PLEASE NOTE that this citation is SIGNIFICANT in that OSHA took issue with how Operating Procedures were controlled/revised/managed! OSHA found operators using three (3) different revisions for the same task that caused the release. Document control records had odd dates as well. A “document control” system is NOT a PSM (or RMP) requirement, BUT we MUST ensure that personnel is using the most recent APPROVED SOP!!!
A Washington state refinery is facing $77,000 in fines from the state Department of Labor & Industries (L&I) for workplace health violations after an investigation into an uncontrolled toxic release last February. L&I began the investigation at the refinery after learning of an incident during which the refinery’s main flare released contaminants into the environment. The release prompted numerous odor complaints from the community nearby. The investigation found that the company had skipped critical decontamination steps while shutting down the main flare for routine maintenance. Failing to implement safe work practices caused an uncontrolled release that exposed workers to toxic substances including mercaptans, hydrogen sulfide, hydrocarbons and pyrophoric iron. The company was also cited in 2013 for skipping critical steps when shutting down the flare. In that case, there was an explosion that nearly injured several contractors and Shell employees. For the recent incident, the refinery was cited for one willful violation and fined the maximum of $70,000 for knowingly and intentionally not following safe work practices for the control of hazards when shutting down the flare. The company was also cited for one serious violation with a penalty of $7,000 for giving workers the incorrect procedure for shutting down the flare. Here is a breakdown of the two (2) citations and a copy of the citations:
Violation 1 Item 1 Violation
Type: Willful Serious; $70,000
WAC 296-67-021(5) The employer intentionally and knowingly did not implement safe work practices to provide for the control of hazards during the execution of the East Flare shutdown procedure in that decontamination steps were skipped and the system released toxic constituents to the atmosphere such as mercaptans, hydrogen sulfide, hydrocarbons, and pyrophoric iron. The employer has an established system for ensuring procedure deviations are carefully reviewed by affected personnel but did not use it. Workers at the interface of hazardous equipment who are directed to deviate from or otherwise change that procedure during its execution in the field may face permanent disability or death should a catastrophic release occur as a result of those changes. Situation not believed to exist any longer. However, if this violation is identified again during future inspections, it may result in repeat or failure to abate violations which may include penalties.
Violation 2 Item 1 Violation
Type: Serious; $7,000
WAC 296-67-021(3) The employer did not assure that workers shutting down the East Flare were using a procedure that reflected current operating practices. During the East Flare shut down in February 2015, operators had been trained on “revision number 4” of procedure 19FLARETA004; but were intended to have been trained on–and follow– revision number 5. A procedure with the revision number of “1” was also used by unit personnel during the shutdown attempt.
Furthermore, the refinery’s Plant Standing Instruction PSIA103 was initiated starting on or around February 18th; but had an authorization date of February 19th. The policy had a stated revision number of “1” on it, but an outdated authorization designee–indicating that PSIA103 should have had a revision number higher than “1” and an updated authority for it.
An operating procedure in high-hazard facilities is a written step-by-step instruction and associated information for safely performing tasks within operating limits. Without an accurate, reviewed and current operating procedure to use, workers in high-hazard chemical environments may interact with the wrong equipment or incorrectly adjust the correct equipment. Policies that give direction to operations specific to feed rates through high-pressure, high-temperature equipment must be accurate and current. Inaccurate policies followed by workers in the field may direct them to interact with equipment incorrectly, potentially causing a catastrophic release resulting in worker fatalities or permanent disabilities. Situation not believed to exist any longer. However, if this violation is identified again during future inspections, it may result in repeat or failure to abate violations which may include penalties.
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