OSHA has cited a refinery for failing to control the use and release of highly hazardous chemicals after an explosion and fire injured several employees. The company faces $83,150 in proposed penalties. Here is a break down of the citations:
Citation 1 Item 1
Type of Violation: Serious; $6,652
29 CFR 1910.119(d)(3)(i)(A): Process safety information pertaining to the equipment in the process did not include the materials of construction:
(a) On or about April 26, 2018, the employer failed to update and maintain process safety information for alterations made to the Primary Absorber (15G-V08), the absorber was noted per original installation to have three nozzles while current documentation showed ten nozzles. Documentation regarding design and installation information for the additional nozzles was not provided.
(b) On or about April 26, 2018, the employer failed to update and maintain process safety information for alterations made to the Sponge Absorber (15G-V09), the absorber was noted per original installation to have three nozzles while current documentation showed eight nozzles. Documentation regarding design and installation information for the additional nozzles was not provided.
Recommended Abatement: Ensure other equipment in the refinery has current and required process safety information.
Citation 1 Item 2
Type of Violation: Serious; $11,641 29 CFR 1910.119(d)(3)(i)(D): The employer’s relief system design and design calculation for 15GSV006, High Pressure Receiver Relief Valve and the flare were not adequately performed:
a) On or about April 26, 2018, the 15G-SV006 relief valve sizing document provided indicated the calculations were performed for pressure relief of the High Pressure Receiver (15G-V07), Primary Absorber (15G-V08), Sponge Absorber (15G-V09) and Water Knockout Drum (15G-V13). The calculations failed to include piping and vessels from the discharge of the gas compressors to the Stripper Column (including the High Pressure (HP) Receiver Condensers, HP Receiver, HP Receiver Water Knockout Drum, Primary Absorber, Sponge Absorber, and Stripper Column).
b) On or about April 26, 2018, the 15G-SV006 relief valve sizing document backpressure calculation included the discharge piping and elbows to the flare header. (measuring less than 30 feet total length); however, the calculation failed to include the full length to the flare (flare header continues for over 100 feet to the flare), as well as, the possible flows and pressures from other relief devices in the common flare header.
c) On or about April 26, 2018, the design calculation for the flare was performed last in about 2003 and does not include changes in processes, equipment, and systems that have been implemented since the calculation was last performed.
Recommended Abatement: Update existing calculations to match current conditions and modify the relief devices and flare lines appropriately based on revised calculations. Please reference applicable recognized and generally accepted good engineering practices such as, but not limited to, API 520 Sizing, Selection, and Installation of Pressure-relieving Devices, 2014; API 521 Pressure-relieving and Depressuring Systems, 2014; and API 537 Flare Details for Petroleum, Petrochemical, And Natural Gas Industries, 2017 to perform calculations and make necessary changes to the system(s) in accordance with the results of the updated calculations.
The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury or illness.
Citation 1 Item 3a
Type of Violation: Serious; $11,641
29 CFR 1910.119(d)(3)(iii): For existing equipment designed and constructed in accordance with codes, standards, or practices no longer in general use, the employer did not determine and document that the equipment in the process was designed, maintained, inspected, tested, and operating in a safe manner (i.e. fit-for-service):
a) On or about April 26, 2018, the employer failed to determine and document that the following equipment including, but not limited to, the Primary Absorber (15G-V08), High Pressure Cooler (15G-E02A), High Pressure Receiver (15G-V07), Stripper Column (15G-V10), Stripper Reboiler (15G-E06), Debutanizer Column (15G-V11), Debutanizer Reboiler (15G-E08), Debutanizer Overhead Condenser (15G-E07), Debutanizer Receiver (15G-V12), Isostripper (16A-V08), and the Acid Settler (16A-V05) constructed of ASTM A-212 steel were fit-for-service based on Minimum Design Metal Temperature (MDMT), embrittlement, and brittle fracture hazards.
Recommended Abatement: The employer must ensure that the vessels utilized to replace the primary and sponge absorbers, destroyed in the incident on April 26, 2018, as well as other listed vessels above, meet recognized and generally accepted good engineering practices. These practices include, but are not limited to, ASME Boiler and Pressure Vessel Code Section VIII, API 510, API 579-1/ASME FFS-1, and should include inspection and testing for embrittlement before they are returned to service.
