OSHA PSM citations @ food processing facility (NH3 & $71K)

OSHA has cited a food processing facility for 13 serious safety and health violations. OSHA opened an investigation at the company, after receiving a complaint about an ammonia leak. Ammonia is used in the refrigeration process in food production facilities. Inspectors found that about eight pounds of ammonia were released March 3, 2015, from a compressor seal leak at the facility. Emergency evacuation procedures were initiated. One employee was taken to a local medical facility for observation but was able to return to work later that day. Eight of the serious violations involved PSM. These include lack of training, failing to conduct periodic evaluations of processes and update procedures, and poor record keeping. OSHA also found the company failed to properly mark doors for emergency exit and did not adequately protect workers from operating machinery parts during service and maintenance. Here is a break down of the citations:

Citation 1 Item 1

Type of Violation: Serious; $5,500

29 CFR 1910.119(d)(3)(ii): The employer did not document that equipment complies with recognized and generally accepted good engineering practices:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of ammonia in that the employer had not documented and implemented compliance with recognized and generally accepted good engineering practices for the marking of Ammonia refrigeration piping and system components to comply with IIAR Bulletin# 114 09/1991; and ANSI A13.1, 2007.

Missing Valve Tag Identifications include but are not limited to 5 sets of the High Gas NH3 Valves; and 2 sets of the Defrost Release Valves.

Citation 1 Item 2a

Type of Violation: Serious; $7,000

29 CFR 1910.119(e)(3)(i): The Process Hazard Analysis did not address the hazards of the process:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of ammonia in that the Process Hazard Analysis did not address the quality of incoming Ammonia.

Citation 1 Item 2b

Type of Violation: Serious; GROUPED

29 CFR 1910.119(e)(3)(iv): The process hazard analysis did not address the consequences of the failure of engineering and administrative controls:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the employer did not verify that the engine room complied with recognized and generally accepted good engineering practices such as IIAR Bulletin #111 06/02; ANSI/ISA; S91.0l-1995 (Identification of Emergency Shutdown Systems and Controls That Are Critical to Maintaining Safety in Process Industries); ANSI/ASHRE-15 2007; ANSI/IIAR 2-2008. The consequences of failure of engineering and administrative controls applicable to the hazards and their interrelationships such as appropriate application of detection methodologies to provide early warning of releases were not implemented to assure that the system operating modes are working at all times, the systems will reliably function when the need arises, and how to address in case the system is not properly working.

Inspection, testing, and calibrating the controls was not conducted in 2012 for the Honeywell E/C-P2 Smart Cell – Ammonia Smart Sensor Module; and in 2014, 2015 for the Gas Guard NH3 Ammonia Sensor.
The GasGuard NH3 Ammonia Sensor in the Baked-Plant Engine Room was mounted at 7 feet 6 inches while the Manufacture Operating and Installation Manual states for optimum personnel protection mount the sensor at a height in the breathing zone of the employees and within 30 feet of potential leak sources.
There is only one ammonia detector installed in the engine room to accommodate for the emergency ventilation control and for machinery room electrical shutdown while it was suggested that at least two detectors/sensors must be installed.

Citation 1 Item 2c

Type of Violation: Serious; GROUPED

29 CFR 1910.119(e)(5): The employer did not establish a system to assure that the recommendations were resolved in a timely manner and that the resolution was documented:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the employer did not document the resolution of action items from the 2011 Process Hazard Analysis for the Ammonia Refrigeration processes. A system was not established/created to promptly address all the findings and recommendations.

Citation I Item 2d

Type of Violation: Serious; GROUPED

29 CFR 1910.119(e)(6): The employer did not update and revalidate by a team meeting the requirements in paragraph (e)(4) of this section, to assure that the process hazard analysis is consistent with the current process, at least every five (5) years after the completion of the initial process hazard analysis:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the employer did not provide documentation such as but not limited to the What-If/Checklist Log Sheet and the final reports with findings and recommendations to demonstrate that it had performed updates and revalidations to assure that the process hazard analysis for the Ammonia Refrigeration processes is consistent with the current process, from 1999 when it developed its Process Safety Management program, to the present, except for 2011. There was no document for the updates in between of every five-year time frame.

