacuation
    in an evacuation preplan would not create a greater hazard to employees. (Issue Q)

49. Respondent was in violation of section 5(a)(1) as
    charged in item 1 of Citation No. 2. (Issue P)

50. An appropriate penalty to be assessed for
    respondent's violation of item 1, Citation No. 2 is $1,000.00. (Issue R)

Conclusions of Law

1. Jurisdiction of this action is conferred upon the
   Commission by section 10(c) of the Act and the Commission has Jurisdiction of the parties
   hereto.

2. The presence of the Illinois Boiler and Pressure
   Vessel Safety Act in no way acts as a bar to the complainant proceeding against the
   respondent herein under section 5(a)(1) of the Occupational Safety and Health Act of 1970.
   (Issue B)

3. Respondent was in willful violation of item 1 of
   Citation No. 1, issued to respondent January 11, 1985, which should be affirmed and a
   penalty of $10,000.00 should be assessed.

4. The standard at 29 C.F.R. 1910.132(a) under which
   respondent was charged in Citation No. 1, item 2, issued to respondent January 11, 1985,
   is not applicable to respondent's fire brigade members, but is applicable to respondent's
   operations personnel who are required by respondent to handle fires or potential fires in
   their units until allowed to evacuate by the chief of the responding fire crew. (Tr. 2745)
   Said operations personnel were not members of respondent's fire brigades, nor were they
   trained as such.

5. Respondent was in willful violation of item 2 of
   Citation No. 1, issued to respondent January 11, 1985, which should be affirmed and a
   penalty of $4,000.00 should be assessed.

6. The standard at 29 C.F.R. 1910.156(c)(1) applied
   to respondent with respect to its fire brigades.

7. The standard at 29 C.F.R. 1910.156(c)(2) applied
   to respondent's fire brigades.

8. The standard at 29 C.F.R. 1910.156(c)(3) applied
   to respondent's fire brigades.

9. The standard at 29 C.F.R. 1910.156(c)(4) applied
   to respondent's fire brigades.

10. Item 3B of Citation No. 1, issued to respondent
    January 11, 1985, should be vacated.

11. Items 3A, 3C and 3E of Citation No. 1, issued to
    respondent January 11, 1985, should be affirmed as willful violations of section 5(a)(2)
    of the Act and a combined penalty of $6,000.00 should be assessed.

12. Items 3D and 3F of Citation No. 1 issued to
    respondent January 11, 1985, should be affirmed as serious violations of section 5(a)(2)
    of the Act and a combined penalty of $1,000.00 should be assessed.

13. Item 1 of serious Citation No. 2, issued to
    respondent January 11, 1985, should be affirmed as a violation of section 5(a)(1) of the
    Act and a penalty of $1,000.00 should be assessed.

ORDER

1. Item 1 of Citation No. 1, issued to respondent
   January 11, 1985, is AFFIRMED as a willful violation of section 5(a)(1) of the Act and a
   penalty of $10,000.00 is ASSESSED.

2. Item 2 of Citation No. 1, issued to respondent
   January 11, 1985, is AFFIRMED as a willful violation of section 5(a)(2) of the Act and a
   penalty of $4,000.00 is ASSESSED.

3. Item 3B of Citation No. 1, issued to respondent
   January 11, 1985, is VACATED.

4. Items 3A, 3C and 3E of Citation No. 1, issued to
   respondent January 11, 1985, are AFFIRMED as willful violations of section 5(a)(2) of the
   Act and a combined penalty of $6,000.00 is ASSESSED.

5. Items 3D and 3F of Citation No. 1, issued to
   respondent January 11, 1985, are AFFIRMED as serious violations of section 5(a)(2) of the
   Act and a combined penalty of $1,000.00 is ASSESSED.

6. Item 1 of serious Citation No. 2, issued to
   respondent January 11, 1985, is AFFIRMED as a violation of section 5(a)(1) of the Act and
   a penalty of $1,000.00 is ASSESSED.

R. M. Child

Judge, OSHRC

Dated: January 19, 1988

FOOTNOTES:

[[1/]] In its decision and remand, the Court of
Appeals presumed that the Commission would assess a penalty "somewhere in between the
$31,000 that OSHA assessed and the $22,000 that the Commission awarded." Because the
court reduced items 1 and 2 of citation 1 from willful, which carries a maximum penalty of
$10,000, to non-willful, which carries a maximum penalty of $1,000, the penalties we
assess are necessarily less than the amount presumed by the court.

