Two (2) frozen food production plants have been cited by OSHA with 27 safety violations carrying fines of $150,000. OSHA received complaints alleging hazards with the ammonia refrigeration systems at these facilities. A fire at the Burlington facility Jan. 30 resulted in the destruction of a portion of the plant’s ammonia refrigeration system, causing significant property damage. No serious injuries were reported. Twenty-two PSM violations at both facilities involve multiple instances of not addressing the consequences of the failure of various engineering and administrative controls. The company also failed to address procedures to perform oil draining activities safely for ammonia compressors and provide and document worker training involving the ammonia systems and related operating equipment. In Burlington, four additional serious violations include insufficient safety guardrails on platforms; inadequate exit routes; lack of an emergency eyewash station near a compressor room, posing potential exposure to anhydrous ammonia; and missing cover plates on several electrical switches. In Franksville, one additional serious violation includes failing to certify that periodic inspections of hazardous energy control procedures had been performed. Here is a breakdown of the citations:
Walking Working Surfaces
Citation 1 Item 1
Type ofViolation: Serious; $4,000
29 CFR 1910.23(c)(1): Open-sided floors and/or platforms four feet or more above adjacent floor or ground level were not guarded with standard railings (or equivalent):
(a) The path providing access to and egress from the West Engine Room (AKA: M & M Engine Room) was an open-sided platform that was 4 feet above ground level and was not guarded with standard railings, exposing workers to a potential fall hazard.
Citation 1 Item 2
Type of Violation: Serious; $4,000
29 CFR 1910.24(f): Rise height and tread width were not uniform throughout any flight of stairs including any foundation structure used as one or more treads of the stairs:
(a) The flight of stairs provided for the West Engine Room exit route did not have uniform rise height. The top step had a rise of approximately 12 inches, whereas the bottom step had a rise of approximately 10 inches.
Emergency Egress
Citation 1 Item 3
Type of Violation: Serious; $5,000
29 CFR 1910.36(g)(4): Objects that projected into the exit route reduced the width of the exit route to less than the minimum width requirements for exit routes:
(a) The exit route from the West Engine Room (AKA: M & M Engine Room) was reduced in width to less than 28 inches because of vessels, piping, and equipment involved with the West anhydrous ammonia system that projected into the exit route. Specifically, the High Temperature Recirculation Tank and the Low Temperature Recirculation Tank, and associated structures were present and encroached upon this exit route.
Employee Partipation
Citation 1 Item 4
Type of Violation: Serious; $5,000
29 CFR 1910.119(c)(1): The employer did not develop a written plan of action regarding the implementation of employee participation:
(a) East Ammonia Refrigeration System: A written plan had not been established and implemented for employee participation, including methods the employer used to consult with employees on the conduct and development of process hazard analyses, and including provision of employee access to process hazard analyses and to all other information required to be developed under this standard.
Process Safety Information (Maximum Intended Inventory)
Citation 1 Item 5
Type of Violation: Serious; $7,000
29 CFR 1910.119(d)(2)(i)(C): Process safety information pertaining to the technology of the process did not include the maximum intended inventory:
(a) The employer’s maximum intended inventory listed a design charge for the East Engine Room of 9,000 lbs. During the OSHA inspection, the employer disclosed that on April 27, 2012, the East ammonia refrigeration system was (after a complete system pump down) recharged with 9,554 lbs anhydrous ammonia, which exceeded the listed design charge. The employer also disclosed that their ammonia refrigeration system lost approximately 6.5 lbs ammonia per day due to leakage. The East ammonia refrigeration system was additionally charged with 3058 lbs of ammonia on December 27, 2012. After adding this 3058 lbs quantity of ammonia to the system which had contained 9,554 lbs (the quantity charged into it on April 27, 2012) and subtracting the quantity lost due to leakage (approximately 1,560 lbs) during the 240 day time frame, the resultant quantity of ammonia in the system on December 27, 2012 was approximately 11,052 lbs, which exceeded both the listed design charge for the East Engine Room and the threshold quantity listed for anhydrous ammonia in Appendix A of this standard. In summary, the employer’s maximum intended inventory for the East Engine Room did not have a factual basis.
Citation 1 Item 6
Type of Violation: Serious; $7,000
29 CFR 1910.119(d)(3)(i)(D): The employer did not include, in the process safety information compilation, the relief system design and the design basis:
(a) With regard to the East anhydrous ammonia refrigeration system at the Burlington facility, the process safety information compilation did not include the design basis for, but not limited to the pressure relief header system, pressure vessels, compressors, evaporators and condensers.
Citation 1 Item 7
Type of Violation: Serious; $7,000
29 CFR 1910.119(d)(3)(ii): The employer did not document that equipment complies with recognized and generally accepted good engineering practices.