Citation 1 Item 3a

Type of Violation: Serious; $7,000

29 CFR 1910.119(f)(1): The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process:

The employer did not develop a written operating procedure or a task procedure with clear instructions as when/what conditions to use, how to use it, and who is authorized to activate the Ammonia Emergency Shut-Off button in case of Ammonia leaking related to the intended use of the emergency stop buttons located outside each exit of the engine rooms.
The employer did not develop written operating procedures for the following process equipment Baked Plant Unit CS14; CS22; CS23; CS24; AP3; AP4; Vl-HPR; V2-RECIRCULATOR; V3-RECIRCULATOR; CS21; GPI; Baked Plant Unit-FRICK Compressors Cl, C2, and C3.
The employer did not develop written operating procedures with clear instructions for receiving Ammonia which addresses quality control for raw materials and control of hazardous chemical inventory levels of the incoming Ainrnonia as how to receive fresh or make-up Ammonia.

Citation 1 Item 3b

Type of Violation: Serious; GROUPED

29 CFR 1910.119(F)(1)(i)(D): The employer did not develop and implement written operating procedures that provide clear instructions for emergency shutdown; including the conditions under which emergency shutdown is required, and the assignment of shutdown responsibility to qualified operators to ensure that emergency shutdown is executed in a safe and timely manner:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that all of the current operating procedures for ammonia process equipment including but not limited to the Frick Ammonia Screw Compressor OP-C-4, OP-C-5, and OP-B-1 did not reflect any discussion about the handling of the emergency situation.

The operating procedures did not include information explaining how to determine when it is safe to enter the engine room or what personal protective equipment to wear before entering to isolate the leaking equipment.

On or about March 03, 2015, Baked Plant/Engine Room, an employee entered the engine room to perform valve closing to isolate the gasket leaking at the C-4 compressor. The employee was exposed to hazards in that a portable ammonia detector was not utilized to assess the unknown ammonia concentration levels prior to performing the task.
On or about March 3, 2015, Baked Plant/Engine Room, an employee entered the engine room to performed valve closing to isolate the gasket leaking at the C-4 compressor. The employee had a full beard while wearing a full-face respirator. Employee was exposed to respiratory hazards in that an efficient seal was not established to protect him from exposure to the unknown ammonia concentration levels.

Citation 1 Item 3c

Type of Violation: Serious; GROUPED

29 CFR 1910.119(f)(1)(iii)(D): The employer’s written operating procedures covering operating limits did not address quality control for raw materials and control of hazardous chemical inventory levels:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the employer did not develop written operating procedure such as Receiver Charging (Procedures for inbounding/receiving Ammonia) which addresses quality control for raw materials and control of hazardous chemical inventory levels of the incoming Ammonia as how to receive fresh or make-up Ammonia. The written procedure shall explain how to verify that the Ammonia received is refrigerant grade, how to manage the receipt, and what the physical connection to the system is.

Citation 1 Item 3d

Type of Violation: Serious; GROUPED

29 CFR 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, and changes to facilities. The employer did not certify annually that these operating procedures were current and accurate:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the current written operating procedures for the Ammonia process equipment including but not limited to the following were not reviewed and certified annually to assure that they reflected current and accurate operating practice:

