Citation 1 Item 1
Type of Violation: Serious; $4,500
Section 88.4 – Code of Iowa (2007)
88.4: The employer did not furnish employment and a place of employment that 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 a serious corrosive chemical hazard, ammonia used as a refrigerant:
(a) In the Plant- There is a variety of ammonia refrigerant piping. A new ammonia pump out line, for the Weiler mixer, was tied-in with an existing pump out line. In the area of the tie-in, there were several piping branches and direction changes. None of the piping was labeled as to content, pressure, physical state, or direction of flow. There existed a greater probability of piping misidentification during line breaking or tie-ins. A feasible and acceptable means of abatement would be to follow the International Institute of Ammonia Refrigeration Bulletin No. 114, “Guidelines for Identification of Ammonia Refrigeration Piping and System Components”. This deficiency was noted on or about 9-12-07.
Citation 1 Item 2a
Type of Violation: Serious; $4,500
IAC 875 – Chapter 10
1910.36 (b)(1): At least two exit route s were not available in the workplace to permit prompt evacuation of employees and other building occupant s during an emergency:
(a) On the PH Mezzanine – The sole exit route took employees directly alongside a Weiler mixer, that had been modified to accept ammonia refrigerant.
On 8-31-07, an uncontrolled ammonia release occurred from the Weiler mixer’s ammonia piping, and employees were required to leave the area immediately. The employees on the PH mezzanine had a single exit route that took them directly into the ammonia release. Two employees were injured from contact with high pressure liquid ammonia. One injured employee was able to exit from the mezzanine. The other employee died from her injuries. With the arrangement of placing a modified ammonia system directly next to the sole exit route, there was an obligation to provide a secondary exit route for employees working on the P H mezzanine.
Citation 1 Item 2b
Type of Violation: Serious;
IAC 875 – Chapter 10
1910.37(a)(2): Exit access(es) were not arranged so that it would not be necessary to travel toward any area of high hazard occupancy in order to reach the nearest exit, and the path of travel was not effectively shielded from the high hazard location by suitable partitions or other physical barriers:
(a) On the PH Mezzanine – The sole exit route took employees directly alongside a Weiler mixer that had been modified to accept ammonia refrigerant.
On 8-31-07, an uncontrolled ammonia release occurred from the Weiler’s refrigerant piping and employees were required to leave the area immediately. Because of the arrangement of the exit access, two exiting employees had to pass through this area of higher hazard and were injured. One employee died from exposure to ammonia.
Citation 1 Item 3a
Type of Violation: Serious; $4,500
IAC 875 – Chapter 10
1910.38(c)(2): The employer’s emergency action plan did not include procedures for emergency evacuation, including types of evacuation and exit route assignments:
(a) At the Plant – The employer has decided to, at least, partially evacuate in the event of an uncontrolled ammonia release. Although the employer has an emergency action plan, it is not up-to-date. Personnel, listed as the plant and maintenance managers, are no longer at the facility. The current plant coordinator is not identified in the plan. Although the plan mentions an evacuation signal, it does not describe the installed manually operated multiple horn system, or who has the responsibility to initiate it. Appendix B, of the company disaster preparedness plan, addresses evacuation routes from different areas of the plant. It does not describe an evacuation route for employees working on the PH mezzanine area.
On 8-31-07, an uncontrolled ammonia release occurred that required plant evacuation. Two employees, working on the PH mezzanine, had difficulty evacuating and were injured by the ammonia. One employee died from her injuries.
Citation 1 Item 3b
Type of Violation: Serious
IAC 875 – Chapter 10
1910.119(n): The employer did not establish and implement an emergency plan for the entire plant in accordance with the provisions of 1910.38(a):
(a) At the Plant – The employer has decided to, at least, partially evacuate in the event of an uncontrolled ammonia release. The employer’s emergency evacuation plan is not up-to-date.
