OSHA has cited a refinery with repeat, serious and other-than-serious violations following the death of two workers at the crude oil refinery. OSHA began its investigation 9/12/2012 following the explosion of a boiler, which killed the employees. The inspection was expanded to include associated contractors and ongoing maintenance activities during a turnaround operation. We need to TAKE NOTICE of the citations for contractors and refinery personnel NOT signing out of process units and the fact that OSHA issued PSM citations against a boiler that was interconnected to a covered process (e.g. the boiler IS part of covered process). I can only imagine that the refinery will challenge these citations, but OSHA has been consistent in its position regarding boilers and covered processes. Here is a breakdown of the citations…
The six (6) repeat citations were cited for failing to:
- ensure that boiler equipment complied with RAGAGEP;
- ensure operating procedures addressed consequences of deviation from operating limits, including steps to avoid deviation from operating limits;
- provide training at least every three years on the practice of igniting boiler burners;
- establish and implement written procedures for testing and inspecting the shutdown and gas train interlocks for the boiler; and
- implement a management of change procedure when modifying boiler operating procedures.
The 15 serious citations include:
- failing to ensure the process safety information includes equipment design codes and standards;
- failing to ensure the process hazard analysis addressed purging the boiler burner firebox; and
- loss of burner pilot/flame, prolonged fuel gas flow and failing to develop and implement operating procedures that address initial start-up of the boiler burner.
The two other-than-serious violations include
- failing to ensure boiler lockout procedures included a statement of intended use and
- ensure a second level storage area was designed, constructed and marked with its maximum intended load.
Here is a breakdown of the citations:
Process Safety Information
1910.119(d)(3)(i)(F) – did not ensure PSI pertaining to the equipment includes the design codes and standards employed. In the Zone 2/CAT Boiler Area the employer did not ensure process safety information pertaining to the equipment included the design codes and standards employed such as National Fire Protection Association (NFPA) Standard 85, Boiler and Combustion Systems Hazard Code, and ASME CSD-1, sections CF-310 & CF-330, and ASME Section VI for the boiler burner and gas train exposing employees to fire and explosion hazards from potential releases of fuel gas and other flammable liquids or gasses. Serious; $7K
1910.119(d)(3)(h): did not document that equipment in the process complies with recognized and generally accepted good engineering practices. In the Zone 2/CAT Boiler Area the employer did not ensure it documented the boiler burner and gas train equipment complied with recognized and generally accepted good engineering practices such as the National Fire Protection Association (NFPA) Standard 85, Boiler and Combustion Systems Hazard Code, and ASME CSD-1, sections CF-310 & CF-330, and ASME Section VI. These practices include, but are not limited to the following equipment:
- Flame scanner/fire eyes.
- Automatic pilot gas shutoff valve.
- Automatic double block (positive shutoff) and automatic bleed on gas train to the burner.
- Burner management system(s) to control firebox purge, pilot ignition, burner starting, and shutdown.
REPEAT; $38500.00
Process Hazards Analysis
1910.119(e)(3)(i): did not ensure the PHA addresses the hazards of the process. In the Zone 2/CAT Boiler Area the employer did not ensure the 1992 and 2008 PHAs addressed the hazards of the process where employees were exposed to fire and explosion hazards from potential releases of fuel gas and other flammable liquids or gasses for hazards of the process such as but not limited to:
- Failure to purge or adequately purge the boiler firebox prior to lighting the burner pilot.
- Loss of burner pilot during the initial start-up of the boiler burner.
- Loss of burner flam.
- High or prolonged fuel gas flow to the burner without a pilot or flame present.
- Failure of the burner to light.
Serious; $7K
1910.119(e)(3)(iii): did ensure the process hazard analysis addresses the engineering and administrative controls applicable to the hazards and their interrelationship, such as, appropriate detection methodologies to provide early warning of releases. In the Zone 2/CAT Boiler Area the employer did not ensure the 1992 and 2008 PHA addressed the engineering and administrative controls applicable to the hazards and their interrelationships such as the appropriate methodologies to provide early warning where employees were exposed to fire and explosion hazards from potential releases of fuel gas and other flammable liquids or gasses for occurrences such as but not limited to:
- Loss of burner pilot during the initial start-up of the boiler burner.
- Loss of burner flame.
- High or prolonged fuel gas flow to the burner without a pilot or flame present.
- Failure of the burner to light.
Serious; $0
1910.119(e)(3 )(iv): did not ensure the PHA addressed the consequences of failure of engineering and administrative controls. In the Zone 2/CAT Boiler Area the employer did not ensure the 1992 and 2008 PHA addressed the consequences of failure of engineering and administrative controls where employees were exposed to fire and explosion hazards from potential releases of fuel gas and other flammable liquids or gasses for occurrences such as but not limited to:
- Loss of burner pilot during the initial start-up of the boiler burner.
