UPDATE: OSHA Settlement (Final)
This week OSHA posted their citations (20 serious and 1 “other-than”) for a fatality involving Anhydrous Ammonia (NH3) at a seafood processing business in Boston, MA. None of the citations were for 1910.119 (PSM) indicating that the process contained less than 10,000 pounds of NH3. However, OSHA did issue two (2) General Duty Clause citations ($19,241) regarding the NH3 process on matters such as: 1) lack of NH3 pipe labeling, 2) not calibrating NH3 sensors per manufacturer’s schedule, 3) lack of proper engine room ventilation, 4) lack of adequate illumination in engine room, 5) improper separation of engine room from other rooms, and 6) improper pressure vessel inspections. At the time of the incident, the BFD stated in their public communications that the fatal release involved around 5,000 pounds of NH3. For unknown reasons, the refrigeration supervisor was overcome by the NH3 and found deceased at the top of some stairs in a stairwell. Here are the OSHA citations:
Citation 1 Item 1
Type of Violation: Serious; $11,224
OSH ACT of 1970 Section (5)(a)(1)
The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed to a potential catastrophic release of ammonia gas or liquid resulting in irritation, pulmonary edema, skin burns and frostbite from the deficient design, lack of proper operation, and lack of maintenance of the ammonia refrigeration facility and equipment:
- On or about March 23, 2016 and at times prior, the employer failed to ensure proper containment of the ammonia within the machine room in that there were large holes in the floor and no door to separate the machine room from the maintenance I storage room below.
- On or about March 23, 2016 and at times prior, the employer failed to properly label ammonia piping in the machine room.
- On or about March 23, 2016 and at times prior, the employer failed to test I calibrate ammonia sensors in accordance with the manufacturers recommendations.
- On or about March 23, 2016 and at times prior, the employer failed to provide adequate illumination within the machine room.
- On or about March 23, 2016 and at times prior, the employer failed to establish and implement an adequate inspection schedule for pressure vessels.
Established, industrially recognized abatement for the noted hazard of employee over-exposure to anhydrous ammonia, has been available for many decades within the ASHRAE 15 standard.
A second ammonia specific standard, that has now been widely applied throughout the ammonia refrigeration industry for approximately 25 years, known as HAR (International Institute of Ammonia Refrigeration), also provides requirements in Standard IIAR-2 for abating ammonia refrigeration facility and process hazards. These two standards are entirely consistent and, often, identical in content.
A third document, National Board Inspection Code Part 2 provides guidance on the inspection of pressure retaining items including pressure vessels. A fourth document, IIAR Bulletin 110, provides guidance on the start-up, inspection and maintenance of ammonia refrigeration systems including the performance of a process hazard analysis to identify and abate process related hazards.
The following items are examples of established anhydrous ammonia hazard abatement provisions that have been a part of the IIAR 2 standard since at least the 1999 edition and the National Board Inspection Code since at least the 2001 edition:
- Requirements for containing fugitive ammonia from the ammonia machine room are detailed in IIAR-2, 2014 edition, Section 6.2.1.
- Requirements for properly identifying piping are detailed in IIAR-2, 2014 edition, Section 5.14.5.
- Requirements for testing Machine Room alarm and ammonia detection systems are detailed in IIAR- 2, 2014 edition, Section 17.3.
- Requirements for minimum illumination levels for ammonia refrigeration machine rooms are detailed in IIAR-2 2014 edition, Section 6.11.
- Requirements for proper inspection of code pressure vessels are detailed in the NBIC 2015 edition, Part 2, Sections 2.3.5.4, 4.4.7, and 4.4.7.2 (t).
Citation 1 Item 2
Type of Violation: Serious; $8,017
OSH ACT of 1970 Section (5)(a)(1)
The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed to a potential catastrophic fire and/or explosion of ammonia gas or ammonia process equipment resulting in severe burns, explosion pressure and struck-by hazards from equipment fragments, due to deficient design, and lack of proper maintenance of the ammonia refrigeration equipment:
On or about March 23, 2016 and at times prior, the employer failed to provide a ventilation system sufficient to prevent combustion or explosion of ammonia vapors resulting from a release from ammonia refrigeration equipment.