Personnel, listed as the plant and maintenance managers, are no longer at the facility. The current plant coordinator is not identified in the plan. Although the plan mentions an evacuation signal, it does not describe the installed manually operated multiple horn system, or who has the responsibility to initiate it. Appendix B, of the company disaster preparedness plan, addresses evacuation routes from different areas of the plant. It does not describe an evacuation route for employees working on the PH mezzanine.
On 8-3 1-07, an uncontrolled ammonia release occurred that required plant evacuation. Two employees, working on the PH mezzanine, had difficulty evacuating and were injured by the ammonia. One employee died from her injuries.
Citation 1 Item 4
Type of Violation: Serious; $4,500
IAC 875 – Chapter 10
1910.119(e)(3)(ii): The process hazard analysis did not identify any previous incident which had a likely potential for catastrophic consequences in the workplace:
(a) At the Plant – The employer uses approximately 85,000 pounds of ammonia refrigerant. A process hazard analysis (PHA) was originally performed in 1998. In September 2000, the employer experienced two ammonia releases that required employee evacuation. These releases were not addressed in the 2003 PHA revalidation and update.
Citation 1 Item 5
Type of Violation: Serious; $4,500
IAC 8 75 – Chapter 10
1910.119(h)(2)(vi): The employer did not maintain a contract employee injury and illness log related to the contractor’s work in process areas:
(a) At the Plant – The employer has multiple contractors working on the ammonia refrigerant system and its associated equipment, a process safety management covered system. The employer has not been keeping a log of contract or employee injuries.
Citation 1 Item 6
Type of Violation: Serious; $4,500
IAC 875 – Chapter 10
1910.119(m)(3): The incident investigation team did not consist of at least one person knowledgeable in the process involved, including a contract employee if the incident involved work of the contractor, and other persons with appropriate knowledge and experience to thoroughly investigate and analyze the incident:
(a) At the Plant – On 8-31-07, the employer had an uncontrolled release of ammonia refrigerant that resulted in the death of an employee. The employer assembled an accident investigation team that excluded Modern Engineering and Piping, the contractor involved in the incident.
Citation 1 Item 7
Type of Violation: Serious; $4,500
IAC 875 – Chapter 10
1910.134(f)(1): The employer did not ensure that employees using a tight-fitting facepiece respirator pass an appropriate qualitative fit test (QLFT) or quantitative fit test (QNFT):
(a) At the Plant – On or about 8-31-07, the employer had an uncontrolled release of ammonia refrigerant that resulted in the death of an employee. During the response after the release, a production superintendent donned a MSA gas mask and reentered the plant. The production superintendent had not been fit tested with this respirator. While wearing this respirator, he inhaled ammonia vapors and experienced breathing difficulties.
Citation 2 Item 1
Type of Violation: Willful; $63,000
IAC 875 – Chapter 1 0
1910.119(f)(1): The employer did not develop and implement written operating procedures that provided clear instructions for safely conducting activities in each covered process consistent with the process safety information and which addressed the elements listed in 1910.119(f)(1)(i) through (f)(1)(v):
(a) At the Plant – On or about 8- 3 1-07, the plant coordinator and two maintenance supervisors attempted to transfer ammonia from the high pressure receiver to the intercooler via the refrigerant pump out line. The ammonia system is a process safety management covered process at this plant.
The employer did not have a written operating procedure to transfer ammonia via the pump out line. Prior to the attempted ammonia transfer, a section of piping had been removed from the pump out line. This allowed high pressure liquid ammonia to be released into the employee work area during the attempted transfer. As a result of this release, an employee was killed. A written operating procedure that clearly and safely directed personnel to accomplish the transfer, via the pump out line, had not been developed and implemented.
Citation 2 Item 2
Type of Violation: Willful; $63,000
IAC 8 75 – Chapter 10
1910.119(f)(3): The operating procedures were not 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:
(a) At the Plant – On or about 8-31-07, three employees attempted to transfer ammonia from the high-pressure receiver to the intercooler. The ammonia system is a process safety management covered process at this plant. These employees did not have up-to-date operating procedures that reflected the addition of a Weiler mixer and associated ammonia piping. Because of this lack of up-to-date operating procedures, ammonia was released into the employee work area. As a result of this release, one employee was killed.