[[1/]] Section 5(a)(1) of the Act:

Sec.5.(a) Each employer--

(1) shall furnish to each of his employees employment and a place of employment which are
free from recognized hazards that are causing or are likely to cause death or serious
physical harm to his employees;

[[2/]] The citation reads:

Citation

Section 5(a)(1) of the Occupational Safety and Health Act 1970: The employer did not
furnish employment and a place of employment which was free from recognized hazards that
were causing or likely to cause death or serious physical harm to employees in that
employees were exposed to serious hazards including being struck, crushed, burned or
asphyxiated resulting from increased likelihood of catastrophic failure of improperly and
inadequately maintained pressure vessels. The employer failed to establish, properly
implement and manage an effective program of pressure vessel safety including maintenance
inspection, rating, repair, alteration and/or replacement. In addition, appropriate
records necessary for informed decision making, documenting the vessel's actual condition
were not prepared, retained, or made available for inspection. Employees working
throughout the refinery were exposed to these hazards on a daily basis including July 23,
1984, when a pressure vessel, Amine Absorber 12D701, released hazardous quantities of
flammable gases and vapors and corrosive liquid.

A feasible and useful method of correcting these
hazards related to catastrophic pressure vessel rupture and failure is to establish and
properly implement an effective program including maintenance inspection, rating, repair
and alteration and/or replacement of refinery pressure vessels and their associated safety
devices. Such a program must include the following elements as a minimum:

(a) Ensure that persons who are authorized to perform
inspections of pressure vessels have education and experience equal to at least one of the
following:

(1) A degree in engineering plus 1 year of experience in the design, construction, repair,
operation, or inspection of boilers or pressure vessels.

(2) A two year certificate in engineering or technology from a technical college plus two
years of experience in the design, construction, repair, operation, or inspection of
boilers or pressure vessels.

(3) The equivalent of a high school education plus 3 years of experience in the
construction, repair, operation, or inspection

of boilers or pressure vessels.

(b) Ensure the effective internal and external inspections are performed prior to
returning pressure to use on a regular periodic basis throughout their service life. Such
inspections must include the following:

(1) Properly prepare vessels for inspection to ensure the safety of the inspector and the
effectiveness of the inspection. Among other steps, parts and components which prevent an
effective inspection must be removed.

(2) Proper inspection techniques and procedures must be used to determine if stress
corrosion cracking, hydrogen blistering and attack, embrittlement, metal fatigue, creep,
erosion, carburization, graphitization or other form of corrosion, deterioration and
defects are present. Where pressure vessels contain amine gas treating solutions,
inspections must include the following:

(i) Proper inspection procedures and techniques must be used by qualified inspectors
to detect cracks at welds and at weld heat affected zones of pressure vessels containing
amine gas treating solutions. Dye penetrant, magnetic particle or other equivalent
inspection techniques must be used.

(ii) Having detected cracks, qualified inspectors must use ultrasonic angle-beam
transducers to evaluate the size and depth of cracks;

(3) Prepare and maintain containing the following information as a minimum:

(i) The results of inspections including the results of tests and measurements;

(ii) Details regarding all maintenance, repair, rating and alterations;

(iii) The identity and qualifications of personnel who have performed maintenance, repair,
rating and alterations;

(iv) Details regarding procedures used in performing maintenance, repair, rating and
alterations.

(4) Recognized engineering principles must be used to determine if the vessel is or may
become hazardous for continued operation.

(5) Remove from service any vessel which is or may become hazardous until it has been
properly repaired and reinspected.

(6) Any vessel which has been repaired must be recertified prior to being returned to
service.

In addition to the above outlined general pressure vessel hazard control and abatement
program, recognized engineering principles and practices must be implemented to safely
construct, alter, replace and/or repair the vessels and their associated safety devices
which contain amine gas treating solutions, so that they are safe for continued operation.
Such principles and practices include the following:

(1) Utilize designs and select materials which are
safe for the containment of amine gas treating solution for operating conditions; and

(2) Utilize appropriate welding procedures and
techniques, including necessary stress relief; and

(3) Prepare and maintain records which document the
actual condition of pressure vessels containing amine gas-treating solutions and
demonstrate that the vessels were constructed, altered and/or repaired to ensure continued
safe operation; and

(4) Any pressure vessel containing amine gas-treating
solution which does not comply with subitems (1), (2) and (3) must be removed from service
until its safe operation can be established.