Established, industrially recognized abatement for the fire/explosion hazard from over-pressurization of ammonia containing equipment or ammonia combustion, has been available for many decades within ammonia refrigeration standards ASHRAE 15 and HAR – 2. These two standards are entirely consistent and, often, identical in content.
- Adhere to the requirements ofIIAR- 2 2014, Section 6.14, to ensure adequate ventilation of the ammonia machine room.
Citation 1 Item 3
Type of Violation: Serious; $8,017
OSHACT of 1970 Section (5)(a)(1): The employer did not furnish employment and a place of employment which was free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed to hazards associated with being crushed by or struck by falling objects:
Employees were exposed to crushing and struck by hazards while working in Cooler B and the Freezer where the commercial steel storage racks used to store seafood were not maintained to prevent collapse of the racks .
- Missing anchor bolts/damaged base in locations including but not limited to: Cooler B – El912, Dl812, Dl811, Sliced Clam
- Damaged front beams in locations including but not limited to: Cooler B S1311/Sl312, E2011/2012, D2011/2012, D1811/1812, Freezer 2511/2512, 2711/2712
- Damaged horizontal braces in locations including but not limited to: Cooler B S 1312, Sliced Clam
Among other methods, one feasible and acceptable means of abatement would be to implement a storage rack inspection and maintenance protocol to identify damaged rack components, missing anchor bolts, and other deficiencies, have a storage rack professional evaluate the deficiencies, and follow the advice of the professional to restore the system as per ANSI MH16.l, 1.4.1 Owner Maintenance.
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 4a
Type of Violation: Serious; $8,017
29 CFR 1910.22(a)(1): All places of employment, passageways, storerooms or service rooms were not kept clean and orderly or in a sanitary condition. Maintenance Room:
Employees were exposed to tripping hazards and impeded access/egress in the maintenance area, where chemicals, vessels, buckets, pallets, compressed gases, electrical cords and wires, pumps and hoses, and hand tools were not stored in an orderly manner. Sheets of plywood and other building material were stored next to the door of the chemical cage, limiting the width of the door opening to the cage.
Citation 1 Item 4b
Type of Violation: Serious; Grouped
29 CFR 1910.37(a)(3): Exit route(s) were not kept free and unobstructed:
a) Maintenance Room: Employees were exposed to prolonged exposure to hazards from fire, ammonia release, and other emergency conditions where the emergency exit route was obstructed by a 55-gallon drum and a 5-gallon bucket.
b) Battery Charging Room: Employees were exposed to prolonged exposure to hazards from fire, ammonia release, and other emergency conditions where the emergency exit route was blocked by two Crown order pickers that were parked near the Exit door.
Citation 1 Item 4c
Type of Violation: Serious; Grouped
29 CFR 1910.303(g)(1): Sufficient access and working space was not provided and maintained about all electric equipment (operating at 600 volts, nominal, or less to ground) to permit ready and safe operation and maintenance of such equipment:
Maintenance Room: Access to the 480/277 V circuit breaker panel under the mezzanine (Lighting Panel PP4-3), was limited by material stored on a wheeled cart and equipment shrink-wrapped on a pallet.
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; $8,017
29 CFR 1910.23(b)(1)(i): Every wall opening from which there was a drop of more than 4 feet was not guarded by one of the following: Rail, roller, picket fence, half door, or equivalent barrier:
Ammonia Machinery Room: Employees were exposed to fall hazards from insufficiently guarded door openings in the second floor ammonia machinery room.
Citation 1 Item 5b
Type of Violation: Serious; Grouped
29 CFR 1910.37(b)(5): Each doorway or passage along an exit access that could be mistaken for an exit was not marked “Not an Exit” or similar designation, or be identified by a sign indicating its actual use (e.g. closet):
Ammonia Machinery Room: Two sets of double doors in the ammonia machinery room that opened to a 17-foot drop were not marked “Not an Exit.”
Citation 1 Item 6
Type of Violation: Serious; $8,017
29 CFR 1910.23(c)(1): Open-sided floors and/or platforms four feet or more above adjacent floor or ground level were not guarded with standard railings (or equivalent) and toe boards:
Roof: Employees were exposed to falls from the roof while inspecting and working on the ammonia refrigeration system where no guardrails or other fall protection was provided.
