Ammonia Evaporator not LOTO’ed leading to 68 pound release and 4 hospitilizations

On May 31, 2012, Employees #1 through #6 were working when an evaporator that had been deactivated was mistakenly activated by a worker.  Approximately 68.5 pounds (31 kilograms) of ammonia were released on an overhead catwalk. Employees #1 through #6 inhaled the fumes, and they were transported to a hospital. Employee #1 was not hospitalized, but Employees #2 through #6 were. The narrative did not specify whether the inadvertent release of the ammonia was caused by a coworker or one of the six employees who were injured.  Here is a breakdown of the OSHA citations:

NOTE:  Rare Emergency Alarm citations using 1910.165,  but this was a PSM covered facility.

Violation Summary
  Serious Willful Repeat Other Total
Initial Violations 21   1 7 29
Current Violations 21   1 7 29
Initial Penalty $114,450 $0 $12,600 $1,950 $129,000
Current Penalty $85,840 $0 $9,450 $1,460 $96,750

 

Violation Items
# ID Type Standard Issuance Abate Curr$ Init$ LastEvent
1. 01001A Repeat

19100212 A03 II – The point of operation of machines whose

operation exposes an employee to injury, shall be guarded.

The guarding device shall be in conformity with any appropriate

standards therefor, or, in the absence of applicable specific

standards, shall be so designed and constructed as to prevent

the operator from having any part of his body in the danger zone

during the operating cycle.

11/21/2012 11/26/2012 $9,450 $12,600

I – Informal

Settlement

2. 01001B Repeat

19100212 A01 – Types of guarding. One or more methods of

machine guarding shall be provided to protect the operator and

other employees in the machine area from hazards such as those

created by point of operation, ingoing nip points, rotating parts,

flying chips and sparks. Examples of guarding methods are-barrier

guards, two-hand tripping devices,electronic safety devices, etc.

11/21/2012 11/26/2012 $0 $0

I – Informal

Settlement

3. 02001 Serious

19100023 C01 – Rungs and steps of portable metal ladders are

corrugated, knurled, dimpled, coated with skid-resistant material,

or otherwise treated to minimize the possibility of slipping;

11/21/2012 11/26/2012 $4,725 $6,300

I – Informal

Settlement

4. 02002 Serious 19100023 E01  11/21/2012 11/26/2012 $2,438 $3,250

I – Informal

Settlement

5. 02003 Serious 19100024 B 11/21/2012 11/26/2012 $1,463 $1,950

I – Informal

Settlement

6. 02004 Serious 19100024 F 11/21/2012 11/26/2012 $1,463 $1,950

I – Informal

Settlement

7. 02005A Serious 19100027 D01 III  11/21/2012 11/26/2012 $4,725 $6,300

I – Informal

Settlement

8. 02005B Serious 19100027 B01 II 11/21/2012 11/26/2012 $0 $0

I – Informal

Settlement

9. 02006 Serious

19100119 D03 II – The employer shall document that equipment

complies with recognized and generally accepted good engineering

practices.

11/21/2012 11/26/2012 $4,725 $6,300

I – Informal

Settlement

10. 02007A Serious

19100119 F01 – The employer shall 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 shall address at least the

following elements.

11/21/2012 01/07/2013 $4,725 $6,300

I – Informal

Settlement

11. 02007B Serious

19100119 F03 – The operating procedures shall be reviewed as often

as necessary to assure that they reflect current operating practice,

including changes that result from changes in process chemicals,

technology, and equipment, and changes to facilities. The employer

shall certify annually that these operating procedures are current and

accurate.

11/21/2012 01/07/2013 $0 $0

I – Informal

Settlement

12. 02008 Serious

19100119 G03 – Training documentation. The employer shall ascertain

that each employee involved in operating a process has received and

understood the training required by this paragraph. The employer shall

prepare a record which contains the identity of the employee, the date

of training, and the means used to verify that the employee understood

the training.

11/21/2012 12/17/2012 $4,725 $6,300

I – Informal

Settlement

13. 02009 Serious

19100119 F04 – The employer shall develop and implement safe work

practices to provide for the control of hazards during operations such

as lockout/tagout; confined space entry; opening process equipment or

piping; and control over entrance into a facility by maintenance, contractor,

laboratory, or other support personnel. These safe work practices shall

apply to employees and contractor employees.

11/21/2012 01/07/2013 $4,725 $6,300

I – Informal

Settlement

14. 02010 Serious

19100119 H02 V – The employer shall periodically evaluate the performance

of contract employers in fulfilling their obligations as specified in paragraph

(h)(3) of this section.

