Point -Counter Point PSM Discussion. Below is my position and counter to “my opinion” is that of a friend who specializes in PSM for the refrigeration industry. You can read his position at his website taocomplaince.com
Scenario: You have a freezer with racking. The racking inside this freezer needs to be replaced. You hire a contractor to do the job. You evaluate and train the contractor as a PSM Contractor. In the midst of removing the racking, the contractor strikes some NH3 piping above the racking with a forklift and causes an ammonia release. NOTE: the piping in this scenario is 18″ above the rack and against the wall and ceiling, but not protected in anyway. The driver of the forklift was trained for the forklift he was operating. The racks were used to store products that were handled by hand – not by forklift, so the forklift being used to remove the racks is only in the freezer to remove the existing racking and install the new racking.
The above scenario was presented to me with the question “does this work/project require a Management of Change (MOC) because of the close proximity of the racking to the Ammonia piping?
I was a bit taken back by the number of PSM professionals who stated they would have done an MOC and/or a PHA to move these storage racks out of the freezer. I am not saying this is a bad thing, but if a large segment of PSM professionals feel this scenario kicks in those two activities, there’s no wonder so many facilities hate PSM/RMP. Let me explain why I believe this scenario does NOT trigger an MOC or a PHA and then I will try to convince you that although the PSM/RMP regualtory language does not specifically call out “Safe Work Permits” and “JSA/JHA”, these are the two tools needed in this type of situation.
First let me make a statement…
The “safety of our process” is NOT the same as saying “process safety”. We have one set of tools to manage our “process safety” and we must have another set of tools to protect the “safety of our process”. The MOC tool belongs in our “process safety” tool box and we have to look outside the traditional PSM/RMP compliance program for tools that will aid us in “protecting our process”.
I see this incident occurring, not because of the actual change that was occurring, but rather we did not “protect our process” while the change was being made. Taking these ordinary everyday racks out of this freezer was in NO WAY going to impact our “process safety”, but the act of removing these racks was going to impact our ability to “protect our process”.
First, let me state my case as to why I believe an MOC is not needed and why the vast majority of MOCs I have used and audited in 20+ years would be of little to no value in preventing this incident. The MOC spelled out in OSHA’s PSM and EPA’s RMP were designed to examine the impact on process chemicals, technology, equipment or facilities. There have been a lot of professionals responding to this scenario who feel that the removal of the racks out of a freezer needed a MOC because of the close proximity of the HHC/EHS piping (NH3 in the scenario). If you are in the camp that agrees this project needs an MOC, think about this, if we are expected to do an MOC anytime a contractor, maintenance, or operations personnel COULD come into contact with a pipe/vessel that contains an HHC/EHS, most of us would be so overwhelmed we would be drowning in paper work of little to no value. Let me be clear here, I am NOT saying or trying to imply the MOC process is nothing more than paperwork, or that the MOC process has no value. I am saying that doing an MOC on every situation like this will diminish the significance of true changes that need a thorough review. We will be so buried by all the MOCs that are not actually needed that we will not have the time or resources to devote to actual process changes. There is a HUGE difference between making a change that will impact “process safety” and having a failure to “protect the process” while implementing that change. Simply removing this racking from the freezer will have NO impact on process chemicals, technology, equipment or facilities. There may be risk in the act of removing the racking, but that risk in of itself does NOT trigger an MOC. There are literally hundreds of high risk activities taking place each day/week/month that could cause a release of our HHC/EHS and to imply that a MOC is the tool to control these high risk and non-routine activities is forcing the use of an incorrect tool. An MOC is a tool to review changes to our process, not to control the work activities involved in making the change.
