A refrigeration warehousing company, which refrigerates various food products and citrus extract/oils and employs approximately 200 workers was cited for 13 safety violations, including one willful violation, for failing to follow the industry recognized and generally accepted good engineering practices for insulation removal and for failing to test the ammonia refrigeration system piping and pressure vessels. Twelve additional serious violations involve failing to maintain accurate and complete piping and instrument diagrams of the ammonia refrigeration systems, not completing actions items on the process safety hazard analysis and not training permanent and temporary workers on the emergency evacuation plan and alarm system for fire and ammonia releases. The facility employs temporary workers from two staffing agencies. The staffing companies do not supervise employees. Facility management is in charge of managing and has direct control of the temporary workers. OSHA did not issue citations to the staffing agencies. Here is breakdown of the citations:
Citation 1 Item 1
Type of Violation: Serious; $3,600
29 CFR 1910.36(g)(2): Exit access(es) were not at least 28 inches (71.1 cm) wide at all points.
a) For the T5/T6 ammonia refrigeration facility, exit aisles in the warehouse areas such as freezer #2 were blocked by pallets of material. At multiple locations, it was impossible to fit through/past material staged in aisles resulting in the emergency exit access being blocked.
Citation 1 Item 2
Type of Violation: Serious; $4,500
29 CFR 1910.119(d)(3)(i)(B): The employer’s piping and instrument diagrams were not accurate and did not represent equipment that was existing and was part of the process:
The piping and instrumentation diagrams for the ammonia refrigeration process were incomplete and inaccurate in that:
a) Spring-loaded self-closing valves at oil pots were not depicted on the process and instrumentation diagrams.
b) Electrical control schemes for accumulator and intercooler high level control cutoffs were not depicted on the process and instrumentation diagrams.
c) Electrical emergency shutdown systems for T6-north and T6-south engine rooms were not depicted on process and instrumentation diagrams.
d) Piping changes connecting T6-North and T6-South refrigeration systems to TS refrigeration system were not depicted on process and instrumentation diagrams.
e) Solenoid valve additions and control schemes to control the flow of ammonia between T6-north, T6-south, and TS ammonia systems/engine rooms were not depicted on process and instrumentation diagrams.
f) TS engine room equipment was not included in the process and safety instrumentation diagrams.
g) Gauges for measurement of temperature and pressure were not depicted on the process and instrumentation diagrams.
Citation 1 Item 3
Type of Violation: Serious; $4,500
29 CFR 1910.119(d)(3)(i)(D): The employer did not include, in the process safety information compilation, the relief system design and the design basis:
a) Information on the design basis of the relief system was not available such as, but not limited to, calculations to show that the relief valves’ sizing and the relief piping sizing were of a safe design to handle all potential release scenarios.
Citation I Item 4
Type of Violation: Serious; $4,500
29 CFR 1910.119(d)(3)(ii): The employer did not document that equipment complies with recognized and generally accepted good engineering practices:
a) Pressure vessels in the engine rooms such as, but not limited to, the T6-North were operated at temperatures below their minimum design metal temperature.
b) Ammonia detectors were not interlocked to ventilation fans in engine rooms, and ventilation fans in engine rooms did not have an interlocked supervisory alarm that would sound if the ventilation fans shut off.
c) Remote actuation of ventilation system, outside of engine room, was not available. The only way to turn on fans was from a breaker inside the engine rooms.
d) Ammonia relief vent discharge was located at a height of 19-20 ft. above ground and only 9-12 ft. from the T6 north engine room’s ventilation intake while the employer’s process safety information stated that the relief discharge shall not be within 20 feet of a ventilation intake. This location exposed employees working outside in the area around the high pressure receiver, the condensers, and at the engine room entrance door to potential ammonia concentrations above ammonia’s IDLH, 300 ppm. The relief discharge’s location also resulted in the potential for ammonia vapors to be pulled back into the engine room from the ventilation intake.
Citation 1 Item 5
Type of Violation: Serious; $4,500
29 CFR 1910.119(e)(5): The employer did not establish a system to promptly address the team’s findings and recommendations; assure that the recommendations were resolved in a timely manner with documented resolutions; document the actions that were to be taken; complete actions as soon as possible; develop a written schedule of action completion dates; or communicate the actions to operating maintenance, and other employees working in the process areas or who may have been affected by the recommendations or actions:
PHA action items that had been initiated in 2007 and 2012 were still not resolved.
There was no system in place to track these items, no expected completion dates, no designation of who the responsible party was, and no priority ranking.
The following action items were still not completed:
a) Single relief valves were not all replaced with dual relief valves – 2007 PHA-Action Item #1
b) Maintenance and calibration of ammonia detectors had not been accomplished – 2007 PHA – Action Item #4
c) Ammonia detectors had not been installed in the warehouse areas – 2007 PHA – Action Item #5
d) Equipment still had single relief valves and a written isolation and change-out procedure had not been established – 2012 PHA – Action Item #2
e) Ammonia detectors had still not been installed and the existing one in T6 engine room north (only detector on site) had not been calibrated. – 2012 PHA- Action Item #7
f) The employer’s emergency action plan (EAP) did not comply with 1910.38 in that there was no alarm system for an ammonia release, no alarm system for a fire that was audible in the freezers, and the EAP did not have procedures to describe how refrigeration employees were to distinguish between a small leak that they could isolate and a larger leak that required evacuation. 2012 PHA- Action Item #11.