a) Evapco – OP-CSl, 2012, 2013, 2014
b) Evapco – OP-CS2, 2012, 2013, 2014
c) Spiral – OP-CS3, 2012, 2013, 2014
d) Packing Room – OP-CS5, 2012, 2013, 2014
e) Packing Room – OP-CS6, 2012, 2013, 2014
f) Spiral – OP-CS7, 2012, 2013, 2014
g) Evapco – OP-CS8, 2012, 2013, 2014
h) Evapco – OP-CS9, 2012, 2013, 2014
i) Evapco – OP-CSlO, 2012, 2013, 2014
j) Evapco – OP-CSll, 2012, 2013, 2014
k) Evapco – OP-CS12, 2012, 2013, 2014
1) Evapco – OP-CS14, 2012, 2013, 2014
m) Evapco – OP-CS15, 2012, 2013, 2014
n) Evapco – OP-CS16, 2012, 2013, 2014
o) Evapco – OP-CS17, 2012, 2013, 2014
p) Evapco – OP-CS18, 2012, 2013, 2014
q) Spiral Pack-Off- OP-19, 2012, 2013, 2014
r) Spiral Pack-Off – OP-20, 2012, 2013, 2014
s) Evaporators/Evapco TFCS5-15510VF-10L- OP-25, 2012, 2013, 2014
t) Evapco – OP-CS29, 2012, 2013, 2014
u) Evapco – OP-CS30, 2012, 2013, 2014
v) Evaporators – OP-31, 2012, 2013, 2014
w) Evaporators – OP-33, 2012, 2013, 2014
x) Imeco Evaporative Condenser/1994 Plant – OP-EC-1, 2012, 2013, 2014
y) Imeco Evaporative Condenser/1994 Plant – OP-EC-2, 2012, 2013, 2014 ·
z) Imeco Evaporative Condenser/1994 Plant – OP-EC-3, 2012, 2013, 2014
aa) + 10 V-2 High Recirculator Pump AP-1/1994 – OP-AP-1, 2012, 2013, 2014
ab)+ 10 V-2 High Recirculator Pump AP-2/1994 – OP-AP-2, 2012, 2013, 2014

Citation 1 Item 4a

Type of Violation: Serious; $7,000

29 CFR 1910.119(g)(1)(i): The employer did not train each employee involved in the operating process, in a overview of the process and in the operating procedures as specified in paragraph (f) of 29 CFR 1910.119:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the employer did not provide training for the Refrigeration Department employees regarding specific safety and health hazards, emergency operations to include shut down and safe work practices related to their assigned duties and responsibilities to perform tasks in the ammonia process. Ammonia Technician employees have not
received the required knowledge, skills, and abilities including but not limited to the training on the Baked Plant site-specific operating procedures; safe work practice such as lockout/tagout; opening process equipment or piping (Line Break Procedure).

Citation 1 Item 4b

Type of Violation: Serious; GROUPED

29 CFR 191O.119(g)(2): Refresher training was not provided at least every three years, and more often if necessary, to each employee involved in operating a process to assure that the employee understands and adheres to the current operating procedures of the process. The employer, in consultation with the employees involved in operating the process, shall determine the appropriate frequency of refresher training:

Citation 1 Item 4c

Type of Violation: Serious

29 CFR 1910.119(g)(3): The employer did not prepare a record which contained the identity of the employee, the date of training, and the means used to verify that the employee understood the training:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the following was not provided:

The employer provided operating procedures for ammonia refrigeration equipment, but did not provide ai1y documentation of training for the Ammonia Technician employees.
The employer did not provide any documentation of the means that the employer used to verify through demonstration that the Ammonia Technician employees understood any training they received including but not limited to the training on the Baked-Plant site-specific standard operating procedures; startup and shutdown; safe work practice such as lockout/tagout; opening process equipment or piping (Line Break Procedure).

Citation 1 Item 5

Type of Violation: Serious; $3,300

29 CFR 1910.119(h)(2)(i): The employer, when selecting a contractor, did not obtain and evaluate information regarding the contract employer’s safety performance and program:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the employer did not obtain and evaluate the safety and health performance and written programs of the contractor that delivers or unloads ammonia from a tank truck to the ammonia refrigeration system.

Citation 1 Item 6a

Type of Violation: Serious; $7,000

29 CFR 1910.119(j)(2): The employer did not establish or implement written procedures to maintain the on-going integrity of process equipment:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the employer did not establish and implement the written mechanical integrity program procedures to ensure the on-going integrity of process equipment such as pressure vessel, storage tanks, piping, emergency shutdown equipment, controls (monitors, high level alarms), relief venting equipment, and pumps. The employer did not address procedures for repairing, rerating, or replacing pressure vessels, receivers, piping, or materials and spare parts control, authorizations, and approval for repairs, steps to accomplish for repairing or replacing equipment, frequency of replacement, employee training and qualifications, welding and heat treating requirements, inspection and testing after repair, and documentation requirements.