[[3/]] The Citation and Standard read:

Citation

29 C.P.R. 1910.132(a): Protective equipment,
including personal protective equipment for eyes, face, head, and extremities, protective
clothing, respiratory devices, and protective shields and barriers was not provided, used,
and maintained in a sanitary and reliable condition wherever it was necessary by reason of
hazards of processes or environment, chemical hazards, radiological hazards, or mechanical
irritants encountered in a manner capable of causing injury or impairment in the function
of any part of the body through absorption, inhalation or physical contact:

(a) The employer did not assure the use of protective clothing for the shift brigade
and unit operating personnel who were required to fight fires and provide control,
suppression and extinguishing measures beyond the incipient stage, including but not
limited to the explosions and fire at Amine Absorber 12D701 on July 23, 1984. Operating
personnel, shift fire brigade members and leaders who initially performed fire brigade
emergency activities prior to the explosions and fires and other employees who entered the
refinery to perform fire brigade activities did not wear appropriate protective clothing,
increasing exposure to fire hazards. Appropriate protective clothing consists of at least
the following components: foot and leg protection; hand protection; body protection; eye,
face and head protection.

Standard

Subpart I--Personal Protective Equipment

�1910.132 General requirements.

(a) Application. Protective equipment, including personal protective equipment for
eyes, face, head, and extremities, protective clothing, respiratory devices, and
protective shields and barriers, shall be provided, used, and maintained in a sanitary and
reliable condition wherever it is necessary by reason of hazards of processes or
environment, chemical hazards, radiological hazards, or mechanical irritants encountered
in a manner capable of causing injury or impairment in the function of any part of the
body through absorption, inhalation or physical contact.

[[4/]] The Citation and Standard read:

Citation

3A

29 C.F.R. 1910.156(c)(1): The employer did not
provide training and education for all fire brigade members commensurate with those duties
and functions that said fire brigade members were expected to perform. Said training and
education was not provided to fire brigade members before they actually performed fire
brigade emergency activities:

(a) Shift fire brigade members and some shift brigade leaders were not trained to be
proficient in the recognition and evaluation of the fire, explosive and related hazards
associated with oil refinery industry fires, the safe positioning of personnel at the fire
site, appropriate placement of fire apparatus and service vehicles, necessary evacuation
procedures and other training and education matters necessary and appropriate to assure
that each member is able to perform his/her assigned duties and functions satisfactorily
and in a safe manner so as not to endanger fire brigade members or other employees.

(b) Employees were assigned to work on the afternoon and evening shifts and during
weekends and holidays on a periodic basis due to changes in shift and job schedules. They
were expected and/or required to perform as shift brigade members without appropriate
training and education. The employer's program for the shift fire brigade involved
educating and training only those employees who routinely worked in the job
classifications which made up the brigade.

(c) Whenever a leak or a fire occurred, unit operators and other employees in their
designated work areas were required to participate and function as fire brigade members
until other fire fighting personnel arrived at the scene and to remain at the scene to
assist as necessary. Said unit operators and other employees were not provided training
and education in the hazards associated with oil refinery fires so as to assure that said
employee is able to perform the assigned duties satisfactorily and in a safe manner so as
not to endanger fire brigade members or other employees.

Standard � 1910.156 Fire Brigades.

(c) Training and education. (1) The employer shall provide training and education for
all fire brigade members commensurate

with those duties and functions that fire brigade members are expected to perform. Such
training and education shall be provided to fire brigade members before they perform fire
brigade emergency activities. Fire brigade leaders and training instructors shall be
provided with training and education which is more comprehensive than that provided to the
general membership of the fire brigade.

[[5/]] The Citation reads:

Citation

3B

29 C.F.R. 1910.156(c)(1): Fire brigade leaders and
training instructors were not provided with training and education which was more
comprehensive than that provided to the general membership of the fire brigade:

(a) Several of the shift brigade leaders, including one of those on duty at the time
of the July 23, 1984 explosions and fires at the Amine Absorber 12D701, had not received
the more comprehensive training and education as required by the standard, in that they
had not received appropriate training and education in the following areas: leadership
principles; strategies and tactics for fire control, suppression, and/or extinguishment;
and rescue and evacuation.

