Many THANKS to John Newquist, Assistant Regional Administrator at OSHA, Region V for sharing this data with us! 

In fiscal year 2012, Region V leads OSHA Regions in conducting Local Emphasis Program (LEP) involving PSM and ammonia seems to be a common theme with several anhydrous ammonia releases that have been investigated. I wanted to focus on what OSHA is citing in the PSM regulations vs. the # of times a regulation was cited. 

 Here are some specific examples that continue to be cited on multiple ocasions:

Process Safety Information

119(d)(3)(i)(B) - Piping and instrument diagrams (P&ID's)

• Relief Valves not on P&ID
• P&ID indicated flame arrestors that did not exist
• P&ID did not indicate correct piping connections to vessels
• Incorrect diameters of piping
• P&ID did not show LEL detectors and interlocks
• No design basis for relief valves on reactor
• Valve tags were reversed, mislabeled
• HF vent line was not marked
• HF dump tank was not identified
• Three way valves were not identified
• Equipment were transposed on the diagrams

119(d)(3)(i)(H) - Safety systems (e.g. interlocks, detection or suppression systems)

PSI did not list:

• Cutout devices and Interlocks
• High and low level sensors
• Ammonia detectors
• High and low pressure devices
• Emergency Stop Buttons
• Electrical Classification of Equipment

119(d)(3)(ii) - document that equipment complies with recognized and generally accepted good engineering practices

• U-1 Form missing for pressure vessel
• Mechanical Room for ammonia had no emergency ventilation
• Electrical Classification of equipment missing
• Venting Flanges did not meet ANSI/ASME 31.3
• No documentation that piping was fit for service per API 570
• Manual block valves were located down stream of automatic dump valves (Hydrogen Fluoride Industry Practice Institute or HFIPI)
• HF tanks not sized 1.5x's for anticipated deliveries (HFIPI)
• HF dump tank did not have capacity of largest HF tank (HFIPI)
• HF liquid flow velocity exceeded 5.9 feet/second
• Eye wash and shower were not configured to sound in the control room (HFIPI)
• No valve capping kit for HF rail car unloading
• High pressure vent lines were not labeled
• Relief valve discharge 3.5` above platform vs. 15 feet (IIAR 2-2008)

Process Hazards Analysis

119(e)(1) - perform an initial process hazard analysis (hazard evaluation) on processes covered by this standard. The process hazard analysis shall be appropriate to the complexity of the process and shall identify, evaluate, and control the hazards involved in the process. Employers shall determine and document the priority order for conducting process hazard analyses based on a rationale which includes such considerations as extent of the process hazards, number of potentially affected employees, age of the process, and operating history of the process

• No PHA on the Hydrogen Storage tank
• PHA missing several elements
• PHA did not address failure of ventilation
• PHA did not address previous fires
• PHA did not previous piping failures
• PHA did not address previous failures of cooling systems

119(e)(3)(i) - hazards of the process

• PHA did not adress the hazards of the process
• The hazard of power failure was not discussed in the PHA
• The Hazard of natural gas draining to the surge drum too long
• The hazard of releasing material in the neutralization pits
• The hazard of weight of hoses on pipe nipples was not addressed
• The Hazards of venting flanges was not addressed in the PHA
• The hazard of forklift traffic was not addressed

119(e)(3)(v) - facility citing

• No analysis of facility siting issues related to formaldehyde dispersion
• Building siting and how affected by the ammonia process
• Ammonia system including piping, recirculator, chiller, receiver, and condensors were located close to the roadway and subject to vehicle impact

119(e)(3)(vi) - human factors

• Human Factors
• Fatigue
• No consideration of opening block valves downstream of remote operated dump valves
• Second and third shift training
• People on vacation leave
• Operational overload during emergencies
• Operation interactions

119(e)(5) - establish a system to promptly address the team's findings and recommendations; assure that the recommendations are resolved in a timely manner and that the resolution is documented; document what actions are to be taken; complete actions as soon as possible; develop a written schedule of when these actions are to be completed; communicate the actions to operating, maintenance and other employees whose work assignments are in the process and who may be affected by the recommendations or actions

• PHA items not resolved for years
• PHA did not address team finding and recommendations such asReconfigurations of valves issue on PHA was not resolved
  • Installing back flow prevention when adding flammable liquids in a tank
  • Automatic Pressure controls for Nitrogen
  • Adding relief valves
  • Facility siting for control rooms

Operating Procedures

119(f)(1) - develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process consistent with the process safety information and shall address at least the following elements

• No written procedures for maintaining ammonia systems
• No procedures for communicating issues during shift changes
• No procedures for upset condition or avoiding deviations beyond operating limits
• Transferring chemicals from pit to pit
• Neutralization of chemicals

119(f)(1)(i)(E) - Emergency Operations

• No procedures for when discharge pressure, suction pressure, discharge temperature, lubrication oil pressure, and lubrication oil temperature exceed normal operating range
• No Specific steps to stop an emergency
• No identification of emergency upset conditions and procedures to take to resolve it
• No procedure for emergency operations for transfer of chemicals out a Surge tank
• No clear procedures for emptying HF tanks with isolating nitrogen systems

119(f)(3) - operating procedures shall be reviewed as often as necessary to assure that they reflect current operating practice, including changes that result from changes in process chemicals, technology, and equipment, and changes to facilities. The employer shall certify annually that these operating procedures are current and accurate

• No certification of operating procedures annually

119(f)(4) - develop and implement safe work practices to provide for the control of hazards during operations such as lockout/tagout; confined space entry; opening process equipment or piping; and control over entrance into a facility by maintenance, contractor, laboratory, or other support personnel. These safe work practices shall apply to employees and contractor employees.

