Swift Historical Perspective • Marriage between Safety and Engineering (good engineering practice) – Involved Corporate Engineering and Plant Engineers • Training, Training, and more Training – Initial.
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Swift Historical Perspective • Marriage between Safety and Engineering (good engineering practice) – Involved Corporate Engineering and Plant Engineers • Training, Training, and more Training – Initial training of PSM Implementers (Primatech) – Use of checklists that clarify what progress really is – Operator training on Ammonia Systems (IIAR/RETA) – Training Engineers on MOC with Ammonia CER’s ¨ Swift 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 ¨ Swift 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 ¨ Swift The Inspection Process ¨ Swift 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 ¨ Swift 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 ¨ Swift 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 noncertified welders.” • “Pipes in the facility are not tested for corrosion.” ¨ Swift Initial Inspection • 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 ¨ Swift 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) ¨ Swift 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 ¨ Swift 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 ¨ Swift Additional Issues • • • • • Asbestos survey PSM consultant Pipe radiography Pipe replacement Full corporate safety and health compliance audit ¨ Swift Inspection Management • Request all documents in writing • 24 hour time to respond • Log all documents given – name of document – file number – double copy ¨ Swift 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 ¨ Swift KANSAS CITY, KANSAS - PSM INSPECTION AREA OF CITATION 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 TOTAL ITEMS CITED # ITEMS CITED 1 1 1 1 2 4 1 2 13 53 ¨ Swift PreCitation Settlement • Potential for megafine and negative publicity • Interest by OSHA – leverage inspection – avoid potential conflict with VPP Partnership Initiative – save resources • UFCW informed and cooperative ¨ Swift 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 ¨ Swift Citation • 53 serious items: – 40 PSM • $256,650 proposed fine • 3 willful violations avoided – mechanical integrity – pre-startup safety review – process hazard analysis ¨ Swift Settlement Agreement Corporate • Region-wide: 5 plants Kansas City, KS Hastings, NE Junction City, KS Carthage, MO Omaha, NE • Citation to be training tool – ASE – ConAgra – Industry groups • Train UFCW • Copies to all ASE facilities ¨ Swift 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 ¨ Swift 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 ¨ Swift Settlement Agreement Region VII • Quarterly reports • Compliance by 4/19/98 – – – – – – – employee participation contractors (except safe work practices) pre-startup safety reviews hot work permit management of change incident investigations emergency response ¨ Swift 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 ¨ Swift 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.” ¨ Swift 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 ¨ Swift 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, 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) ¨ Swift PROCESS SAFETY INFORMATION The facilities PSI Information did not include: • Verification of good engineering practices in ammonia system including: – a) Location of the discharge of pressure relief valves (PRV’s) for new system – b) The size of common vent header for PRV’s – c) Suitability of pipe and vessel insulation materials – d) Installation of PRV’s on appropriate devices (#’s 3 and 25 accumulators) – e) Location of king valves (not operable from floor & no access platform) ¨ Swift PROCESS SAFETY INFORMATION • Demonstration of good engineering practice for of electrical classification – a) Engine room not classified – b) No remote emergency stop switches in engine rooms ¨ Swift 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: • 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 ¨ Swift 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 ¨ Swift Operating Procedures • The facility did not have compete (SOP’s) for the ammonia system • The facility’s written SOP’s did not address: – – – – 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. ¨ Swift Operating Procedure (cont.) • 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 ¨ Swift 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 ¨ Swift 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 ¨ Swift 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 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 ¨ Swift 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 ¨ Swift 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 ¨ Swift Management of Change • No requirement to establish and implement written MOC procedures • Numerous changes were implemented without performing MOC’s ¨ Swift 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 ¨ Swift Incident Investigation • 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 ¨ Swift Compliance Audits • 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 • Failure to develop plan for resolution of compliance audit findings • Failure to resolve compliance audit findings in a timely manner ¨ Swift 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 ¨ Swift Related Work Practices (cont.) • Hazwoper - 1910.120 – Failure to develop an emergency response plan that adequately addressed: • 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 ¨ Swift Related Work Practices (cont.) • Respiratory Protection - 1910.134 – Utilization cartridge respirators in lieu of SCBA during ammonia releases – No procedures for emergency’s involving sulfuric acid and carbon dioxide – Failure to perform air sampling prior to entering potentially hazardous atmosphere ¨ Swift 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: • • • • 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) ¨ Swift 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: • 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 ¨