Citation 1 Item 7
Type of Violation: Serious; $8,017
29 CFR 1910.24(g): Stairway platforms were less than 30 inches in length measured in the direction of travel:
Stairway Platform in Ammonia Machinery Room: Employees were exposed to fall hazards while walking up and down the stairs where the upper landing measured approximately 24-inches, and where a fixed ladder on the same landing further restricted the length of the platform to 12.5-inches
Citation 1 Item 8
Type of Violation: Serious; $8,017
29 CFR 1910.26(c)(1): Good safe practices in the use and care of ladder equipment were not employed by the users to get maximum serviceability, safety, and to eliminate unnecessary damage of equipment:
Ammonia Machinery Room: Employees were exposed to fall hazards where a portable straight metal ladder that was used to gain access to the roof was modified to permanently fix it in place by attaching metal brackets to the top of the side rails to connect it to the metal roof hatch. Metal plates were also added to the top rung and the second rung to the bottom of the ladder, and a steel cable was run down the front of the ladder between these two plates, creating additional hazards for employees ascending or descending the ladder.
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 9a
Type of Violation: Serious; $6,413
29 CFR 1910.27(b)(1)(iii): The clear length of rungs or cleats was not at least 16 inches:
Maintenance Room: Employees were exposed to falls while using the fixed ladder in the maintenance shop to access the mezzanine where the rungs on the fixed ladder were 14 inches in width.
Citation 1 Item 9b
Type of Violation: Serious; Grouped
29 CFR 1910.27(e)(2): Substandard fixed ladders, installed within the substandard pitch range of 60 and 75 degrees with the horizontal, were permitted where it was not necessary to meet conditions of installation:
Maintenance Room: Employees were exposed to fall hazards while accessing the mezzanine using a fixed metal ladder with a pitch range of 60.2 – 60.3 degrees .
Citation 1 Item 10
Type of Violation: Serious; $11,224
29 CFR 1910.38(d): The employer did not have and maintain an employee alarm system with a distinctive signal for each purpose so that it complied with the requirements of 1910.165:
Ammonia Machine Room: The ammonia alarm system for the Ammonia Machine Room was disabled for prolonged periods of time. Ammonia refrigeration equipment continued to operate while the alarm system was disabled.
In the alternative: 29 CFR 1910.120(q)(2)(ix): The emergency response plan did not address, to the extent not addressed elsewhere, emergency alerting and response procedures
Facility: The emergency response plan did not address alternate emergency alerting and response procedures when the M&M control alarm system was disabled.
Citation 1 Item 11
Type of Violation: Serious; $11,224
29 CFR 1910.38(e): The employer did not designate and train a sufficient number of persons to assist in the safe and orderly emergency evacuation of employees:
Facility: Employees were not adequately trained in emergency evacuation procedures.
On April 23, 2016, the facility was evacuated in response to an anhydrous ammonia release, and none of the Area Captains or Co-Captains were on-site to perform their duties outlined in the Building Evacuation Plan.
In the alternative: 29 CFR 1910.120(q)(2)(vi): The emergency response plan did not address, to the extent not addressed elsewhere, evacuation routes and procedures:
Facility: The emergency response plan referred to “Section 3” for evacuation procedures for General Facility Employees, but there was no Section 3 in the emergency response plan provided.
Citation 1 Item 12
Type of Violation: Serious; $11,224 29
CFR 1910.132(d)(1)(i): When the employer had assessed the workplace hazard(s) and determined that hazard(s) were present, the employer did not select and/or use the types of personal protective equipment that would protect the affected employee from the hazard:
Facility: The employer’s written hazard assessments for maintenance operations in the machinery room and cleaning operations in Cooler A did not assign or select proper personal protective equipment to be worn that would protect against dermal and ocular exposure to ammonia, and dermal exposure to quaternary ammonium, ethanol, and potassium and sodium hydroxides in the cleaning products. There was no assessment for dermal and eye protection when handling ethylene glycol.