[[6/]] The Citation and Standard read:

Citation

3C

29 C.F.R. 1910.156(c)(2): The employer did not assure
that training and education was conducted frequently enough to assure that each member of
the fire brigade was able to perform the member's assigned duties and functions
satisfactorily and in a safe manner so as not to endanger fire brigade members or other
employees:

(a) The employer's program did not assure that each shift fire brigade member received the
required frequent training and education. An attendance goal of 80% was considered
satisfactory for the bi-monthly training and education sessions provided by the employer.

(b) The employer's program required attendance of only those employees working regularly
in the job classifications which make up the shift fire brigade. Other employees, who
could reasonably be expected to function as shift fire brigade members and leaders as a
result of changes in shift or job assignment were not required to and did not attend and
participate in training and education sessions prior to fire brigade assignment.

Standard

� 1910.156 Fire Brigades.

(c) Training and education. (2) The employer shall assure that training and education
is conducted frequently enough to assure that each member of the fire brigade is able to
perform the member's assigned duties and functions satisfactorily and in a safe manner so
as not to endanger fire brigade members or other employees. All fire brigade members shall
be provided with training at least annually. In addition, fire brigade members who are
expected to perform interior structural fire fighting shall be provided with an education
session or training at least quarterly.

[[7/]] The Citation reads:

Citation

3D

29 C.F.R. 1910.156(c)(2): All fire brigade members
were not provided with training at least annually:

(a) Fire brigade members were not provided with appropriate annual instruction and
hands-on training and practice in the operation of fire fighting equipment including field
training in the control, suppression and extinguishment of oil refinery fires.

[[8/]] The Citation and Standard read:

Citation

3E

29 C.F.R. 1910.156(c)(3): The employer did not
provide a training and education program for oil refinery fire brigade members which was
similar in quality to the programs conducted by Texas A & M University, Lamar
University, Reno Fire School or the Delaware State Fire School:

(a) Several shift fire brigade leaders, who were designated by the employer to be in
charge of fire ground control and suppression tactics during initial brigade operations,
were not provided with the required training and education;

(b) Shift brigade members, who were required to provide initial control and/or
suppression measures, were not provided with the required training and education:

(c) Unit operators and other employees, who were expected to use hand hose lines and
monitor nozzles, had not been provided with the required training and education; and

(d) Some of the off shift employees, who participated in fire fighting operations
during the July 23, 1984 explosions and fires were not provided with the required training
and education.

Standard

� 1910.156 Fire Brigades.

(c) Training and education. (3) The quality of the training and education program for fire
brigade members shall be similar to those conducted by such fire training schools as the
Maryland Fire and Rescue Institute; Iowa Fire Service Extension; West Virginia Fire
Service Extension; Georgia Fire Academy, New York State Department, Fire Prevention and
Control; Louisiana State University Firemen Training Program, or Washington State's Fire
Service Training Commission for Vocational Education. (For example, for the oil refinery
industry, with its unique hazards, the training and education program for those fire
brigade members shall be similar to those conducted by Texas A & M University, Lamar
University, Reno Fire School, or the Delaware State Fire School.)

[[9/]] The Citation and Standard read:

Citation

3F

29 C.F.R. 1910.156(c)(4): The employer did not inform
fire brigade members about special hazards to which they might be exposed during fire and
other emergencies. The employer did not develop and make available to fire brigade members
written procedures that describe the actions to be taken in situations involving the
special hazards.

(a) An appropriate written special hazard information program was not developed and
implemented as part of the training and education of the shift fire brigade and unit
operating personnel who had fire fighting duties. Such a program must include written
procedures describing the actions to be taken in situations involving oil refinery special
hazards, including but not limited to the failure of a pressure vessel and the sudden
massive release of flammable vapors and/or gases such as the incident which occurred an
July 23, 1984. The program must describe actions to be taken, how to carry out fire
fighting operations and the protective equipment and clothing that must be worn during
fire and other emergencies.

Standard

� 1910.156 Fire Brigades.

(c) Training and education. (4) The employer shall inform fire brigade members about
special hazards such as storage and use of flammable liquids and gases, toxic chemicals,
radioactive sources, and water reactive substances, to which they may be exposed during
fire and other emergencies. The fire brigade members shall also be advised of any changes
that occur in relation to the special hazards. The employer shall develop and make
available for inspection by fire brigade members, written procedures that describe the
actions to be taken in situations involving the special hazards and shall include these in
the training and education program.

[[10/]] The Citation reads:

Citation

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 was
free from recognized hazards that were causing or likely to cause death or serious
physical harm to employees in that employees were exposed to serious hazards including
being struck, crushed, burned or asphyxiated resulting from the lack of effective
emergency evacuation procedures and education and training of personnel in said
procedures.