Citation 2 Item 3
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.119(f)(4): The employer did not develop and implement safe work practices for employees and contractor employees 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:
(a) At the Plant – Employees and contractor employees occasionally open or “break” ammonia lines.
The employer’s written policy is to follow the International Institute of Ammonia Refrigeration(IIAR) Bulletin No. 107, “Suggested Safety and Operating Procedures When Making Ammonia Refrigeration Plant Tie-ins”. IIAR Bulletin No. 107 directs the use of lockout for system isolation. This employer does not use lockout when opening or line breaking ammonia piping. Contractor employees also perform ammonia piping tie-in or line breaking work. This employer has not put IIAR Bulletin No. 107 into effect for contractor employees.
Citation 2 Item 4
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.119(g)(1)(i): The initial training program for employees involved in operating a process did not include an emphasis on the specific safety and health hazards of the process, emergency operations including shutdown, and safe work practices applicable to the employee’s job tasks:
(a) At the Plant – On 8-31-07, the plant coordinator and two maintenance supervisors attempted to transfer high pressure liquid ammonia refrigerant from the high pressure receiver to the intercooler.
None of the employees h ad been trained in the proper transfer procedure. One of the employees had received some on-the-job training in using an ammonia pump out line, rather than the dedicated ammonia transfer line, for this transfer. As a result, high pressure liquid ammonia was introduced into a pump out line under construction. An opening in the pump out line allowed high pressure liquid ammonia to spill out into the employee work area. One employee died from exposure to ammonia.
Citation 2 Item 5
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.119(h)(2)(iv): The employer did not develop and implement safe work practices consistent with 1910.119(f)(4), to control the entrance, presence, and exit of contract employers and contract employees in covered process areas:
(a) At the Plant – Contract employers perform work on the process safety management covered ammonia system. The employer did not adequately control the contract employer’s work activity during tie-in of the Weiler mixer ammonia pump out line to the existing ammonia pump out line.
Additionally, the employer did not control the later removal of a pump out line section, by the same contract employer. As a result of this failure to monitor and control the contractor’s work activity and presence in the plant, high pressure liquid ammonia was released into the employee work area and an employee was killed. This condition existed on or about 8-3 1 -07.
Citation 2 Item 6
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.119(i)(1): The employer did not perform a pre-startup safety review for new facilities:
(a) At the Plant – The employer set a Weiler M16110 meat mixer around February-March 2007.
Ammonia refrigerant liquid and suction lines were later connected to the mixer. In July 2007, the ammonia refrigerant pump out line was connected.
On 8-3 1 -07, the employer introduced ammonia refrigerant into the Weiler pump out piping. An opening in the new line allowed high pressure liquid ammonia t o spill out into the employee work area. As a result of this ammonia spill, one employee was killed and others were injured. The ammonia system at this plant is covered under the employer’s process safety management program. The employer’s pre-startup safety review (PSSR) policy requires that the PSSR form be completed prior to the introduction of ammonia into the area being modified, or into new equipment such as pipe. Although the employer had a PSSR form for this project, it had never been completed or implemented.
Citation 2 Item 7
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.119(j)(6)(ii): Appropriate checks and inspections were not performed t o assure that equipment was installed properly and consistent with design specifications and the manufacturer’ s instructions:
(a) At the Plant – The employer set a Weiler and Company manufactured M16110 meat mixer, in February-March 2007. Although this mixer was never designed, manufactured, or factory refurbished to accommodate ammonia refrigerant, the employer had modified it to accept ammonia.
This reconfiguration was not compatible with the manufacturer’s provided instructions.
Safety information, in these instructions, caution the user not to use this machine for purposes other than the original intended use. The employer connected ammonia liquid, suction, and pump out lines to this mixer. The ammonia refrigerant system is a process safety management covered process at this facility.
On 8-3 1-07, ammonia was released from an opening in the Weiler mixer’s ammonia pump out line. As a result of this release, an employee was killed and others were injured.