Citation 1 Item 13
Type of Violation: Serious; $11,224
29 CFR 1910.151(c): Where employees were exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body were not provided within the work area for immediate emergency use:
Ammonia Machine Room and Maintenance Room: Employees were exposed to anhydrous ammonia in the machinery room, as well as corrosive cleaning chemicals in the maintenance room, and there was no facility for quick drenching or flushing of the body, i.e., a shower, proximate to either room.
Hazardous Chemicals: 1) ZEP FS Amine Z, containing quaternary ammonium chloride 2) FS Formula 4089, containing sodium and potassium hydroxide, sodium hypochlorite 3) Anhydrous Ammonia
Citation 1 Item 14
Type of Violation: Serious; $8,017
29 CFR 1910.303(b)(2): Listed or labeled electrical equipment was not used or installed in accordance with instructions included in the listing or labeling:
a) Maintenance Room – Stairs leading to the Ammonia Machine Room: A relocatable power tap was secured to the stairs and was daisy chained to another relocatable power tap, which in turn was powered by an extension cord that was plugged in upstairs. A battery charger and an extension cord used to power a circular saw were plugged in to the relocatable power tap.
b) Freezer Office: A relocatable power tap was secured to the inside wall of the freezer office and was plugged into a receptacle outlet outside the freezer office. The power cord was run through a hole that was cut in the office wall. There were five power cords plugged into the tap. One of these was an extension cord that was connected to a multi-outlet extension cord.
Citation 1 Item 15
Type of Violation: Serious; $8,017
29 CFR 1910.303(b)(7)(i): Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings were not effectively closed to afford protection substantially equivalent to the wall of the equipment:
Ammonia Machine Room: Employees were exposed to electrical and fire hazards where there were unused openings in the emergency shut-offs to the ammonia refrigeration equipment, as well as the raceway above these shutoffs.
Citation 1 Item 16
Type of Violation: Serious; $8,017
29 CFR 1910.303(f)(1): Each disconnecting means required by Subpart S of Part 1910 for motors and appliances was not legibly marked to indicate its purpose, nor located and arranged so the purpose was evident. Maintenance Room: The 480/277V circuit breaker panel under the mezzanine (Lighting Panel PP4-3) had three circuit breakers installed. One was labeled “lighting,” but it was not clear what the other two circuits werert
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 17a
Citation 1 Item 17a
Type of Violation: Serious; $8,017 29 CFR 1910.305(g)(1)(iv)(A): Flexible cords and/or cables were used as a substitute for the fixed wiring of a structure:
29 CFR 1910.305(g)(1)(iv)(A): Flexible cords and/or cables were used as a substitute for the fixed wiring of a structure:
Extension cords were used in place of permanent wiring in the following locations: a) Loading Dock: Plugged in next to a dock door, run over the door to a pump, b) Freezer Hut: Plugged into a Relocatable Power Tap and zip-tied to the wall, c) Cooler B Outside Battery Charging Room: Plugged in behind workstation, zip-tied to conduit on the wall, run to the scale. Citation 1 Item 17b
a) Loading Dock: Plugged in next to a dock door, run over the door to a pump, b) Freezer Hut: Plugged into a Relocatable Power Tap and zip-tied to the wall, c) Cooler B Outside Battery Charging Room: Plugged in behind workstation, zip-tied to conduit on the wall, run to the scale. Citation 1 Item 17b
b) Freezer Hut: Plugged into a Relocatable Power Tap and zip-tied to the wall, c) Cooler B Outside Battery Charging Room: Plugged in behind workstation, zip-tied to conduit on the wall, run to the scale. Citation 1 Item 17b
c) Cooler B Outside Battery Charging Room: Plugged in behind workstation, zip-tied to conduit on the wall, run to the scale. Citation 1 Item 17b
Citation 1 Item 17b
Type of Violation: Serious; Grouped 29 CFR 1910.305(g)(1)(iv)(B): Flexible cords and cables were run through holes in walls, ceilings, or floors
29 CFR 1910.305(g)(1)(iv)(B): Flexible cords and cables were run through holes in walls, ceilings, or floors
Employees were exposed to electrical and fire hazards where electrical cords and cables were run through holes in walls and floors in the following locations: a) Ammonia Machinery Room: A yellow electrical cord was plugged
a) Ammonia Machinery Room: A yellow electrical cord was plugged in to a receptacle and run through a hole in the floor. b) Freezer Office: A power cord for a Relocatable Power Tap in the freezer office was run through a hole cut in the wall of the office and plugged into a receptacle outside the office.
b) Freezer Office: A power cord for a Relocatable Power Tap in the freezer office was run through a hole cut in the wall of the office and plugged into a receptacle outside the office.