(a) Although the employer did have a document entitled, “Safety System Design – East Compressor Room”, which included information regarding actuation of the emergency ventilation system by the ammonia detection system, the provided information was inadequate with regard to its description of the inlet louver, which did not take into account that this was a manually operated louver. According to the provided document, the ventilation system was designed to meet and exceed the requirements of ANSI/IIAR 2 – 1999. However, whereas ANSI/IIAAR 2 – 1999 specified that provision shall be made for inlet air to replace that being exhausted, the only provision for inlet air in the East Compressor Room was by means of a manually operated louver, which was normally in the closed position, consisting of a plywood board secured by a locking pin. Since this manually operated louver would not be actuated by the ammonia detection system, in the event of an ammonia release the emergency ventilation system would not function in accordance to the design specifications as described by the document provided by the employer. This condition could result in a hazardous accumulation of ammonia vapor in the East Compressor Room.
Process Hazards Analysis
Citation 1 Item 8
Type of Violation: Serious; $7,000
29 CFR 1910.119(e)(3)(iv): The process hazard analysis did not address the consequences of failure of engineering and administrative controls.
(a) Process Hazard Analysis (PHA) item #4.13 did not address the consequence of failures of engineering or administrative controls [as referenced in 1910.119(e)(3)(iv)]. PHA#4.13 addressed: “What if there is a high level in the vessel?” The PHA described the resulting scenario: “NH3 carries over to compressor. Slugging of compressor occurs … resulting in an NH3 release.” Regarding engineering and/or administrative controls, the PHA stated that: “Compressor shutdown interlocks.” The consequences of failure of the interlocks to effect compressor shutdown, in the event of a high level in the vessel, were not addressed as required by 1910.119(e)(3)(iv).
(b) Process Hazard Analysis (PHA) item #12.5 did not address the consequence of failures of engineering or administrative controls [as referenced in 1910.119(e)(3)(iv)]. PHA#12.5 addressed: “What if the emergency ventilation system is non-existent, inadequate or inoperable during an emergency situation?” Regarding engineering and/or administrative controls, the PHA stated that “Current ventilation is adequate.” However, this PHA did not take into account that the make-up air for the emergency ventilation system in the East Compressor Room depended on a manually operated inlet louver, and thus would not be automatically activated by the ammonia detection system. The consequences of failure of the manually operated inlet louver to be opened, in an ammonia release emergency situation, were not addressed as required by 1910.119(e)(3)(iv).
(c) Process Hazard Analysis (PHA) item #16.8 did not address the consequence of failures of engineering or administrative controls [as referenced in 1910.119(e)(3) (iv)]. PHA#16.8 addressed: “What if ignition sources are present in a machinery/vessel room with an explosive mixture ofNH3?” Regarding engineering and/or administrative controls, the PHA stated that “Detection and ventilation systems are designed to evacuate NH3 and shutdown system if necessary.” However, this PHA did not take into account that the make-up air for the emergency ventilation system in the East Compressor Room depended on a manually operated inlet louver, and thus would not be automatically activated by the ammonia detection system. The consequences of failure of the manually operated inlet louver to be opened, in an ammonia release emergency situation, were not addressed as required by 1910.119(e)(3)(iv).
(d) Process Hazard Analysis (PHA) item #17.1 did not address the consequence of failures of engineering or administrative controls [as referenced in 1910.119( e )(3)(iv)]. PHA #17 identified a previous ammonia release incident in the East Compressor Room when a shaft seal on #6 Booster leaked, saturating the room with ammonia and the ventilation was inadequate. The PHA indicated that a wall louver, an engineering control, was installed next to #6 Booster, allowing replacement of air being exhausted. Also the PHA indicated the existing engineering controls included an ammonia detection system that would activate the ventilation, and that no further mitigation action was required. However, this PHA did not take into that the referenced wall louver required manual operation, and thus would not be automatically be activated by the ammonia detection system. The consequences of failure of the manually operated inlet louver to be opened, in an ammonia release emergency situation, were not addressed as required by 1910.119(e)(3)(iv).
Citation 1 Item 9
Type of Violation: Serious; $7,000
29 CFR 1910.119(e)(5): The employer did not assure that PHA recommendations were resolved in a timely manner.
The following items were not corrected as soon as possible:
(a) PHA 4.8 relating to the hazard of external corrosion on vessels listed the corrective action as “Ensure mechanical integrity inspections include vessel inspection.” The original due date of 11/30/2012 was extended to 5/1/2013 and the item status was listed as: “In progress.”
(b) PHA 5.6, relating to the hazard of additional weight of ice on evaporator breaks/deflects structural support listed corrective action as “Ensure mechanical integrity inspections include evaporator support inspections.” The original due dated of 11/30/12 was extended to 5/1/13, and the item status was listed as: “In progress.”