Would I have done a PHA on the removal of these racks? Nope! As I said above, the removal of these racks will have NO impact on process chemicals, technology, equipment or facilities. When we conduct a PHA we are looking for process deviations that could result in a release of our HHC/EHS. Now I will grant you that the original PHA or any revalidation that had been done since these racks were installed in the freezer (also not an MOC activity), the “facility siting” review should have included an examination of external forces that could impact the process. And with a refrigeration system, a siting study can be far reaching into areas some personnel never even considered a PSM covered area. It is in this original PHA or a later revalidation that we should have examined these external forces and taken action to protect from external forces (e.g. forklifts in this scenario, but it will often include cranes making a lift over a live process and other powered and manual equipment traffic). But to do a PHA for the removal of the racks from a freezer is a bit much, and again, if we are expected to do a PHA (and to do it right) we would never have time to do any work as we would always be examining these types of scenarios day and night using the MOC and PHA tools.
So how would I have managed this work inside one of my process battery limits?
1) Placing any type of racking around HHC/EHS piping would have been rejected from the get go. This is not to say I’ve never found objects (i.e. racking) around the HHC/EHS piping; but as soon as we discovered the issue in our routine auditing of process area(s) it was addressed. We did not just move the racking away from the piping! Often times we saw this as a design flaw of how our piping was routed through the area. We were never so naive as to think “we moved the racking and no one will ever put it there again”. We took the approach that we were LUCKY this time but we need to ensure that we do NOT rely on luck again; so we would more than likely move the piping so that it is rerouted from the area and just let production or maintenance have the area to do with as they wish. This meant getting the piping out of the room, which we usually did this by moving the run of pipe on the other side of the wall or across the roof and then drop the pipe through the ceiling directly over the equipment. Keep in mind, this still may not be enough and when you run pipe outside, the Mechanical Integrity inspection protocol may be a bit different than when it was run inside the building. (NOTE: all of this redesign is done under an MOC and it may involve a PHA depending on all the factors involved) Of course we cannot reroute every run of pipe in a facility, so sometimes we will need to guard the piping in place. Most of my facilities had a pipe guarding spec based on the Hazard Level of the pipe circuit in question. This was based on the consideration for the results of a pipe failure incident (e.g. a 3” liquid NH3 pipe in an occupied room will get more protection than a 1/4” pipe of hot gas on the roof). This guarding was not just put in place; it was painted high visibility yellow and labeled with the pipe contents by name and NFPA 704 Diamond. The guarding was added to the shift inspection so that it was inspected like all the other guards on production equipment in the area. Any damage to these guards would be investigated – not as a “nearmiss” but as a more significant level we called “property damage”. Yes, we would raise the level of investigation, the same way we would raise it if one of our machinery guards were damage by a forklift. But bottom line, our HHC/EHS piping must be treated with the utmost respect by maintaining a safe distance. Too often, the racking that was asked to be placed there was for “hand held” objects, only to become pallets of materials later on. By having the simple policy and engineering standard that nothing can be placed within XX’ of a vessel or pipe containing a HHC/EHS or a critical utility (natural gas, fire water, etc.) it prevents a lot of these situations. So for me, the first failure of this incident is “PROCESS DESIGN”, by allowing racking to be placed in close proximity to this piping.
2) Job Planning – EVERY NON-ROUTINE TASKS that takes place in a facility that has a process covered by PSM/RMP should be considered a hazardous activity. The ONLY exceptions that we make to this rule is within the Admin areas and parking lots; but even then, if the HHC/EHS runs through these areas, then even non-routine tasks done in these normally low hazard locations BECOMES HIGH HAZARD WORK and would require a “Job Plan” (as well as other items to be discussed later in this article). This is often called a “pre-bid” meeting if contractors are being hired for the work; but if it will be facility personnel doing the work, the personnel will still meet with their supervisor and anyone else involved in the scope of work to discuss potential hazards and safe guards needed for the scope of work. So unless there is an operating procedure or maintenance procedure for removing and installing this racking inside this freezer, this would be a NON-ROUTINE TASK. Here is the tricky part, more often than not this meeting focuses on “worker safety” and not “process safety”. In the job planning meetings, a walk-down of the scope of work with the supervisor responsible for the racks and the area will hopefully (!!!!!) identify the HHC/EHS piping in the freezer and its close proximity to the racks. Notice I said “hopefully”; so it should be obvious I am not putting all my eggs in one basket and hanging my supervisor out there as the scape goat. But for the sake of this scenario, let’s say it is missed in the Job Planning review, what next?