Citation 1 Item 18
Type of Violation: Serious; $6,413 29 CFR 1910.1200(e)(1)(i): The employer did not compile a list of the hazardous chemicals known to be present using a product identifier that was referenced on the appropriate safety data sheet.
29 CFR 1910.1200(e)(1)(i): The employer did not compile a list of the hazardous chemicals known to be present using a product identifier that was referenced on the appropriate safety data sheet.
Facility: The company’s chemical inventory, required under the OSHA Hazard Communication Standard, listed only 3 chemical products, not inclusive of all chemicals present at the facility, including, but not limited to, water treatment biocides, ethylene glycol, paint thinners, ZEP Provisions High Foaming Equipment Cleaner, Evap-Pow-C for condenser coil cleaning, and ZEP A-One.
Citation 1 Item 19
Type of Violation: Serious; $4,811 29 CFR 1910.1200(f)(6): The employer did not ensure that each container of hazardous chemicals in the workplace was labeled, tagged or marked with the information specified
29 CFR 1910.1200(f)(6): The employer did not ensure that each container of hazardous chemicals in the workplace was labeled, tagged or marked with the information specified under paragraphs (f)(6)(i) through (ii) of this section: Maintenance Room: Among other chemical containers in the maintenance room, a large drum of AIRX 33 Bio-Enzymatic Odor Digester was not labeled with its identity and health and physical hazards.
Maintenance Room: Among other chemical containers in the maintenance room, a large drum of AIRX 33 Bio-Enzymatic Odor Digester was not labeled with its identity and health and physical hazards.
Citation 1 Item 20
Type of Violation: Serious; $11,224 29 CFR 1910.1200(h)(1): Employees were not provided effective information and training on hazardous chemicals in their work area at the time of their initial assignment and whenever a new hazard that the employees had not been previously trained about was introduced into their work area:
29 CFR 1910.1200(h)(1): Employees were not provided effective information and training on hazardous chemicals in their work area at the time of their initial assignment and whenever a new hazard that the employees had not been previously trained about was introduced into their work area:
Facility: a) The employer did not provide adequate chemical hazard communication training to employees who used cleaning chemicals such as ZEP FS Amine Z, containing Quaternary Ammonium Chlorides, and FS Formula 4089, containing potassium hydroxide, sodium hydroxide, and sodium hypochlorite.
a) The employer did not provide adequate chemical hazard communication training to employees who used cleaning chemicals such as ZEP FS Amine Z, containing Quaternary Ammonium Chlorides, and FS Formula 4089, containing potassium hydroxide, sodium hydroxide, and sodium hypochlorite.
b) The employer did not provide adequate training on the hazards of anhydrous ammonia to all employees.
Citation 2 Item 1
Type ofViolation: Other-than-Serious; $0.00 29 CFR 1910.101(b): The in-plant handling, storage, and utilization of all compressed gases in cylinders, portable tanks, rail
29 CFR 1910.101(b): The in-plant handling, storage, and utilization of all compressed gases in cylinders, portable tanks, rail tankcars, or motor vehicle cargo tanks were not in accordance with Compressed Gas Association Pamphlet P-1-1965, which is incorporated by reference as specified in CFR 1910.6:
Maintenance Room: Two Argon gas cylinders, one without a regulator, were being stored without valve protection caps in place, in contradiction to the Compressed Gas Association Pamphlet P-1-1965 guidelines.
CLICK HERE for the citations
New Story of Accident: https://www.bostonglobe.com/metro/2016/03/24/search-underway-for-cause-fatal-ammonia-leak-south-boston-fish-warehouse/RXnsiu1fzef9r18RSUflGI/story.html