Citation 2 Item 8
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.119(l)( 1 ): The employer 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) At the Plant – The employer set a Weiler Ml6110 mixer around February-March 2007. The Weiler mixer had previously been modified to accept ammonia refrigeration. This modification was not performed by the original manufacturer, Weiler and Company, Inc.
Ammonia refrigerant suction, liquid, and pump out lines were connected to the Weiler mixer. On 8-31-07, the employer discharged ammonia refrigerant to the Weiler’s pump out line piping. An opening in this piping allowed high pressure liquid ammonia to spill into the employee work area. An employee died and others were injured from exposure to ammonia.
Although the employer had a written management of change(MOC) procedure, it had not been implemented and was not followed. The corporate process safety coordinator did not complete the MOC form or pass it on for others to review.
Citation 2 Item 9
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.120(q)(1): Employer s whose employees were engaged in emergency response, did not develop and implement an emergency response plan to handle anticipated emergencies prior to commencement of emergency response operations:
(a) At the Plant – An uncontrolled release of ammonia occurred on August 31, 2007. Employees responded to the release by assisting in evacuation, containment of the release, stoppage of the release, and clean up after the incident. Several responding employees were injured from exposure to ammonia. One production employee died from exposure to the ammonia release.
The employer did not have a written comprehensive emergency response plan for employees engaged in emergency response to an uncontrolled chemical release.
Citation 2 Item 10
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.120(q)(3)(iii): Based on the hazardous substances and/or conditions present, the individual in charge of the ICS did not implement appropriate emergency operations and did not assure that the personal protective equipment worn was appropriate for the hazards to be encountered:
(a) At the Plant – An uncontrolled ammonia release occurred on August 31, 2007. Employees responded to the release, under the direction of the plant coordinator. The plant safety manager and safety supervisor assisted the plant coordinator. Responding employees, who reentered the plant, were not provided sufficient protective clothing to prevent skin contact with liquid ammonia. At least two of the responding employees were sprayed with high pressure liquid ammonia and suffered chemical burns.
Citation 2 Item 11
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.120(q)(3)(iv): Positive-pressure self-contained breathing apparatus was not worn by employees engaged in emergency response and expose to hazardous substances presenting an inhalation hazard or potential inhalation hazard, until such time that the individual in charge of the ICS determined through the use of air monitoring that a decreased level of respiratory protection would not result in hazardous exposures to employees:
(a) At the Plant – An uncontrolled ammonia release occurred on August 31, 2007. Employees responded to the ammonia release under the direction of the plant coordinator. The plant safety manager and plant safety supervisor assisted the plant coordinator. Although they did not know the actual ammonia exposure levels, responding employees wore MSA gas masks. MSA gas masks are not acceptable respiratory protection for entry where there is an unknown level of ammonia. Self- contained breathing apparatus were available at the plant but were not worn. Several of the responding employees experienced ammonia break-through of their respirator canisters, and they experienced respiratory irritation. One production employee died from exposure to the ammonia release.
Citation 2 Item 12
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.120(q)(6): The skill and knowledge levels required for all new responders, those hired after the effective date of this standard, were not conveyed to them through training before they were permitted to take part in actual emergency operations on an incident:
(a) At the Plant – An uncontrolled ammonia release occurred on August 31, 2007. Employees responded to the release under the direction of the plant coordinator. The plant safety director and plant safety supervisor assisted the plant coordinator. Employees assisted in evacuation, containment of the release, stoppage of the release, and clean up after the incident. None of the responding employees had been trained in emergency response operations. One production employee was killed and several were injured from the ammonia release.
Citation 2 Item 13
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.134(c)(1)(iv): The employer did not establish and implement a worksite specific written respiratory protection program to include procedures for proper use of respirators in routine and reasonably foreseeable emergency situations:
(a) At the Plant – An uncontrolled ammonia release occurred on 8-31-07. Responding employees wore MSA gas masks with canisters into an unknown ammonia environment. The employer’s written respiratory protection program did not include procedures for the wearing of MSA gas masks in emergency response to an uncontrolled chemical release.