Citation 1 Item 3b
Type of Violation: Serious
29 CFR 1910.119(j)(4)(ii): The employer’s inspection and testing procedures did not follow recognized and generally accepted good engineering practices:
a) On or about April 26, 2018, the employer failed to perform inspection and testing to determine if the following equipment constructed of ASTM A-212 steel was fit-for-service to include, but not be limited to, the Primary Absorber (15G-V08), High Pressure Cooler (15G-E02A), High Pressure Receiver (15G-V07), Stripper Column (150-V1O), Stripper Reboiler (15G-E06), Debutanizer Column (150-Vll), Debutanizer Reboiler (15G-E08), Debutanizer Overhead Condenser (15G-E07), Debutanizer Receiver (15G-V12), Isostripper (16Ac V08), and the Acid Settler (16A-V05) based on Minimum Design Metal Temperature (MDMT), embrittlement, and brittle fracture hazards.
Recommended Abatement: The employer must ensure that the vessels listed above are inspected and tested, prior to returning them to service, in accordance with recognized and generally accepted good engineering practices, including but not limited to, APT 510 and API 579-1/ASME FFS-1. Only those vessels determined to be fit-for-service should be returned to service.
Citation 1 Item 4
Type of Violation: Serious; $11,641
29 CFR 191
1910.119(e)(3)(i): The employer has not identified critical hazards of the process in the Process Hazard Analysis (PHA):
a) On or about April 26, 2018, the employer did not include the hazard of air introduction from the Fluid Catalytic Cracking Unit (FCCU) regenerator into the reactor due to loss of catalyst and or loss of seal on the spent catalyst slide valve.
b) On or about April 26, 2018, the employer did not adequately address the hazards associated with shutdowns, including but not limited to, the hazards associated with operation in manual mode, distractions from additional operators and workers in areas, introduction of air or other materials into the systems, deviations from procedures, inerting and purging of equipment, and other abnormal conditions and situations experienced during shutdowns.
Recommended Abatement: FCCU and Gas Concentration PHAs shall include the hazards of introduction of air into the system from the regenerator and from other sources; as well as, the hazards introduced during shutdowns. Revisit PHAs for this and other areas of the refinery to address introduction of air and shutdown hazards.
The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury or illness.
Citation 1 Item 5a
Type of Violation: Serious; $11,641
29 CFR 1910.119(f)(1)(i)(D): The employer did not develop and implement written operating procedures that provide clear instructions for emergency shutdown, including the conditions under which emergency shutdown is required, and the assignment of shutdown responsibility to qualified operators to ensure that emergency shutdown is executed in a safe and timely manner:
(a) On or about April 26, 2018, operating procedure OPP1517 Fluid Catalytic Cracking Unit (FCCU) Stops (E-Stops) does not provide clear instructions to include the conditions and parameters under which emergency shutdown is required and the assignment of shutdown responsibility.
Recommended Abatement: Update emergency shutdown procedure OPP1517 to include clear instructions that address the conditions and parameters under which emergency shutdown is required, as well as, the assignment of shutdown responsibility. Review and revise other operating procedures at the refinery to include this information.
Citation 1 Item 5b
Type of Violation: Serious;
29 CFR 1910.119(f)(1)(ii): 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 addressing consequences of deviation and the steps required to correct or avoid deviations per 1910.119(f)(1)(ii)(A) & (B):
(a) On or about April 26, 2018, consequences of deviation and the steps required to correct and avoid deviations were not clear, inclusive, and consistent’ in that operating procedures such as, but not limited to, OPP1512-Fluid Catalytic Cracking Unit(FCCU) Control Room Pressurization, OPP0563 – FCCU, Gas Concentration, Merox, and C3C4 Splitter Shutdown, OPP0590 Loss of Catalyst Level from Regenerator, and OPP1537 Slide Valve Over-rides (COPS) referred operators to other documents for time critical events.
Recommended Abatement: Include consequences of deviation in the operating procedures at the refinery, as well as, the steps required to correct or avoid deviations.
Citation 1 Item 5c
Type of Violation: Serious
29 CPR 1910.119(f)(1)(iv): The employer failed to ensure operating procedures included safety systems and their functions:
(a) On or about April 26, 2018, information on safety systems and their functions were not addressed and implemented in operating procedures such as, but not limited to, OPP0563 – Fluid Catalytic Cracking Unit (FCCU), Gas Concentration, Merox, and C3C4 Splitter Shutdown and OPP0590 Loss of Catalyst Level from Regenerator.
Recommended Abatement: Include safety system information and the function of these safety systems in the operating procedures at the refinery.