3) Safe Work Permit – Although not specifically required for PSM/RMP compliance, many facilities have come to the conclusion that a “Safe Work Permit” for ALL NON-ROUTINE WORK (defined as any work that is NOT specifically guided by an approved SOP or Maintenance Procedure) is a tool they cannot do without! It is not the answer to all our problems with “non-routine” work taking place on, in or adjacent to our process, as it is just an administrative control; but it sure is a nice layer of protection to ensure non-routine work is closely examined and monitored by those responsible for the area where the work is taking place. It is the issuing of this work permit, to both contractors and in-house personnel, that will REQUIRE a thorough examination of the tools, equipment, and personnel that will be used to do the “permitted work” (i.e. removing these racks from the freezer). It is this safe work permit that will trigger the JSA/JHA type step-by-step review for the removal of these racks which will include a review of all the tools and equipment the personnel will be using.
Before I go further into this, I need to explain the differences in a PHA and a JHA (Job Hazard Analysis). Using my example of “process safety” is different than “protecting my process” a PHA is a tool for us to examine deviations from our process that could lead to a release of our HHC/EHS. A JHA is a detailed examination of activities that take place within our process battery limits that could impact the “safety of our process”. A facility could do a “what-if” on the rack removal, but it is of my opinion the JHA is a better tool for the specific task of removing this racking. Merely placing or removing racking near our HHC/EHS piping will have no impact on our “process safety”, but it could impact the “safety of our process”, thus the difference in tools needed for the applicable hazards.
I have come to the conclusion there are two (2) safe options for this scope of work:
- evacuate and isolate the HHC/EHS (e.g. ammonia in this case) from the pipe that is exposed to the forklift (PIT) contact and lock it out so that we can be certain that if the PIT strikes the pipe it will not result in an immediate release; however, with this option we will still be exposed if the PIT does strike the pipe and the personnel doing the work do not feel the incident warrants reporting. When the isolation is removed we could have a release from the damaged piping! This also may not be a viable option if the freezer needs to remain at temperature; but even then, every effort should be made to reschedule the project so that we can evacuate and isolate this line that is only 18” away from the racking.
- breakdown the racking by hand inside the freezer and stack it outside the freezer where the PIT can safely operate well away from any HHC/EHS piping. Of course there are inherent risks by doing this work by hand in freezing temperatures and these needs to be considered in the overall risk scheme when choosing between the two options.
KEEP IN MIND our process safety takes precedent in this situation. I am in NO WAY saying we throw worker safety out the window, but when faced with a release of our HHC/EHS vs. a potential injury to a worker from having them break down this racking by hand – we have to keep the big picture in sight.
Option 1 would be the easiest if we could shutdown the entire freezer and option 2 would be the option if we could not shutdown the freezer. Bottom line… there is no way in hell that a supervisor who is authorized to issue safe work permits is going to put his/her job on the line by allowing a forklift to operate within 18” of a live pipe carrying an HHC/EHS. It would be made clear to the “group responsible” for the racking and freezer that they are in direct control of their process area and the decision is theirs to make; but with this authority comes responsibility and the person who authorizes the work in this situation is putting their job on the line. Regardless of the outcome (a release or no release of HHC/EHS), a supervisor/manager who permits this work to take place is not the type of individual we want making day to day decisions in, on or adjacent to our covered process. They may get away with it once or twice, but it will eventually catch up with them and our employees, contractors, and community deserve better.
So, I would NOT have initiated a MOC or conducted a PHA to remove these racks from the freezer. I would have instead used my other safety tools, relying heavily on my “Safe Work Permitting” and the JSA/JHA that is completed as part of this “Permit to Work” process. The “Job Planning” would have been my first opportunity to identify this risk, but my front-line supervisor issuing the work permit inside the freezer would have been the layer of protection that I would have really relied on. It would be this permit and the associated JSA/JHA that would have forced option 1 or 2 or the supervisor would have had to seek higher authority to deviate from the permit.