Several responding employees received ammonia breakthrough of their respirator canisters and experienced respiratory irritation.
Citation 2 Item 14
Type of Violation: Willful; $63,000
IAC 8 75 – Chapter 10
1910.147(c)(4)(ii): The energy control procedures did not clearly and specifically out line the scope, purpose, authorization, rules, and techniques to be utilized for the control of hazardous energy, including, but not limited to Items A – D of this section:
(a) At the Plant – Employees occasionally perform service, repair, and maintenance work on a variety of equipment. Although the employer has a general lockout procedure, there is no specific lockout procedure for ammonia piping and valves associated with the high pressure receiver and Weiler mixer pump out line.
On or about 7-11-07 , a maintenance supervisor opened a flange on the ammonia pump out line associated with the high pressure receiver and Weiler mixer. Lockout was not used for system isolation. There was no specific lockout procedure available for this work.
(b) At the Plant – Employees perform service, repair and maintenance work on a variety of equipment. Equipment operators on the PH mezzanine daily perform work on the PH enhancing (PHE) ammonia spargers. Although the employer has a specific lockout procedure for the PHE ammonia spargers, the procedure does not address isolating and locking out the ammonia supply valve. This condition was noted on or about 11-20-07.
Citation 2 Item 15
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.147(c)(7)(i): The employer did not provide adequate training to ensure that employees acquired the knowledge and skills required for the safe application, usage, and removal of energy control devices:
(a) At the Plant – Employees perform service, repair, and maintenance work on a variety of equipment. On or about 7-11-07, a maintenance supervisor engaged in “line breaking” of the high pressure receiver and Weiler mixer ammonia pump out line. The employee had not been trained on “line breaking” procedures and the importance of locking out ammonia line stop valves.
(b) At the Plant – Employees perform service, repair, and maintenance work on a variety of equipment. Equipment operators on the PH mezzanine daily perform work on the PH enhancing(PHE) ammonia spargers. Although the PHE ammonia supply valve is closed, it is not locked out. The equipment operators have not been trained on the importance of locking this valve out during service, repair, and maintenance work. This condition was noted on or about 11-20-07.
Citation 2 Item 16
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.147(d)(4)(i): Lockout or tagout devices were not affixed to each energy isolating device by authorized employees:
(a) At the Plant – Employees perform service, repair, and maintenance work on a variety of equipment. Around 7-11-07, a maintenance supervisor loosened bolts and opened a flange on the high pressure receiver ammonia pump out line. This was done to break vacuum, so that the Weiler mixer pump out line could be tied in. Stop valves, on the pump out line, were not locked out on this date.
(b) At the Plant – Employees perform service, repair, and maintenance work on a variety of equipment. On or about 8-31-07, an equipment operator, on the PH mezzanine, performed work on the PH enhancing (PHE) ammonia spargers. Although the PRE sparger ammonia valve was closed, it was not locked out.
(c) At the Plant – The ammonia refrigeration system was being modified. The modification required the cutting of ammonia lines. The ammonia stop valves, on the pump out line near the high pressure receiver, were not locked out to prevent the unexpected release of ammonia. This condition existed on or about 8-31-07.
Citation 2 Item 17
Type of Violation: Willful; $63,000
IAC 875 – Chapter 10
1910.165(b)(1): The employee alarm system did not provide a warning for necessary emergency action as called for in the emergency action plan, or for reaction time for the safe escape of employees from the workplace or the immediate work area, or both:
(a) At the Plant – On 8-3 1 -07, there occurred an uncontrolled ammonia release. The employer’s evacuation signal was supposed to be a ten-second blast on three separate, manually operated air horns. Either the air horns were not used or they were ineffective in warning employees.
Employees did not hear them. Some employees heard about the release over radios. Most employees saw others running and yelling to get out. Some employees did not get the evacuation notice and had to be led out of the plant.
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