The respondent was the owner or operator of the cheese production facility that used anhydrous ammonia in its refrigeration processes. Respondent was required to have a material safety data sheet for anhydrous ammonia under the Occupational Safety and Health Act of 1970, 29 U.S.C. § 651 et seq. , and its associated regulations. Respondent produced, processed, handled, or stored a regulated substance...

The accidents described in this chapter are not due to a fifth type of error. They are due to the failure of senior managers to realize that they could do more to prevent accidents. They are thus mainly due to lack of training, but some may be due to lack of ability and a few to a deliberate decision to give safety a low priority. As stated in Section 5.1, these accidents are sometimes said to be due...

As we have discussed before, energy isolation in a process is VERY DIFFERENT than energy isolation in a manufacturing plant. And the work we do as part of achieving a Zero Energy State (ZES) is the evacuation of hazardous energy. And man, have I seen some hockey setups to evacuate serious hazardous materials! Here is a “hockey” set up involving a flammable petroleum product. What is...

The respondent was an owner or operator of the ice manufacturing facility where anhydrous ammonia is used in the manufacturing of ice. Anhydrous ammonia, CAS #7664-41-7, has a reportable quantity of 100 pounds, as indicated in 40 C.F.R. Part 355, Appendix A. On July 27, 2023, at or about 4:34 a.m. CDT, a release of anhydrous ammonia from the Respondent’s Facility occurred. It was later determined that...

Respondent operated a manufacturing, packaging, and distribution facility that is located immediately across the street from a residential neighborhood, less than a half mile from a high school and several businesses, and approximately a mile from US. Routes 5 and 84 and the Connecticut River. At all times relevant to the violations alleged herein, the Facility’s ammonia refrigeration system (“System”)...

A point has been reached in the development of technology where the greatest dangers stem not so much from the breakdown of a major component or from isolated operator errors, as from the insidious accumulation of delayed-action human failures occurring primarily within the organizational and managerial sectors. These residual problems do not belong exclusively to either the machine or the human domains....

On October 17, 2007, a wiring employee came to a press brake to get more pieces from Employee #1, a press operator. Employee #1 turned and put down a piece, collapsed to the floor, and experienced convulsions. The wiring employee panicked and asked the laser operator for help. The laser operator cleared the area. As he stood from the kneeled position, he also became lightheaded and lost consciousness...

On February 7, 2017, an employee, 50, was making preparations to replace the relief valve of a 1,000-gallon ammonia (NH3) tank. The incident investigation reported that the tank was empty of liquid NH3. However, it contained approximately 80 psi of vapor pressure. The employee set up a 30-gallon drum that contained water and affixed it to the nurse tank by way of a hose. He then turned the relief...

At 8:30 a.m. on May 24, 2018, Employee #1, 45, set up a booth representing the control laboratory for a safety day event at the plant, which involved approximately 1,000 employees, visitors, and vendors. Employee #1 wanted a fog effect at the booth to attract visitors. Employee #1 made plans to have coworker #1 get dry ice for the effect. When coworker #1 could not get dry ice, coworker #1 asked...

I talk a lot about “safe locations” when we discuss Pressure Relief Device (PRD) discharge. The phrase “safe location” is used in just about every PRD RAGAGEP; however, none of them DEFINE or QUANTIFY the phrase, leaving it open to some poor designs. Here is a case where two workers were doing work 30′ under a Rupture Disc discharge. On January 15, 2022, Employee...

We have discussed this many times: far too many employees fail to recognize the proper application of “pounds per square inch” (PSI). In my LOTO training, I spend 15 minutes explaining that even 1.0 PSI can be lethal. This case was brought about by poor planning and a LOTO failure, but it shows that even low PSI can be lethal. On March 25, 2003, two employees were instructed to remove...