Citation 1 Item 5d
Type of Violation: Serious 29
CFR 1910.119(f)(2): Operating procedures were not readily accessible to employees who work in or maintain a process area:
(a) On or about April 26, 2018, operating procedures for the Fluid Catalytic Cracking Unit (FCCU), Gas Concentration Unit, and the Alkylation Unit were not provided with safe upper and lower limits,. the consequences of deviation, and the steps required to co1Tect or avoid.deviations as the operating procedures referred the operators to other documents that were not always readily available in events such as, but not limited to, loss of power, loss and/or malfunction of operating system, or some other event.
Recommended Abatement: Keep Cu1Tent hard copies of the operating procedures at a known and accessible location in each control room.
Citation 1 Item 6
Type of Violation: Serious; $11,641
29 CFR 1910.119(j)(5): The employer did not correct deficiencies in equipment that were outside acceptable limits before further use, or in a safe and timely manner, when necessary to ensure safe operation:
(a) On or about April 26, 2018, the employer did not implement interim risk mitigation measures to address deficiencies and potential hazards, including failure of the spent catalyst slide valve (s/n C98-3629-2) utilized at the time of the incident.
Recommended Abatement: Equipment deficiencies should be addressed per the facilities Mechanical Integrity Program and per industry recognized and generally accepted good engineering practices to determine if the equipment can be safely operated, or if a shutdown is necessary; if continued operation of deficient equipment requires some form of interim additional safeguards or monitoring, to ensure safe operation until the deficiency can be corrected, then the management of change process shall be followed.
Citation 1 Item 7
Type of Violation: Serious; $6,652
29 CFR 1910.119(j)(6)(iii): The employer did not ensure that maintenance materials, spare parts, and equipment were suitable for the process application:
(a) On or about April 26, 2018, the employer could not demonstrate that there was an adequate process in place to ensure the right materials, parts and equipment were being specified, purchased, provided to, and used by the trades for repair and replacement of process equipment.
Recommended Abatement: Implement a process that ensures the right materials, spare parts, and equipment are being used by employees and contractors in the field. The management of change process must be followed before changes in materials, spare parts, and/or equipment are made.
The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury or illness.
Citation 1 Item 8a
Type of Violation: Serious; $11,641
29 CFR 1910.119(l)(3): Employees involved in operating a process, as well as, maintenance and contract employees whose job tasks would be affected by a change in the process were not informed of, and trained in the change, prior to the process commencing:
a) On or about April 26, 2018, employees were not adequately trained on operating procedure OPP0563 ( dated 4/25/18) Fluid Catalytic Cracking Unit (FCCU), Gas Concentration, Merox, and C3C4 Splitter Shut-down utilized during the shutdown; changes were made to the procedure including, but not limited to, the addition of vapor phase cleaning, the order in which shutdown was performed, and when equipment was blinded.
Recommended Abatement: Ensure that the management of change process is followed when changes are made to procedures, and that affected employees and contractors receive adequate training to the procedures before they perform any functions in the new or revised procedures.
Citation 1 Item 8b
Type of Violation: Serious 29 CFR 1910.119(l)(5): A change covered by this paragraph resulted in a change in the operating procedures or practices required by paragraph (f) of this section, and such procedures or practices were not updated accordingly:
a) On or about April 26, 2018, adequate management of change procedures wer~ not performed prior to utilization of operating procedure OPP0563 (dated 4/25/18) Fluid Catalytic Cracking Unit (FCCU), Gas Concentration, Merox, and C3C4 Splitter Shut-down; changes were made to the procedure including, but not limited to, the addition of vapor phase cleaning, the order in which shutdown was performed, and when equipment was blinded.
Recommended Abatement: Provide additional instruction to supervisors and managers at the refinery so that changes to procedures (as well as other changes) follow the management of change process prior to implementation.
CLICK HERE for the citations, See Below for the OSHA Letter addressing 5(a)(1) potential citations:
October 2, 2018
XXXXXXXXXXXX, LLC.
Attn: XXXXXXXXXXXXX
RE: Inspection #1312169
Dear XXXXXXXXXXXX:
Occupational Safety and Health Administration
Eau Claire Area Office
1310 West Clairemont Ave
Eau Claire, WI 54701
An on-site inspection of the refinery was opened on April 27, 2018. Based on this inspection, the following recommendations are being provided to enhance employee safety and health.
Additionally, for some of the listed recommendations, no OSHA standard may apply and it was deemed inappropriate at this time, based on the information gathered per this inspection, to invoke Section 5(a)(1), the General Duty Clause of the Occupational Safety and Health Act.