- Loss of burner flame.
- High or prolonged fuel gas flow to the burner without a pilot or flame present.
- Failure of the burner to light.
Serious; $0K
Operating Procedures & Safe Work Practices (SWP)
1910.119(f)(l)(i)(A): the written operating procedures covering the steps for each operating phase do not address initial startup. In the Zone 2/CAT Wickes Boiler Area the employer did not ensure the written operating procedures covered steps for each operating phase including initial startup such as but not limited to:
- The length of time in which the gas can flow to the boiler burner without the burner lighting.
- A description of how much the main gas valve can be opened or what the maximum pressure should/can be at the inlet to the burner.
- The length of time the firebox is to be purged of gas prior to or after a failed burner lighting attempt.
- The maximum gas pressure at the inlet to the gas train on the boiler burner.
- The use of natural/purchased gas versus refinery gas.
Serious; $7K
1910.119(f)(1)(ii): did not implement written operating procedures that address operating limits; including at least the following elements: consequences of deviation and the steps required to correct or avoid deviation:
a) In the Zone 2/CAT Boiler Area the employer did not ensure the written operating procedures addressed the operating limits of the process such as, but not limited to:
- Minimum/Maximum gas pressure to the boiler burner gas train.
- Minimum and maximum pressure (PI 721 & PI 711) at the fuel gas inlet to the boiler.
- Minimum and maximum fuel gas flow to the boiler burner (FI 702).
- Minimum and maximum combustion air flow to the boiler burner (FI-706).
- Composition of the gas flow streams to the boiler burner (fuel gas and purchased gas) including BTU content, lower explosive limits etc.
b) In the Zone 2/CAT Boiler Area the employer did not ensure the written operating procedures addressed the consequence of deviation from the safe upper and lower limits of the process such as, but not limited to:
- Minimum/Maximum gas pressure to the boiler burner gas train.
- Minimum and maximum pressure (PI 721 & PI 711) at the fuel gas inlet to the boiler.
- Minimum and maximum fuel gas flow to the boiler burner (FI 702).
- Minimum and maximum combustion air flow to the boiler burner (FI-706).
- Composition of the gas flow streams to the boiler burner (fuel gas and purchased gas) including BTU content, lower explosive limits etc.
c) In the Zone 2/CAT Boiler Area the employer did not ensure the written operating procedures addressed the steps to correct or avoid deviation from the safe upper and lower limits of the process such as but not limited to:
- Minimum/Maximum gas pressure to the boiler burner gas train.
- Minimum and maximum pressure (PI 721 & PI 711) at the fuel gas inlet to the boiler.
- Minimum and maximum fuel gas flow to the boiler burner (FI 702).
- Minimum and maximum combustion air flow to the boiler burner (FI-706).
- Composition of the gas flow streams to the boiler burner (fuel gas and purchased gas) including BTU content, lower explosive limits, etc.
REPEAT; $38500.00
1910.147(c)(4)(ii)(B): did not ensure the energy control procedures clearly and specifically outline the steps for shutting down, isolating, blocking and securing machines or equipment to control hazardous energy. In the Zone 2/CAT Boiler Area the employer did not ensure the energy control procedures for the lockout/tagout of the fuel gas and purchased gas supply lines to the Boiler burner clearly and specifically outlined the steps for shutting down, isolating, blocking, and securing equipment to control hazardous energy. Serious; $7K
1910.147(c)(4)(ii)(D): did not ensure the energy control procedures clearly and specifically outline the requirements for testing a machine or equipment to determine and verify the effectiveness of lockout devices, tagout devices, and other energy control measures. In the Zone 2/CAT Boiler Area the employer did not ensure that the energy control procedures for the lockout/tagout of the fuel gas and purchased gas supply lines to the Boiler clearly and specifically outlined the requirements for testing a machine or equipment to determine and verify the effectiveness of lockout devices. Serious; $0
1910.147(d)(3): did not ensure all energy isolating devices that are needed to control the energy to the machine or equipment are physically located and operated in such a manner as to isolate the machine or equipment from the energy source. In the Zone 2/CAT Wickes Boiler Area the employer did not ensure all energy isolating devices for the lockout/tagout of the fuel gas and purchased gas supply lines such as, but not limited to, the control valves (FC.702 & FC 704) and bleed valves to the Boiler were physically located and operated in such a manner as to isolate the machine or equipment from the energy source. Serious; $7K
1910.147(d)(5)(i): did not ensure all potentially hazardous stored or residual energy is relieved, disconnected, restrained or otherwise rendered safe after the application of lockout or tagout devices to energy isolating devices. In the Zone 2/CAT Boiler Area the employer did not ensure all potentially hazardous stored or residual energy was relieved after the application of lockout or tagout devices such as between the two control valves (FC 702 and FC 704) on the fuel gas and purchased gas supply lines to the Boiler. Serious; $0
1910.147(c)(4)(ii)(A): did not ensure energy control procedures contain a specific statement on the intended use of the procedure. In the Zone 2/CAT Boiler Area the employer did not ensure the energy control procedures for the lockout/tagout of the fuel gas and purchased gas supply lines to the Boiler burner contained a specific statement on the intended use. Employees were exposed to fire and explosion hazards from potential releases of fuel gas and other flammable liquids or gasses. Other-than-Serious $0.00
1910.119(f)(3): did not ensure operating procedures are 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, or changes to facilities. In the Zone 2/CAT Boiler Area the employer did not ensure written operating procedures for the Boiler Burner System were reviewed as often as necessary to assure that they reflected current operating practice. Identified errors include but not limited to:
- The amount of time the firebox is purged prior to attempting to light the pilot or after a failed burner lighting attempt.