The employer did not develop and implement a comprehensive written mechanical integrity procedure that addressed inspecting pressure vessels, piping for corrosion under the insulation and minimum wall thickness.
The employer did not develop and implement a written mechanical integrity procedure for evaluating valves such as the King valve in the ammonia process.
The employer did not develop and implement a written mechanical integrity procedure for evaluating relief and vent systems and devices.
The employer did not develop and implement a written mechanical integrity procedure for evaluating emergency shutdown systems.
The employer did not develop and implement a written mechanical integrity procedure for evaluating controls (including monitoring devices and sensors, alarms, and interlocks).
The employer did not develop and implement a written mechanical integrity procedure for evaluating pumps.

Citation 1 Item 6b

Type of Violation: Serious

29 CFR 1910.119(j)(3): The employer did not train each employee involved in maintaining the ongoing integrity of process equipment in the procedures applicable to the employee’s job tasks to ensure that the employee can perform the job tasks in a safe manner:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the employer did not provide training for refrigeration employees related to the maintenance activities for the process covered-equipment; the inspection, testing and preventive maintenance procedures applicable to the employee’s job tasks.

Citation 1 Item 6c

Type of Violation: Serious;

29 CFR 1910.119(j)(4)(i): Inspections and tests were not performed on process equipment to maintain its mechanical integrity:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the following inspections and tests were not performed:

Inspection and testing was not performed for emergency shutdown systems including but not limited to the King valves.
Inspection and testing was not performed for vessels and tanks such as Evaporators, Auto purgers, High Pressure Receiver VI, and Condensers.
Non-destructive testing on the pressure vessels or ammonia piping lines in the process was not performed.

Citation 1 Item 6d

Type of Violation: Serious

29 CFR 1910.119(j)(4)(iii): The frequency of inspections and tests of process equipment to maintain its mechanical integrity, was not consistent with applicable manufacturer’s recommendations and good engineering practices, or more :frequently determined to be necessary by prior operating experience:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that inspections and tests have not been performed and documented based on the appropriate inspection frequency required by the employers mechanical integrity inspection program or the applicable manufacturers’ recommendations and good engineering practices for the following process equipment:

Frick Ammonia Screw Compressors only have records of Daily Rounds and Annual inspection. There were no records showing other various inspections have been performed for four times per year or every 1000, 5000 hours.
Krack Evaporators only have records of Daily Rounds. There were no records showing other various inspections have been performed for 0.2, 1, 2, 12, or 52 times per year.
Imeco Condensers only have records of Daily Rounds. There were no records showing other various inspections have been performed for 0.02, 1, 2, 4, 12, or 52 times per year.
Teikoku Ammonia Pumps only have records of Daily Rounds. There were no records showing other various inspections have been performed for 0.2, 1 or 12 times per year.
IFS V-1 High Pressure Receiver only has records of Daily Rounds. There were no records showing other various inspections have been performed for 0.2, 1 or 52 times per year.

Citation 1 Item 7a

Type of Violation: Serious; $7,000

29 CFR 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:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the employer had not implemented the management of change program to address changes to the Ammonia process; there have been several changes to the processes such as but not limited to the following:

MOC 2014-1, the employer submitted a document on 7-17-2014 for adding 2 of the 2″ Hansen Globe Valves to Hot Gas Header Baked Plant, the document is incomplete in that the employer could not provide document to support that Standard Operating Procedures had been changed; the Process Safety Information such as P&IDs have been updated with the new valves on the drawings; and the Ammonia process employees (Refrigeration Specialists) have been trained.
MOC 2014-2, the employer submitted a document on 2-06-2014 for replacing the Booster Compressor for more capacity (30hp – 58hp), the document is incomplete in that the employer did not fill out all the yes/no questions on the second section of the form. The employer could not provide document to support that the Process Safety Information have been updated; and the Refrigeration Specialists have been trained.
MOC 2014-3, the employer submitted a document on 3-10-2014 for removing the flanges on liquid line and check valves to roof to reduce potential leaks inside plant, the document is incomplete in that the employer could not provide document to support that the Process Safety Information such as P&IDs have been updated with the removing items on the drawings; and the Refrigeration Specialists have been trained about the changes.
MOC 2014-2, the employer submitted a document on 12-04-2014 for replacing the C-1 Compressor loader un-loader valve with different name brand (Vickers to Yuken), the document is incomplete in that the employer could not provide document to support that the Process Safety Information such as P &IDs have been updated with the replacing valves on the drawings; and the Refrigeration Specialists have been trained about the changes.
The employer did not have any management of change (MOC) documentation for the stripping off/removal of insulation, and the replacing the new piping in 2013.
The employer did not have any management of change (MOC) documentation for the installation of the Ammonia Emergency Shut-Off button and the Exhaust Fan switch outside of the engine room.