1) Mechanical Integrity- It was identified per documentation received (SUPERIOR0O 1650-SUPERIOR00l 729) that ASTM A-516-70 steel is utilized in the following equipment: – 16A-V09-1 (Isostripper Receiver) – 16A-V28 (Liquid Trap Relief Gas Scrubber) – 15G-Vl 7 (Settler) This specific composition of steel was noted to have been utilized in the 1984 Romeoville Refinery incident in which inspection and testing found the metal to be brittle. The inspection team recommends that your facility add ASTMA-516 to an embrittlement testing list for inspection and testing per the facilities mechanical integrity program. As well as, review other metals (i.e. ASTM A-201) and incidents related to metal failure per API 579-1/ASME FFS-1 (2016) Fitness-For-Service.
2) Mechanical Integrity- For equipment involved in the fire that is being considered for continued service; the inspection team recommends following the requirements of API 579-1/ASME FFS-lFitness-For-Service (2016) as applicable, specifically Part 11 – Assessment of Fire Damage.
3) PHAs- The most recent PHAs do not inherently have a manager or a main representative from the maintenance and inspection department listed and included in the full PHA. It was noted that maintenance personnel would come in as needed for certain sections of the PHAs; however, none of their names were actually represented on the list of team members. The 1995 PHA listed other personnel such as maintenance, electrical, operations, etc. that were additionally involved. None of the other PHAs provided listed a maintenance team member. The inspection team recommends having maintenance involved in every aspect of PSM especially the PHAs as they can be the most familiar with the equipment and how it can fail.
4) PHAs- XXXXXXXXXXXX currently utilizes a checklist addressing human factors as part of their PHA process. However, several other human factors could be addressed to include those associated with unfamiliar steps or deviations in routine and non-routine shutdown/start-up processes. The inspection team recommends that additional checklist questions be developed to address how operators and maintenance personnel would respond when faced with unfamiliar steps or deviations in the steps of operating or maintenance procedures. For example, the Center for Chemical Process Safety has a publication, “Guidelines for Preventing Human Error in Process Safety”, which discusses many human factors not listed in the PHAs, including but not limited to: • Frequency of personnel involvement • Complexity of process events • Time constraints • Lighting • Work hours and overtime • Production pressures and safe practices • Performance changes associated with emergencies • Training level of the workers • Operating and maintenance procedure adequacy • Deviations from procedures
5) Handling and resolution of incidents and near misses- XXXXXXXXXXXX has four recommendations, out of nine total, that have not been documented as completed and are beyond the due dates listed in the incident reports. Furthermore, during the inspection it was indicated that near misses and incidents along with resolutions were not always covered with contractors. The inspection team recommends good communication and follow-through with all near misses and incidents to ensure they are addressed in a timely manner and both parties are apprised as to how they are being handled.
6) Hot work- XXXXXXXXXXXX utilizes two hot work programs, one for high energy hot work and another for low energy hot work. Low energy hot work requires no atmospheric monitoring or testing even though a fire or explosion can occur with low energy ignition sources in the presence of a fuel. The inspection team recommends that initial atmospheric monitoring be required as well prior to utilization of low energy devices. It may be easier to require atmospheric monitoring for all hot work permits verses having employees differentiate between high and low energy.
7) Compliance Audits- XXXXXXXXXXXX currently has nine open action items remaining from the July 2016 compliance audit, with eight of the nine open beyond their due dates. The inspection team recommends additional emphasis on timely completion of action items.
8) Training- The inspection team identified through interviews and documentation that training of operator personnel was not adequate. It was noted that newer and less experienced operators were training new operators, and that training was not always consistent as the most experienced operator would not always train the new individual for the entire period of training.
This was previously addressed in the Non-PSM Incident Investigation Recommendations (SUPERIOR012647) and noted: – consider a “train-the-trainer” program to certify trainers; – strong operators should be trainers; – there should be some type of performance evaluation; – the head operators should be responsible for proper training, operator performance, and monitoring of the training process; – consider developing a competency test in addition to the written test for operator training.
9) Process Safety Information- The inspection team recommends reviewing the FCCU stack height to ensure it is tall enough, so that vapors blowing away from the stack will not get sucked into the FCCU control room through the intake ventilation system.
In the interest of workplace safety and health, I recommend that you voluntarily take the necessary steps to eliminate or materially reduce your employees’ exposure to the hazards described above.
OSHA welcomes any report of your efforts to reduce the above-mentioned exposures. If you have any questions concerning this matter, please feel free to contact this office.
Sincerely,
Mark W. Hyse
Area Director