We can not be so naïve to think that any one or even all of these safety systems would have prevented this incident from occurring, if they had been “pencil whipped”! Every one of these layers of protection rely on ONE COMMON MODE… PEOPLE. And even well trained and well intentioned people get lazy, get pressured, get mad, and make mistakes. So we need our administrative controls to have checks and balances built-in. I like doing this with field audits of the majority of “work permits” (e.g. LOTO, CS Entry, Line Break, Crane/Elevated Work, Hotwork-Welding, Hotwork-Electrical, Excavation/Trenching, and General Safe Work Permit) issued each day. Yes, you read that correctly, my facilities had work permits for ALL of those related NON-ROUTINE TASKS and in fact a Safe Work Permit would be the core work permit for all non-routine tasks and the other more specific permits would be issued based on the scope of work as needed. In regards to the permit auditing, having a second set of eyes take 5-10 minutes to STOP and EXAMINE the permit(s) to determine that the permit fits the work environment and that all the workers involved in the work are meeting the permit requirements can have huge benefits.
I would like to point out an often overlooked part of OSHA’s PSM standard… Appendix C. Now this appendix is NOT “mandatory”, but it actually states the following in regards to “non-routine work” done in, on, or adjacent to a covered process. Nonroutine work which is conducted in process areas needs to be controlled by the employer in a consistent manner. The hazards identified involving the work that is to be accomplished must be communicated to those doing the work, but also to those operating personnel whose work could affect the “safety of the process” (the quotations are mine to stress that even OSHA views “process safety” and the “safety of the process” differently). A work authorization notice or permit must have a procedure that describes the steps the maintenance supervisor, contractor representative or other person needs to follow to obtain the necessary clearance to get the job started. The work authorization procedures need to reference and coordinate, as applicable, lockout/tagout procedures, line breaking procedures, confined space entry procedures and hot work authorizations. This procedure also needs to provide clear steps to follow once the job is completed in order to provide closure for those that need to know the job is now completed and equipment can be returned to normal.
Lastly, the investigation that would follow this incident would hopefully lead the facility to examine their need for some type of work permit process to control the NON-ROUTINE WORK ACTIVITIES on, in or adjacent to their covered process. For those who feel that this incident was a result in the failure to perform an MOC and/or a PHA, consider this: This would mean ANY non-routine work taking place on, in or adjacent to a covered process would require a MOC and/or PHA; and folks these two “process safety” tools were NEVER intended to play this role, nor does any facility on this earth have the resources and time to conduct an MOC for every non-routine activity taking place that could impact the “safety of the process”.
I would also like to believe that blame would not be laid on the forklift driver for causing this incident, as there were many failures long before he/she came into the equation. In fact, I would place much more responsibility on facility personnel for placing this driver in a no-win situation! To me this incident would be an eye opener and would also identify a failure in process design. Many safety professionals are fans of the “Five Why’s” investigation method; but using this investigative method did NOT lead me to a failure in the MOC or PHA programs. In fact, this is the best way for me to support my position:
1) Why was there a release of ammonia? A forklift hit an ammonia pipe
2) Why did a forklift hit the ammonia piping? Workers were moving racks out of Freezer XX and the PIT driver would lift the racks individually and maneuver them out of the freezer in one piece. There was only 18” of clearance between the pipe and the racks. When he lifted the 3rd rack he struck the pipe.
3) Why did we decide to move the racks in one piece with a forklift rather than break them down and then move them since they were so close to the ammonia piping? We needed the freezer back in production by the weekend and this method was faster.
We could go on, but I honestly do not see how this investigation would bring an MOC or PHA into the failure modes of this incident. Maybe if the original PHA missed this arrangement, but in no way would I fault anyone for not doing a PHA or MOC on removing these racks.