Employees working throughout the refinery were exposed to these hazards on a daily basis
including July 23, 1984, when a pressure vessel, Amine Absorber 12D701, released hazardous
quantities of flammable gases vapors and corrosive liquid.

A feasible and useful method of correcting these
hazards is to establish and properly implement a refinery emergency action plan which
includes the following elements as a minimum:

(a) Emergency escape procedures and emergency escape route assignments;

(b) Procedures to be followed by employees who remain to operate critical plant operations
before they evacuate;

(c) Procedures to account for all employees after emergency evacuation has been completed;

(d) Rescue and medical duties for those employees who are to perform them;

(e) The preferred means of reporting fires and other emergencies;

(f) Names and regular job titles of persons who can be contacted for further information
or explanation of duties under the plan;

(g) An alarm and notification system adequate to alert personnel in all areas of the need
for evacuation and control procedures;

(h) Establish the types of evacuation to be used in emergency circumstances;

(i) Before implementing the emergency action plan, designate and train a sufficient number
of persons to assist to the safe and orderly emergency evacuation of employees;

(j) Review the plan with each employee covered by the plan at the following times:

(1) Initially when the plan is developed;

(2) Whenever the employee's responsibilities or designated actions under the plan change;
and

(3) Whenever the plan is changed.

(k) Review with each employee upon initial assignment those parts of the plan which the
employee must know to protect the employee in the event of an emergency.

(l) Maintain the written plan at the workplace and make it available for employee review.

Step 1 Submit to the Area Director a written detailed plan of abatement outlining a
schedule for the implementation of the emergency evacuation procedure and emergency
evacuation procedure and the education and training of personnel in those procedures.

Step 2 - Abatement shall have been completed by the implementation and verification of the
effectiveness of the emergency evacuation program.

[[11/]] Illinois Boiler and Pressure Vessel Safety
Act:

Section 10. Inspection of Boilers and Pressure
Vessels. (A) Each boiler or pressure vessel . . . shall be thoroughly inspected as to its
construction, installation, condition and operation as follows:

*         *
         *

3. Pressure Vessels subject to internal corrosion shall receive a certificate inspection
   as required by rules and regulations of the Board. However, the standards of inspection
   and repair of pressure vessels in service by an owner user qualified under Section 15
   shall, at the option of such owner user, be either (1) the applicable rules and
   regulations embodied in the National Board Inspection Code, 1972 Edition; or (2) the
   applicable rules and regulations embodied in the American Petroleum Institute published
   codification known as API RP 510, 1975 Edition API Recommended Practice for Inspection
   Repair, and Rating of Pressure Vessels in Petroleum Refining Service, with such revisions,
   reissues, amendments and interpretations of either of the foregoing inspection standards
   as are subsequently approved and adopted. (Exhibit C-59)

[[12/]] Illinois Boiler and Pressure Vessel Safety
Act:

Section 8. Special Inspectors--How Appointed--Duties.
(a) In addition to the Deputy Boiler Inspectors authorized by section 7 of this Act, the
State Fire Marshal shall, upon the request of any company authorized to insure against
loss from explosion of boilers in this State or authorized under section 15 of this Act to
self-insure against such loss, issue to any boiler inspectors of such company commissions
as Special Inspectors, provided that each such inspector before receiving his commission
shall satisfactorily pass the examination provided for in Section 9 of this Act, or, in
lieu of such examination, shall hold a Certificate of Competency as an inspector of
boilers or pressure vessels for a State that has a standard of examination substantially
equal to that of the State of Illinois or a Certificate as an inspector of boilers from
the National Board of Boiler and Pressure Vessel Inspectors.

[[13/]] API Pressure Vessel Inspection Code:

2.2 Inspector Qualifications

Inspectors employed by an owner-user inspection organization shall have education and
experience equal to at least one of the following:

1. A degree in engineering plus 1 year of experience
   in the design, construction, repair, operation, or inspection of boilers or pressure
   vessels.

2. A 2-year certificate in engineering or technology
   from a technical college plus 2 years of experience in the design, construction, repair,
   operation, or inspection of boilers or pressure vessels.

3. The equivalent of a high school education plus 3
   years of experience in the construction, repair, operation, or inspection of boilers or
   pressure vessels. (Exhibit C-60, p.3)