- The level the gas control valve bypass valve is to be opened.
- The time the gas control valve bypass valve is allowed open before the burner lights.
Serious; $0
Walking & Working Surfaces
1910.23(a)(2): did not ensure every ladderway floor opening or platform was guarded by a standard railing, or swinging gate or so offset that a person cannot walk directly into the opening. This violation was observed on or about November 26, 2012, in the Crude and Alky Units where the employer did not ensure that ladderway floor openings were guarded by standard railing, or equivalent means, exposing employees to fall hazards greater than 4 feet above the ground. Serious; $7K
Compressed Gas Cylinders
1910.101(b): did not ensure the in-plant handling, storage, and utilization of all compressed gases in cylinders, portable tanks, rail tankcars, or motor vehicle cargo tanks is in accordance with Compressed Gas Association Pamphlet P-l-1965, which is incorporated by reference as specified in CFR 1910.6. This violation was observed on or about October 29, 2012, in the welding shop the employer did not ensure that compressed gas cylinders were stored with protective caps exposing employees to struck-by hazards. Serious; $3300.00
Contractors
1910.119(h)(2)(v): Refinery did not evaluate whether or not each contractor:
- Trains their employees in the work practices necessary to safely perform their job;
- Instructs their employees on the known potential fire, explosion, or toxic release hazards related to their job and the applicable provisions of the emergency action plan;
- Documents, records and maintains a record that all their employees have received and understand the training required;
- Assures that each employee follows the safety rules of the facility. Contractor employees were observed exiting various process areas without signing out; not wearing appropriate eye or face protection while mixing and applying refractory products, and working on scaffolds that were not properly designed or erected. No formal process to evaluate contractor performance is in place at the refinery.
Serious; $3300.00
1910.119(h)(2)(iv): did not develop and implement safe work practices consistent with 29 CFR 1910.119(f)(4), to control the entrance, presence and exit of contract employers and employees in covered process areas. On or about October 25,2012, and at times prior thereto, the employer did not ensure contract employees are properly signed in/out process units:
- Four (4) XXXXXXXXXX employees failed to sign out of Zone 3.
- Two (2) XXXXX employees failed to sign out of the FCCU.
- One (1) XXXXXXX employee failed to sign out of the FCCU.
- One (1) XXXXXXX employee, two (2) XXXXXX employees, one (1) XXXXXXXXX employee, and one (1) refinery employee failed to sign out of the FCCU.
- On October 20, 2012, seven (7) scaffolding employees, two (2) employees failed to sign out of the Alkylation Unit.
- On October 12, 2012, three (3) employees failed to sign out of the SRU 48002 area in the Alkylation Unit.
Serious; $5500.00
Management of Change
1910.119(l)(1): did not establish and implement written procedures to manage changes to process chemicals, technology, equipment, and procedures; and, changes to facilities that affect a covered process.
a) In the Zone 2/CAT Boiler Area the employer did not ensure management of change procedures were implemented to manage changes to the process operating procedures such as, but not limited to:
- The amount of time the firebox is purged prior to attempting to light the pilot or after a failed burner lighting attempt.
- The amount that the gas control valve bypass valve is to be opened.
- The time that the gas control valve bypass valve is allowed open before the burner lights.
b) In the Zone 2/CAT Boiler Area the employer did not ensure management of change procedures were implemented to manage changes to the process equipment, such as the addition of temporary power to operate the Boiler.