11/21/2012 01/07/2013 $4,725 $6,300

I – Informal

Settlement

15. 02011 Serious

19100119 J02 – Written procedures. The employer shall establish and

implement written procedures to maintain the on-going integrity of

process equipment.

11/21/2012 01/07/2013 $4,725 $6,300

I – Informal

Settlement

16. 02012 Serious

19100119 N – Emergency planning and response. The employer shall

establish and implement an emergency action plan for the entire plant

in accordance with the provisions of 29 CFR 1910.38. In addition, the

emergency action plan shall include procedures for handling small

releases. Employers covered under this standard may also be subject

to the hazardous waste and emergency response provisions contained

in 29 CFR 1910.120 (a), (p) and (q).

11/21/2012 01/07/2013 $4,725 $6,300

I – Informal

Settlement

17. 02013A Serious

19100120 Q06 IIA – Knowledge of the basic hazard and risk assessment

techniques.

11/21/2012 12/17/2013 $2,438 $3,250

I – Informal

Settlement

18. 02013B Serious

19100120 Q08 I – Those employees who are trained in accordance with

paragraph (q)(6) of this section shall receive annual refresher training of

sufficient content and duration to maintain their competencies, or shall

demonstrate competency in those areas at least yearly.

11/21/2012 01/07/2013 $0 $0

I – Informal

Settlement

19. 02014 Serious 19100133 A03 –  11/21/2012 11/26/2012 $2,438 $3,250

I – Informal

Settlement

20. 02015 Serious 19100146 C08 I 11/21/2012 01/07/2013 $4,725 $6,300

I – Informal

Settlement

21. 02016 Serious

19100147 F02 I – Whenever outside servicing personnel are to be engaged

in activities covered by the scope and application of this standard, the on-site

employer and the outside employer shall inform each other of their respective

lockout or tagout procedures.

11/21/2012 01/07/2013 $4,725 $6,300

I – Informal

Settlement

22. 02017 Serious

19100165 B02 – The employee alarm shall be capable of being perceived above

ambient noise or light levels by all employees in the affected portions of the

workplace. Tactile devices may be used to alert those employees who would

not otherwise be able to recognize the audible or visual alarm.

11/21/2012 06/30/2014 $4,725 $6,300

P – Petition to

Mod

Abatement

23. 02018 Serious

19100165 B03 – The employee alarm shall be distinctive and recognizable

as a signal to evacuate the work area or to perform actions designated

under the emergency action plan.

11/21/2012 06/30/2014 $4,725 $6,300

P – Petition to

Mod

Abatement

24. 02019 Serious 19100212 A05 11/21/2012 11/26/2012 $4,725 $6,300

I – Informal

Settlement

25. 02020 Serious 19100305 B01 II 11/21/2012 11/26/2012 $4,725 $6,300

I – Informal

Settlement

26. 02021 Serious 19100305 G02 II 11/21/2012 11/26/2012 $4,725 $6,300

I – Informal

Settlement

27. 03001A Other

19100119 E05 – The employer shall establish a system to promptly address

the team’s findings and recommendations; assure that the recommendations

are resolved in a timely manner and that the resolution is documented;

document what actions are to be taken; complete actions as soon as possible;

develop a written schedule of when these actions are to be completed;

communicate the actions to operating, maintenance and other employees

whose work assignments are in the process and who may be affected by

the recommendations or actions.

11/21/2012 01/07/2013 $730 $975

I – Informal

Settlement

28. 03001B Other 19100119 D03 IE – Ventilation system design; 11/21/2012 01/07/2013 $0 $0

I – Informal

Settlement

29. 03001C Other 19100119 D02 IC – Maximum intended inventory; 11/21/2012 11/26/2012 $0 $0

I – Informal

Settlement

30. 03002 Other 19100212 B 11/21/2012 11/26/2012 $730 $975

I – Informal

Settlement

31. 03003A Other 19100303 G01 I 11/21/2012 11/26/2012 $0 $0

I – Informal

Settlement

32. 03003B Other 19100303 G01 II 11/21/2012 11/26/2012 $0 $0

I – Informal

Settlement

33. 03004 Other 19100305 B01 11/21/2012 11/26/2012 $0 $0

I – Informal

Settlement

34. 03005 Other 19100305 B02 11/21/2012 11/26/2012 $0 $0

I – Informal

Settlement

35. 03006 Other 19100305 G01 IVA 11/21/2012 11/26/2012 $0 $0

I – Informal

Settlement

36. 03007 Other 19100334 A02 II 11/21/2012 11/26/2012 $0 $0

I – Informal

Settlement

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