Citation 1 Item 6
Type of Violation: Serious; $4,500
29 CFR 1910.119(f)(1): The employer did not develop and implement written operating procedures that provided clear instructions for safely conducting activities involved in each covered process consistent with the process safety information and addressing at least steps for each operating phase, safe operating limits, safety and health considerations, and safety systems and their functions as outlined by this paragraph:
Complete and clear operating procedures for the following employee process activities were not developed and implemented for using new computerized G-force compressor control panels.
Citation 1 Item 7
Type of Violation: Serious; $4,500
29 CFR 1910.119(:f)(3): The employer did not certify that operating procedures were current and accurate:
a) The employer did not annually certify operating procedures for its T5/T6 anhydrous ammonia refrigeration process.
Citation 1 Item 8
Type of Violation: Serious; $4,500
29 CFR 1910.119(f)(4): The employer did not develop and implement safe work practices 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) Safe work procedures were not developed for operational activities that resulted in the opening of the ammonia process such as draining/purging of oil.
Citation 1 Item 9a
Type of Violation: Serious; $4,500
29 CFR 1910.119(i)(1): The employer did not perform a pre-startup safety review for new facilities and for modified facilities when the modification was significant enough to require a change in the process safety information.
a) A pre-startup safety review was not conducted when the TS ammonia refrigeration system had its high pressure receiver removed, condensers taken out of service, and new piping and solenoid valves installed to connect the TS system to the T6-North and T6-South high pressure receivers.
Citation 1 Item 9b
Type of Violation: Serious; Grouped
29 CFR 1910.119(l)(1): The employer did not implement procedures to manage changes to process chemicals, technology, equipment, and procedures, and changes to facilities that affect a covered process:
Management of change procedures were not implemented for the following technological and equipment changes that were conducted on the system:
a) Changes were made to compressor control panels in that replacement/upgrading of the Mycom compressor control panels with G-force panels started in 2012 and is being continued to present day.
b) In 2012, the TS engine room was connected to the T6 north and south engine rooms. This resulted in the eliminating of the TS receiver, compressor, and their associated valves and piping in TS engine room. It also involved the installation of piping and valves connecting T6 north and south process piping to TS process piping and pressure vessels and the addition of solenoid valves to control the distribution of ammonia between engine rooms.
Citation 1 Item 10a
Type of Violation: Serious; $4,500
29 CFR 1910.119(j)(2): The employer did not implement written procedures to maintain the on-going integrity of process equipment:
Preventative maintenance/mechanical integrity procedures were not implemented, in that, equipment was not serviced on a programmed basis as established by PM/mechanical integrity procedures; rather, equipment was serviced as needed when it failed. Equipment such as, but not limited to, the following were not inspected or serviced in accordance with the employer’s mechanical integrity program:
a) Compressors oil quality was not analyzed
b) Heat exchanger/condenser tubes were not inspected/cleaned at least monthly
c) Compressor high pressure safety cutoffs were not tested at least bi-annually
d) Pressure vessels such as intercoolers and accumulators were not inspected or tested to determine the condition of their wall thickness.
Citation 1 Item 10b
Type of Violation: Serious; Grouped
29 CFR 1910.119(j)(4)(iv): The employer did not document each inspection and test that was performed on process equipment wherein the documentation identified the date of the inspection or test, the name of the person who performed the inspection or test, the serial number or other identifier of the equipment on which the inspection or test was performed, a description of the inspection or test performed, and the results of the inspection or test.
Preventative maintenance/mechanical integrity inspections of process equipment were not documented. Mechanical integrity inspection/testing documentation for serviced equipment such as, but not limited to, the following were not available:
a) Inspections of piping insulation were not documented.
b) Vibration inspections/analysis of compressors were not documented.
c) Annual testing of compressor float switches, alarms, and cutoffs were not documented.
d) Changing of compressor oil was not documented.
Citation 1 Item 11
Type of Violation: Serious; $4,500
29 CFR 191O.119(n): The employer did not establish an emergency plan for the entire plant in accordance with the provisions of 29 CFR 1910.38:
a) The emergency plan was not reviewed with all employees. multiple employees at the facility were not aware of the exit procedures, where the evacuation point was, or who they were supposed to report to in event of an evacuation.
b) There was no alarm system to indicate an ammonia release and fire alarms were only visible/audible on the docks, not in the warehouse freezers/coolers.
Citation 1 Item 12
Type of Violation: Serious; $4,500
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:
a) Eyewash/shower stations were not accessible in the work area in that eyewash/shower stations were not located within ammonia refrigeration engine rooms where refrigeration technicians worked.
Citation 2 Item 1
Type of Violation: Willful; $63,000
29 CFR 1910.119(j)(4)(iii): The frequency of inspections and tests of process equipment was not consistent with applicable manufacturers’ recommendations and good engineering practices, and more frequently if determined to be necessary by prior operating experience.
Piping inspection, pressure vessel inspections and tests were not consistent with good engineering practice in that:
a) Refrigerant piping with compromised vapor seal and visibly damaged insulation was not inspected for corrosion damage nor was its insulation repaired. It was observed on site that in engine room T6 North, TS, and for multiple refrigerant piping for evaporators in T5 and T6, insulation was damaged, severe icing was present, and process vessels such as the intercooler in TS engine room had extensive corrosion present underneath its insulation.
b) Non-destructive testing had not been implemented for insulated ammonia piping and pressure vessels since the process was initiated in 1996-1997. Severe icing was present, melting, icing, and remelting was observed, insulation was damaged its vapor barrier removed, and insulation was wet to the touch in that water had absorbed through it. No testing had been done to determine the integrity of the piping of process vessel walls underneath the damaged insulation.
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