Company failed to lockout and/or positively seal off an oil discharge which are readily adaptable to lockable controls and readily sealed to prevent the release of ammonia gas into the atmosphere when performing a “Hot Gas” procedure to correct an operational defect, product icing in the chiller. As direct result of this violation, an employee suffered a fatal exposure to ammonia gas which was released from a discharge valve on Chiller #11. Here is a breakdown of the citations from CA-OSHA…
- Citation 1 Item 1 Type of Violation: General California Code of Regulation Title 8 Section 3203(a) – Injury and Illness Prevention Program.
Company failed to maintain an effective Injury and Illness Prevention Program meeting the requirements of the standard for elements: (a)(4); (a)(7)(F) and failure to establish a safety committee meeting the requirements of (c)(l through 7) as set forth in the employer’s written program.
Proposed Penalty: $275.00
- Citation Item 2 Type of Violation: General California Code of Regulation Title 8 Section 3220(a) – Emergency Action Plan
Company failed to establish an Emergency Action Plan meeting the requirements of the standard for designated actions employees must take in fire and other emergencies, including elements (2) Procedures to be followed by employees who remain to operate critical plant operations before they evacuate; (4)- Rescue and medical duties for those employees who are to perform them; and (6) – Names or regular job titles of persons or departments who can be contacted for further information or explanation of duties under the plan.
Proposed Penalty: $310.00
- Citation 1 Item 3 Type of Violation: General California Code of Regulation Title 8 Section 5144(c)(l) – Respiratory Protection
Company’s written “Respirator Program” submitted to the Division does not contain essential elements (A through I) required by the standard.
Proposed Penalty: $550
- Citation 1 Item 4 Type of Violation: General California Code of Regulation Title 8 Section 5144(d)(2)(A) – Respiratory Protection
Company provides maintenance personnel, half-face tight fitting elastomeric air purifying respirator with ammonia cartridges for use in uncharacterized environments that are considered to be Immediately Dangerous to Life and Health in violation of the standard and exceeds the certification of the respirator.
Proposed Penalty: $410.00
- Citation 1 Item 5 Type of Violation: General California Code of Regulation Title 8 Section 5189 (f)(l)(A)2. – Process Safety Management of Acutely Hazardous Materials
Company failed to develop and implement written procedures that provide for clear instructions for safely conducting activities associated in each process consistent with the process safety information and contains specific procedures as required by subpart (A)(1 through 6) for each operating phase
Proposed Penalty: $550.00
- Citation 1 Item 6 Type of Violation: General California Code of Regulation Title 8 Section – 5189(g)(3) – Process Safety Management of Acutely Hazardous Materials
Company failed to prepare a certification record containing the identify of the employee, date of training, and signatures of the persons administering the training to authenticate each employee has received and successfully completed a training course as specified by this subsection.
Proposed Penalty: $135.00
- Citation 1 Item 7 Type of Violation: General California Code of Regulation Title 8 Section 5189(j)(1) – Process Safety Management of Acutely Hazardous Materials
Company failed to establish and implement written procedures to maintain the ongoing integrity of process equipment and appurtenances, which include subparts (A through D) of this subsection.
Proposed Penalty: $550.00
- Citation 1 Item 8 Type of Violation: General California Code of Regulation Title 8 Section 5192(q)(2)(A) Hazardous Waste Operations and Emergency Response
Company failed to develop and implement Emergency Response Plan meeting the requirements of subsection to make pre-emergency planning and coordination with outside parties, including municipal safety and emergency responders.
Proposed Penalty: $685.00
- Citation 2 Item 1 Type of Violation: Serious California Code of Regulation Title 8 Section 331O(a). Discharge Location.
Oil discharge drains from Chiller #11, #13 and receivers located in proximity to work areas are located so as to endanger employees to exposure of an ammonia gas in the event of a release.
Proposed Penalty: $4,950
- Citation 3 Item 1 Type of Violation: Serious California Code of Regulation Title 8 Section 3203(a)(4) – Injury and Illness Prevention Program.
Company failed to perform effective hazards evaluation inspections to identify unsafe conditions with the potential for resulting in an uncontrolled release of ammonia gas.
Proposed Penalty: $6,185
- Citation 4 Item 1 Type of Violation: Serious California Code of Regulation Title 8 Section 3203(a)(7)(F). Injury and Illness Prevention Program.
Company failed to provide supervisors training for with specific health and safety hazards associated with ammonia refrigeration systems and failure of these systems resulting in an ammonia gas release.
Proposed Penalty: $6,185
- Citation 5 Item 1 Type of Violation: Serious California Code of Regulation Title 8 Section 3328(g) – Machinery and Equipment
Company failed to maintain ammonia refrigerant Chillers #11, 13 an refrigeration process receivers in a safe operating condition.
Proposed Penalty: $6,185
- Citation 6 Item 1 Type of Violation: Serious California Code of Regulation Title 8 Section 3314(d) – The Control of Hazardous Energy for the Cleaning and Repairing, Servicing, Setting-Up, and Adjusting Operations of Prime Movers, Machinery and Equipment including Lockout/Tagout
Company failed to lockout and/or positively seal off oil discharge which are readily adaptable to lockable controls and readily sealed to prevent the release of ammonia gas into the atmosphere when performing a “Hot Gas” procedure to correct an operational defect, product icing in the chiller. As direct result of this violation, an employee suffered a fatal exposure to ammonia gas which was released from a discharge valve on Chiller #11.
Proposed Penalty: $18,000
- Citation 7 Item 1 Type of Violation: Serious California Code of Regulation Title 8 Section 514l(a) – Control of Harmful Exposure to Employee
Company failed to prevent and control the harmful exposure, as defined in 8CCR 5140, of employees, to anhydrous ammonia by using feasible engineering controls. On September 11, 2012, an employee suffered a fatal harmful exposure to anhydrous ammonia refrigerant release.
Proposed Penalty: $18,000
- Citation 8 Item 1 Type of Violation: Serious California Code of Regulation Title 8 Section 5155(c)(2)(B). Airborne Contaminants.
Company failed to control a release of ammonia gas at concentrations above the Permissible Exposure Limit so as to prevent a harmful exposure to employees.
Proposed Penalty: $6,185
- Citation 9 Item 1 Type of Violation: Serious California Code of Regulation Title 8 Section 5189(d) – Process Safety Management of Acutely Hazardous Materials
Company failed to develop and maintain a compilation of written safety information meeting the requirements of subsections (1)(A through G), (2)(A through E) and (3)(A) of the standard to enable employees operating the process to identify and understand hazards associated with anhydrous ammonia refrigerant systems.
Proposed Penalty: $4,950
- Citation 10 Item 1 Type of Violation: Serious California Code of Regulation Title 8 Section 5189(g)(1) – Process Safety Management of Acutely Hazardous Materials
Company failed to provide initial training to employees involved in operating or maintaining an ammonia refrigeration system, which includes operating procedures as specified in subsection (f) of this standard and emphasizes specific safety and health hazards, procedures and safe practices applicable to employee’s work tasks.
Proposed Penalty: $6,185
- Citation 11 Item 1 Type of Violation: Serious California Code of Regulation Title 8 Section 5192(q)(1). Hazardous Waste Operations and Emergency Response
The Emergency Safety Procedures section of the Emergency Response Plan adopted, developed and ,submitted to the Division requires positive response to “serious” ammonia leak (uncontrolled release) by maintenance personnel with in appropriate personal protection devices, no specific emergency response protocol reliance on ‘response from the Sanger Fire Department.
Proposed Penalty: $6,185
CLICK HERE to download the citations.
CLICK HERE to see the NRC Report for this incident.