REPEAT; $38500.00
1910.119(l)(3): did not ensure employees involved in operating a process and maintenance and contract employees whose job tasks will be affected by a change in the process are informed of, and trained in, the change prior to start-up of the process or affected part of the process. In the Zone 2/CAT Boiler Area the employer did not ensure employees whose job tasks were affected by a change in the process were informed of and trained on the change prior to startup of the process. Employees were exposed to fire and explosion hazards from potential releases of fuel gas and other flammable liquids or gasses for process changes such as, but not limited to:
- Standard Operating Procedures covering the start-up of the Boiler burner after the 2008 Boiler Explosion.
- Use of temporary power to power the boiler during the shutdown/turnaround.
Serious; $7K
Fire Extinguishers
1910.157(c)(1): did not ensure portable fire extinguishers are mounted, located and identified so that they are readily accessible without subjecting the employees to injuries. This violation was observed on or about October 29, 2012, the employer did not ensure fire extinguishers were free from obstruction and readily accessible exposing employees to the hazards of fire, trips and falls: a) A fire extinguisher in the warehouse was blocked by boxes. b) A fire extinguisher in the pump shop was blocked by a large crate and air lines. c) Two fire extinguishers in the welding shop were not mounted. Serious; $3300.00
Machine Guarding
1910.212(a)(3)(ii): did not ensure point of operation guards are designed and constructed as to prevent the operator from having any part of their body in the danger zone during the operating cycle. This violation was observed on or about October 29, 2012, in the pump shop the employer did not ensure a horizontal band saw was provided a guard exposing employees to the hazard of contact with the point of operation. Serious; $5500.00
1910.215(a)(2): did not ensure abrasive wheels used on grinding machinery are provided with safety guards which cover the spindle end, nut, and flange projections. This violation was observed on or about October 29, 2012, in the pump shop the employer did not ensure abrasive wheels on a grinding machine were provided with safety guards covering the spindle end, nut, and flange projections exposing employees to the hazard of caught-by. Serious; $5500.00
1910.215(b)(9): did not ensure the distance between the grinding wheel periphery and the adjustable tongue or the end of the peripheral member at the top does not exceed one-fourth inch. This violation was observed on or about October 27,2012, in the maintenance shop where the distance between the grinding wheel periphery and the adjustable tongue guard on a bench grinder exceeded one-fourth inch exposing employees to the hazards of caught-by and struck-by flying debris resulting from an exploding grinding wheel. Serious; $0
1910.215(d)(3): did not ensure the contact surfaces of wheels, blotters or flanges on grinding machines are flat and free of foreign matter. This violation was observed on or about October 27,2012, in the maintenance shop for a bench grinder where the contact surface of a grinding wheel was not kept flat and smooth exposing employees to the hazard of struck-by flying debris from an exploding grinding wheel. Serious; $0
Electrical
1910.303(g)(1): did not provide and maintain sufficient access and working space about all electric equipment (operating at 600 volts, nominal, or less to ground) to permit ready and safe operation and maintenance of such equipment. This violation was observed on or about October 29, 2012, in the pump shop where an electrical panel was not accessible exposing employees to fire and electrical hazards. Serious; $4400.00
1910.305(b)(l)(ii): did not ensure unused openings in cabinets, boxes, and fittings are effectively closed. This violation was observed on or about October 29, 2012, in the maintenance shop where the employer did not ensure that a pre-punched knockout was effectively closed on an electrical panel exposing employees to fire and electrical hazards. Serious; $3300.00
1910.305(g)(l)(iv)[A]: did not ensure flexible cords are not used as a substitute for fixed wiring of a structure. This violation was observed on or about October 29, 2012, in the welding shop where extension cords were used as a substitute for fixed wiring exposing employees to electrical hazards. Serious; $4400.00
Walking and Working Surfaces
1910.22(d)(1): every building or other structure, or part thereof, used for mercantile, business, industrial, or storage purposes, the employer does not ensure the second level storage area is designed, constructed, and maintained to support its maximum intended load. This violation was observed in the warehouse the employer did not ensure the second level storage area was designed, constructed, and maintained to support its maximum intended load. Serious; $0
Training
1910.119(g)(2): did not provide refresher training at least every three years to each employee involved in operating a process to assure that the employee understands and adheres to the current operating procedures of the process. In the Zone 2/CAT Boiler Area the employer did not ensure refresher training was provided at least every three years to each employee involved in operating the Boiler to assure that the employee understood and adhered to the current operating procedures. REPEAT; $38500.00
Mechanical Integrity
1910.119(j)(2): did not establish and implement written procedures to maintain the on-going mechanical integrity of process equipment. In the Zone 2/CAT Boiler Area the employer did not ensure written procedures were established and implemented for the testing and inspection of the Low Combustion Air Flow Fuel Gas Shut-off system safeguard. Employees were exposed to fire and explosion hazards from potential releases of fuel gas and other flammable liquids or gasses. REPEAT; $38500.00