Citation 1 Item 7b

Type of Violation: Serious; GROUPED

29 CFR 1910.119(l)(5): A change covered by this paragraph resulted in a change in the operating procedures or practices required by paragraph (f) of this section, and such procedures or practices were not updated accordingly:

Employees engaged in production activities throughout the facility were exposed to chemical hazards associated with the catastrophic release of Ammonia in that the employer did not update current standard operating procedures and practices related to the installation and intended use of the Ammonia Emergency Shut-Off devices located outside of the engine rooms. All of the current emergency shutdown procedures within the standard operating procedures including but not limited to the Frick Ammonia Screw Compressor OP-C-4, OP-C-5, and Booster Compressor OP-B-1 did not reflect any discussion about the emergency shutdown devices.

Citation 1 Item 8a

Type of Violation: Serious; $3,300

29 CFR 1910.119(o)(1): The employer did not certify that they had evaluated compliance with provisions of 29 CFR 1910.119 at least every three years to verify that the procedures and practices developed under this standard were adequate and are being followed:

The employer provided no certifications that it had performed compliance evaluations to verify that its procedures and practices developed under the standard are adequate and being followed for the 2009 PSM Compliance Audit.
The employer provided no certifications that it had performed compliance evaluations to verify that its procedures and practices developed under the standard are adequate and being followed for the 2012 PSM Compliance Audit.

Citation 1 Item 8b

Type of Violation: Serious;

29 CFR 1910.119(o)(4): The employer did not promptly determine and document an appropriate response to each of the findings of the compliance audit, and document that deficiencies have been corrected:

The employer did not document the corrective actions pending or taken in relation to each of the deficiencies noted from the 2009 PSM Compliance Audit.
The employer did not document the corrected deficiencies from the 2012 PSM Compliance Audit. The audit has uncompleted findings, and the current status is unknown.

Citation 1 Item 9

Type of Violation: Serious; $7,000

29 CFR 1910.134(c)(1): The employer did not establish and implement a written respiratory protection program.with worksite-specific procedures in any workplace where respirators were necessary to protect the health of the employee or whenever respirators were required by the employer:

On or about March 3, 2015, An employee engaged in maintenance activities in the Bake Plant Engine Room, for the purpose of valve closure in order to isolate a leaking gasket at the C-4 compressor, was exposed to inhalation and chemical hazards in that a written respiratory program was not provided

Citation 1 Item 10

Type of Violation: Serious; $3,300

29 CPR 1910.147(c)(6)(ii): The employer did not certify that periodic inspections of the energy control procedures had been performed:

Employees perform servicing and maintenance activities on equipment including, but not limited to the AU Unit (LO/T0-94-CSl); the Vessel (LO/TO-P004); the Vessel (LO/T0-94-V-1); and the Pump (LO/TO-AP-1) were exposed to hazards associated with the unexpected energizing or start-up of equipment in that periodic inspections of energy control procedures for equipment were not performed nor documented.

Citation 1 Item 11

Type of Violation: Serious; $3,300

29 CFR 1910.305(a)(1)(i): Metal raceways, cable armor, and other metal enclosures for conductors were not connected to all boxes, fittings, and cabinets to provide effective electrical continuity:

Employees engaged in production and maintenance activities on the rooftop of Baked Plant were exposed to electrical shock hazards in that the metal raceway for the electrical conductors connected for the Hansen valve was broken exposing live conductors. The broken raceway no longer effectively bonded to ensured electrical continuity.

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