Transcript Precitation Settlement

FHM TRAINING TOOLS
This training presentation is part of FHM’s
commitment to creating and keeping safe
workplaces.
Be sure to check out all the training programs
that are specific to your industry.
Process Safety Management
1910.119 and 1926.64
Historical Perspective
•
Marriage between Safety and Engineering
(good engineering practice)
– Involved Corporate Engineering and Plant Engineers
•
Training, Training, and more Training
– Initial training of Process Safety Management
Implementers
– Use of checklists that clarify what progress really is
– Operator training on Ammonia Systems (IIAR/RETA)
– Training Engineers on MOC with Ammonia CER’s
Historical Perspective
•
Keeping PSM on the Front Burner
– Quarterly progress reports on PHA and CA
•
Deficiencies (signed by plant manager)
– Facility safety reviews
– Monthly conference calls
•
Auditing, Auditing, and more Auditing
– Plants performed self-audits per CPL checklist
– Corporate Safety and Engineering did PSM audits
– Third party audits
Historical Perspective
•
OSHA PSM Inspections
– Wallace, NC was first on 1/96 by State
OSHA
– Turlock, CA was second on 1/97 by State
OSHA
– Kansas City, KS was third on 5/97 by
Federal OSHA
The Inspection Process
Process Safety Management
Kansas City, KS
•
Processed meats facility producing:
– Deli products
– Sliced luncheon meat
– Breakfast strips
– Sausage franks
– Lunchmakers®
•
Constructed 1979, addition 1996
• 225,000 square feet
• 55,000 pound ammonia system
• Four system operators
Original Complaint Investigation
January 8,1997
•
“The ammonia piping and valves on the
manufacturing floor of the plant are
deteriorated and in very dangerous condition
exposing employees to injury.”
– Very brief inspection
– No review of PSM
– No interviews
– No citations issued
Second Complaint Investigation
April 9, 1997
“Manufacturing floor, evaporative units 1 through
6 have valves that are deteriorating, stems that
are 1/3 their original size, and have severe
corrosion problems.”
• “Some pipes in the engine room are schedule 40
rather than standard schedule 80.”
• “Pipes and pressure vessels are welded on by
non-certified welders.”
• “Pipes in the facility are not tested for corrosion.”
•
Initial Inspection
•
•
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One inspector from Overland Park office
Minimal visits to inspect physical conditions
– takes video and still pictures
Requests and receives numerous documents
including:
– pipe inspection report
– mechanical integrity program
– process hazard analysis and status report
– completed compliance audits
Interviews operators
– interviews each operator for up to four hours
Salt Lake City
Inspection Team
•
Four inspections
– original inspector (Safety Engineer)
– Assistant Regional Director (Industrial
Hygienist)
– Salt Lake City inspectors:
•
•
Mechanical Engineer (PE/Industrial Hygienist)
Industrial Hygienist (CIH)
Team Inspection Process
•
Request and receive numerous
additional documents
– inspectors pair up to focus on specific
elements
– continue interviews with operators
– group interview with management
– several tours to view engine room, roof,
and pipe runs
Documents Furnished
•
All PSM program elements and
supporting information including:
– all Management of Change forms
– equipment manuals
– all PSM incident investigation reports
– all employee training records for operators
– ancillary programs (LOTO, PPE, confined
space, etc.)
– ConAgra Annual Report
Additional Issues
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Asbestos survey
PSM consultant
Pipe radiography
Pipe replacement
Full corporate safety and health
compliance audit
Inspection Management
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Request all documents in writing
24 hour time to respond
Log all documents given
– name of document
– file number
– double copy
KANSAS CITY, KANSAS
PSM INSPECTION
AREA OF CITATION
Employee Participation
Process Safety Information
Process Hazard Analysis
Operating Procedures
Training
Contractors
Pre-Startup Safety Reviews
Mechanical Integrity
Management Of Change
Incident Investigation
Compliance Audits
Total PSM
# ITEMS CITED
2
3
3
7
2
2
4
7
4
3
3
40
KANSAS CITY, KANSAS
PSM INSPECTION
AREA OF CITATION
# ITEMS CITED
Related H&S Programs
OSHAct General Duty - Section 5 (a)(1)
Emergency Action Plans - 1910.38
HAZWOPER - 1910.120
Personal Protective Equipment - 1910.132
Respiratory Protection - 1910.134
Control of Hazardous Energy
(Lockout) - 1910.147
Employee Alarm Systems - 1910.165
Electrical Safety - 1910.303, 304, & 305
Total Related H&S Programs
4
1
2
13
TOTAL ITEMS CITED
53
1
1
1
1
2
PreCitation Settlement
•
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Potential for megafine and negative
publicity
Interest by OSHA
– leverage inspection
– avoid potential conflict with VPP
Partnership Initiative
– save resources
•
UFCW informed and cooperative
PreCitation Settlement
•
•
OSHA provides draft citation
ASE develops abatement plan
– aggressive dates
– $500,000 + spent on mechanical integrity
and PSM implementation
•
Abatement plan reviewed with UFCW
Citation
•
53 serious items:
– 40 PSM
•
•
$256,650 proposed fine
3 willful violations avoided
– mechanical integrity
– pre-startup safety review
– process hazard analysis
Settlement Agreement
Corporate
– Region-wide: 5 plants
Kansas City, KS Carthage, MO
Hastings, NE
Omaha, NE
Junction City, KS
– Citation to be training tool
• ASE
• ConAgra
• Industry groups
– Train UFCW
– Copies to all ASE facilities
Settlement Agreement
Kansas City
– Full PSM implementation by 7/1/98
– Corporate Safety Department to monitor
progress
•
•
on-site visits
60 day monitoring reports
– 3rd party audit on or before 7/1/99
– OSHA Institute training
Settlement Agreement
Kansas City (cont.)