• No safe work procedures developed for contractors or maintenance employees working on PSM covered processes for
  • Lockout
  • Confined space
  • Hot works

Mechanical Integrity

119(j)(2) - establish and implement written procedures to maintain the on-going integrity of process equipment.

• No inspection procedures for:
  • Pressure Vessels
  • Piping, components, Hose adapters
  • Pumps
  • Venting Flanges
  • Compressors and cutout switches
  • Relief Systems and change out schedules
  • Emergency Shutdown Systems
  • Valves requiring Carseals
  • No Procedures for torquing bolts

119(j)(4)(i) - Inspections and tests shall be performed on process equipment

• No inspections on
  • Relief valves
  • Pressure vessels (Oil pot, Accumulator, Receiver, and Transfer Drum)
  • Ammonia Feed Pumps
  • Venting flanges
  • Pipe Nipples, Deadlegs, Inspection ports, hose adapters
  • High Level alarms and emergency shutdown systems

119(j)(4)(ii) - Inspection and testing procedures shall follow recognized and generally accepted good engineering practices

• No authorized API 570/574 piping inspector or piping inspections
• No API 510 pressure vessel inspections
• No corrosion rates established for pressure vessels
• Pump not maintained and lubricated per manufacturer’s recommendations
• Rupture Disk was not replaced per manufacturer’s recommendations
• No 100% Radiography or Ultrasonic testing on process pipe weld repair per ANSI B31.1
• No fitness for service for repairs per API 579 for tanks undergoing repair at head nozzles

119(j)(4)(iii) - frequency of inspections and tests of process equipment shall be consistent with applicable manufacturers' recommendations and good engineering practices, and more frequently if determined to be necessary by prior operating experience

• No annual piping inspection
• No API internal pressure vessel inspection
• No inspection testing of the condensate vapor system for buildup that might clog the system
• No hydrostatic testing of HF tanks
• No testing or exercising of HF vent valves/dump valves
• Not testing compressor cutout switches
• Blast Evaporators, heat exchangers not inspected
• No pump inspections

Management of Change

119(L)(1) - employer shall establish and implement written procedures to manage changes (except for "replacements in kind") to process chemicals, technology, equipment, and procedures; and, changes to facilities that affect a covered process

• No implementation of procedures after change
• No MOC for replacing manual valves with pneumatic actuated valves
• NO MOC for installing a LEL detector
• NO MOC for disconnection of the Cooling water System
• NO MOC for installing an alarm on the quench system
• NO MOC for expanding Toulene tank system
• NO MOC for leak at Relief Header Rupture disk
• NO MOC for bolt torquing procedure change
• NO MOC for making changes in the Ammonia system
• No MOC for condenser removed from process

Incident Investigation 

119(m)(1) - employer shall investigate each incident which resulted in, or could reasonably have resulted in a catastrophic release of highly hazardous chemical in the workplace.

• No incident investigation for
  • Ice buildup and cracks in evaporator coils
  • Prior incident of adding high temperature product to flammables
  • Prior ammonia release
  • Prior corrosion in pipes

 Compliance Audits

119(o)(1) - certify that they have evaluated compliance with the provisions of this section at least every three years to verify that the procedures and practices developed under the standard are adequate and are being followed

• No PSM evaluation audits were conducted
• No audits of Mechanical integrity, Management of Change, PHA, and Emergency Response

Other Issues noted during PSM Inspections

• Lockout
• Emergency Response
• Confined Space Rescue
• Electrical Classification
• Hot Works
• Boiler Safety

Some comments made or heard by CSHO's during PSM Inspections

• In most of the cases that we investigate, we have found that most firms completely ignore the 1910.119(j)(5) requirement, and don’t even consider doing an MOC for a temporary change that meets the requirements of 1910.119(l).  
• We have two or three cases in our backlog of open cases that deal exactly with these issues. Guess the refinery NEP is having some impact.  
• I fully agree on the MOC’s; they are called by the workers “Matter of Convenience” because they believe they are used to justify exceptions and deviations.I would add a couple to your list; PSSR (Pre Start-up Safety Review) and organizational issues. 
• I just reviewed a couple of investigations where there was an unexpected shutdown on a portion of the unit and in a rush to get the unit back up (they did not fully understand why it had shutdown) and they ended up in a more serious situation. Most companies only apply the PSSR part of the PSM standard to a cold start, and even the procedures are written for a cold start and do not work for hot restarts.

Summary & Suggestions

• Identify the top risks in the facility
• Look at corrosion monitoring on pipes and vessels
• Pump vibration leads to failures and fires
• Procedures related to boiler startup, hot works
• Evaluate hydrogen sulfide monitoring, hydrofluoric acid
• Address fatigue and control panel alarms during start ups
• Management of change is slipping
• Gasket torquing procedures should be reviewed as well as gasket compatibility for service
• Relief valve inspection and testing is a must
• Facility siting is ever present

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