# Presentation: 270963

## 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

## 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

## 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

- 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

- Asbestos survey
- PSM consultant
- Pipe radiography
- Pipe replacement
- Full corporate safety and health compliance audit

## Inspection Management

- 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_	_	__	__# ITEMS CITED_
- Employee Participation				2
- Process Safety Information			3
- Process Hazard Analysis				3
- Operating Procedures				7
- Training						2
- Contractors					2
- Pre-Startup Safety Reviews			4
- Mechanical Integrity				7
- Management Of Change				4
- Incident Investigation				3
- _Compliance Audits__	__	__	__	__3_
- Total PSM					40

## AREA OF CITATION			# ITEMS CITED
Related H&S Programs
OSHAct General Duty  - Section 5 (a)(1)		1
Emergency Action Plans - 1910.38			1
HAZWOPER - 1910.120				1
Personal Protective Equipment - 1910.132		1
Respiratory Protection - 1910.134			2
Control of Hazardous Energy 
	(Lockout) - 1910.147				4 
Employee Alarm Systems - 1910.165		1
Electrical Safety - 1910.303, 304, & 305		2
Total Related H&S Programs			13

TOTAL ITEMS CITED				53

- Related H&S Programs
- OSHAct General Duty  - Section 5 (a)(1)		1
- Emergency Action Plans - 1910.38			1
- HAZWOPER - 1910.120				1
- Personal Protective Equipment - 1910.132		1
- Respiratory Protection - 1910.134			2
- Control of Hazardous Energy
- 	(Lockout) - 1910.147				4
- Employee Alarm Systems - 1910.165		1
- _Electrical Safety - 1910.303, 304, & 305__	__	__2_
- Total Related H&S Programs			13
- TOTAL ITEMS CITED				53

- KANSAS CITY, KANSAS - PSM INSPECTION

## 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

## 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
- 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, 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:
- 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)

## 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

## 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

## 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 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.

## 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

## 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 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

- 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

- 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

- 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

## 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:
- 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 emergency’s 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:
- 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:
- 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