– Serve as benchmark
– 5-year inspection by 7/1/98
• IIAR Bulletins
• ANSI/ASHRAE
• Replace piping with wall thickness loss of 50%
or greater
Settlement Agreement
Region VII
– Quarterly reports
– Compliance by 4/19/98
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employee participation
contractors (except safe work practices)
pre-startup safety reviews
hot work permit
management of change
incident investigations
emergency response
Settlement Agreement
Region VII (cont.)
– Compliance by 10/9/99
• process safety information
• process hazard analysis
• standard operating procedures
• mechanical integrity (except 3rd party visual
inspection (6 months))
• compliance audits
OSHA’s
Press Release
•
“… employers with ammonia
refrigeration PSM related programs are
being notified of OSHA’s intent to hold
them accountable for complying with the
IIAR Bulletins.”
Employee Participation
•
The facility’s Employee Participation
Guidelines did not:
– Address employee consultations during PSM
program development
– Assign responsibility or authority for implementing
PSM
– Establish methods for soliciting input from contract
employees regarding PSM
•
The facility did not consult with employees on
various elements of PSM
Process Safety Information
•
The facilities PSI Information did not include:
– A block flow or simplified process flow diagram
– The expected maximum inventory of site vessels
– Safe upper and lower operating limits for temperature,
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–
–
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–
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pressure, etc.
Expected results of deviations from safe upper and lower
operating limits
Design codes and standards, materials of construction,
etc., used in system design
Complete Process & Instrumentation Diagrams (P&ID’s)
Electrical classification of machine rooms
Information regarding ventilation system design
Information regarding safety systems (e.g. interlocks,
cutouts, detection systems)
Process Safety Information
The facilities PSI Information did not include:
– Verification of good engineering practices in ammonia
system including:
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Location of the discharge of pressure relief valves
(PRV’s) for new system
The size of common vent header for PRV’s
Suitability of pipe and vessel insulation materials
Installation of PRV’s on appropriate devices (#’s 3 and 25
accumulators)
Location of king valves (not operable from floor & no
access platform)
Process Safety Information
•
Demonstration of good engineering practice
for electrical classification
– Engine room not classified
– No remote emergency stop switches in engine
rooms
Process Hazard Analysis
•
The facility’s initial (1994) Process Hazards
Analysis (PHA) did not:
– Identify, evaluate, and establish controls for the hazards
associated with the process
– Address previous PSM incidents
– Address engineering and administrative controls for the
following:
•
•
•
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detection methodologies for ammonia nor emergency
ventilation
PRV’s or their vent header sizing
emergency isolation (king) valves or compressor emergency
cut-off switches
mechanical integrity procedures
Process Hazard Analysis
(cont.)
•
Address the consequences of failure of
engineering and/or administrative controls
• Address facility siting or human factors
• The facility’s initial (1994) Process Hazards
Analysis (PHA) did not:
– Promptly address all recommendations
– Discuss recommendations with refrigeration
operators
Operating Procedures
The facility did not have complete (SOP’s) for
the ammonia system
• The facility’s written SOP’s did not address:
•
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–
–
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Normal operating procedures
Temporary operations
Emergency shutdown conditions
Procedures for isolation and control of engine room leaks,
including PPE
– Operating limits, i.e., flow rates, pressure limits, temperature
ranges, etc.
– Hazards of the chemicals used in the process
– Safety systems and their functions, i.e., emergency stop
switches, king valves, etc.
Operating Procedures (cont.)
