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Process Safety Management and

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 ,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 Participation2 Process Safety Information3 Process Hazard Analysis3 Operating Procedures7 Training2 Contractors2 Pre-Startup Safety Reviews4 Mechanical Integrity7 Management Of Change4 Incident Investigation3 Compliance Audits3 Total PSM40

AREA OF CITATION # ITEMS CITED Related H&S Programs OSHAct General Duty - Section 5 (a)(1)1 Emergency Action Plans HAZWOPER Personal Protective Equipment Respiratory Protection Control of Hazardous Energy (Lockout) Employee Alarm Systems Electrical Safety , 304, & 3052 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, NEOmaha, 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: 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: 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: – 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.) 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 – 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 – 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 – Failure to perform workplace hazard assessment for ammonia system repairs

Related Work Practices (cont.) Respiratory Protection – 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) – 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 – Alarm system was not capable of being heard throughout the workplace Electrical Safety , 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