(c) PHA 7.1, relating to the hazard of external corrosion on ammonia pump piping, listed the corrective action as: “Ensure MI inspections address piping conditions.” The original due date of 11/30/2012 was extended to 5/1/2013 and the item status was listed as: “In progress.
(d) PHA 7.14, relating to the hazard of pump valves left in the shut or open position for a long period of time without cycling, listed corrective action as “Add valve inspections to PM system.” The original due date of 8/30/2012 was extended to 5/11/2013 and the item status was listed as: “Incomplete.”
Operating Procedures
Citation 1 Item 10
Type of Violation: Serious; $5,000
29 CFR 1910.119(f)(1)(i)(B): The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process consistent with the process safety information and did not address normal operations:
(a) Operating procedures for East Engine Room compressor C-1 did not include detailed procedures for oil draining operations suitable for its drain point.
(b) Operating procedures for East Engine Room compressor C-2 did not include detailed procedures for oil draining operations suitable for its drain point.
(c) Operating procedures for East Engine Room compressor C-3 did not include detailed procedures for oil draining operations suitable for its drain point.
(d) Operating procedures for East Engine Room compressor C-4 did not include detailed procedures for oil draining operations suitable for its drain point.
(e) Operating procedures for East Engine Room compressor C-5 did not include detailed procedures for oil draining operations suitable for its drain point.
(f) Operating procedures for East Engine Room compressor C-6 did not include detailed procedures for oil draining operations suitable for its drain point.
(g) East Ammonia System: The operating procedure for the East HTR Oil Pot V-4 did not include detailed procedures for oil draining operations suitable for its drain point.
Training
Citation 1 Item 11a
Type of Violation: Serious; $7,000
29 CFR 1910.119(g)(1)(i): The employer did not train each employee before being involved in operating a newly assigned process in the operating procedures as specified in paragraph (f) of this section:
(a) East Ammonia Refrigeration System: Adequate training was not provided and documented regarding operating procedures for processes and ammonia refrigeration equipment. Nor was adequate training provided and documented regarding operational phases, operational limits and safety and health considerations.
(b) Adequate training was not provided to workers performing daily rounds, during which observations and readings were taken on various process equipment in the East Ammonia System. For example, the training provided to these workers did not cover the consequences of deviation from operational limits for the process equipment.
Citation 1 Item 11b
Type of Violation: Serious; Grouped
29 CFR 1910.119(g)(3): 29 CFR 1910.119(g)(3): The employer did not maintain a record of training for employees operating a covered process:
(a) The employer provided operating procedures for ammonia refrigeration equipment, but did not provide any documentation of training for the operators.
Mechanical Integrity
Citation 1 Item 12
Type of Violation: Serious; $7,000
29 CFR 1910.119(j)(2): The employer did not establish or implement written procedures to maintain the on-going integrity of process equipment.
(a) East Ammonia Refrigeration System: Written procedures to maintain the on-going integrity of process equipment had not been implemented for equipment such as but not limited to pressure vessels, piping systems, pressure relief systems and emergency control systems.
Management of Change
Citation 1 Item 13
Type of Violation: Serious; $7,000
29 CFR 1910.119(l)(2): Management of change procedures did not assure that the considerations required by (1)(2)(1) through (1)(2)(v) were addressed prior to any change:
(a) For example, in April 2012, two smaller condensers atop the East Compressor Room were replaced by a large roof-top condenser, but no management of change was conducted to evaluate the considerations required by (1)(2)(i) through (1 )(2)(v).
Eyewash/Safety Showers
Citation 1 Item 14
Type of Violation: Serious; $5,000
29 CFR 1910.151(c): Where employees were exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body were not provided within the work area for immediate emergency use:
(a) In the area of the West Engine Room workers’ eyes and bodies were potentially exposed to anhydrous ammonia, a corrosive chemical. Yet no suitable emergency eyewash and safety shower were provided in the area of the West Engine Room. For example, there was no emergency eyewash and safety shower installed just outside the engine room’s exit door (in accordance with HAR Bulletin 109).
Electrical
Citation 1 Item 15
Type of Violation: Serious; $5,000
29 CFR 1910.305(b)(2)(i): Pull boxes, junction boxes, and fittings were not provided with covers approved for the purpose:
(a) On or around January 24, 2013, in the East Engine Room, covers for several electrical switches on the Vilter #5 Low Stage Compressor were not in place (covers had previously been removed to enable replacement of these switches, although the maintenance activity was not ongoing). The circuit breaker controlling power to these switches was in the off position, but no lockout device had been affixed to the circuit breaker by the authorized employee.
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