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The facility did not perform annual
certification of their SOP’s
The facility had not developed and
implement safe work practices for:
– Contractors entering the facility
– Entering process equipment or piping
Training
•
The facility’s PSM training program did
not:
– Require refresher training at least once every
three years
– Require consultation with employees
regarding the frequency of refresher training
– Document employee training on specific
SOP’s
– Require verification of employee
understanding of SOP’s
Contractors
•
The facility’s PSM Contractor Safety Program
did not require:
– Evaluation of contractor safety performance and
programs prior to contract initiation
– Periodic review of contractor safety performance
– Periodic evaluation of contractor safety training
programs
– Periodic evaluation of contractor employees
understanding safety training
Pre-Startup Safety Reviews
•
The Pre-Startup Safety Review for the new
ammonia system failed to confirm that:
– construction and equipment of process was in
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–
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accordance with design specifications
P& ID’s were complete and verified as accurate
Acceptance tests were performed on computer
hardware & software, protection devices including
alarms, interlocks, cutouts and level controls
Safety, operating, maintenance, and emergency
procedures were complete
PHA had been performed
Employee training had been performed and
understood
Mechanical Integrity
•
The facility’s Mechanical Integrity
Program contained the following
deficiencies:
– No procedures for repair of process
equipment
– No procedures for replacement of PRV’s
– Inspection and tests were not performed
on vessels, piping, PRV’s, emergency
shutdown systems, control systems,
pumps and compressors
Mechanical Integrity (cont.)
– No documentation of inspection & tests on
process equipment
– The facility did not correct known
deficiencies in a safe and timely manner
– No procedures ensuring that new
refrigeration plant was installed to design
specifications and manufacturer’s
instructions
– No procedures to ensure that maintenance
materials, spare parts and equipment were
suitable for the process applications
Management of Change
•
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No requirement to establish and
implement written MOC procedures
Numerous changes were implemented
without performing MOC’s
Management of Change
(cont.)
•
Written MOC procedures did not assure
that the following issues were
addressed:
– Technical basis for proposed changes
– Safety & Health considerations
– Modifications to operating procedures
•
Failure to update process information
and operating procedures after
implementing MOC’s
Incident Investigation
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Failure to develop an incident investigation
procedure that met the requirements of PSM
Failure to investigate numerous PSM related
incidents
Failure to train investigation teams in incident
investigation techniques
Failure to include at least one member with
process knowledge on investigation team
Failure to establish system to promptly
address and resolve investigation report
findings
Compliance Audits
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Failure to verify that procedures and practices
developed under the standard were being
following, i.e., failure to correct PSI issues
identified in earlier compliance audits
•
Failure to include at least one member with
process knowledge on the audit team
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Failure to develop plan for resolution of
compliance audit findings
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Failure to resolve compliance audit findings in
a timely manner
Related Work Practices
•
OSHAct General Duty - Section 5 (a)(1)
– Failure to provide positive securing
mechanism for chain hoist on freezer doors
– Failure to maintain chain hoists on freezer
doors
•
Emergency Action Plans - 1910.38
– Failure to train employees in changes to
site alarm system
– Failure to train employees in changes to
emergency egress routes
Related Work Practices (cont.)
•
Hazwoper - 1910.120
– Failure to develop an emergency response plan that
adequately addressed:
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Ammonia release and response criteria
Protocols for Carbon Dioxide or Sulfuric Acid releases
Methods for determining safe distances and places of
refuge
Personal Protective Equipment - 1910.132
– Failure to perform workplace hazard assessment for
ammonia system repairs
Related Work Practices (cont.)
•
Respiratory Protection - 1910.134
– Utilization cartridge respirators in lieu of
SCBA during ammonia releases
– No procedures for emergencies involving
sulfuric acid and carbon dioxide
– Failure to perform air sampling prior to
entering potentially hazardous atmosphere
Related Work Practices (cont.)
•
Control of Hazardous Energy (Lockout) 1910.147
– Use of tagout procedure in lieu of lockout where
lockout was appropriate
– No specific lockout procedures for the following
equipment:
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Shirmatic unit in TRM Stuffing Dept
Cozzini Vacuum Hopper & Mill in TRM Stuffing Dept.
Various pieces of ammonia refrigeration equipment
Transfer of ownership procedures
– Failure to perform annual audits of lockout program
– Failure to verify employee understanding of lockout
program (as evidenced by numerous injuries of
employees while performing lockout)
Related Work Practices (cont.)
•
Employee Alarm Systems - 1910.165
– Alarm system was not capable of being heard throughout
the workplace
•
Electrical Safety - 1910.303, 304, & 305
– Electrical services not identified
– Live electrical parts (operating above 50 volts) not
guarded:
•
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Electrical box in Sizzlean area
Electrical panel in old engine room
– Ground pin removed on fan in new engine room
– Damaged insulation on electrical cord (TRM Shiramatic)
– Receptacle on reeves drive (Sizzlean) not water tight,
electrical hazard during clean-up