Category: Uncategorized (Page 1 of 2)

How Many Operators do we Need?

Disclaimer: This post is a collaboration between an industry friend and colleague, Victor Dearman and I. The views expressed here do not necessarily represent the opinions of any entity whatsoever which we have been, are now, or will be affiliated.

It’s a question we hear often – sometimes as part of a PHA or Compliance Audit, but more often with someone just struggling to justify their staffing requests. Unfortunately, there really isn’t a simple, definitive answer to the question. No controlling RAGAGEP exists and state / local laws on the topic are relatively rare. This sort of problem isn’t rare in PSM because it is a performance-based standard. Our performance basis is that we are staffed sufficiently to ensure the safety of the people within the building and the surrounding community.

We need to answer the “How many Operators do we need?” question in a way that we can support it, or as we like to say, “Build a defensible case for the answer we arrive at. The answer itself will depend on many, many factors. So, let’s go on a journey and see how we can arrive at an answer we can feel confident in.

 

The road to an answer

The biggest factor for many is the design (age!?) of the system controls. A modern system with advanced controls requires less oversight on a day-to-day basis. If your system still relies on manual controls and people writing down pressures every hour, then that’s going to have a significant impact on your staffing needs. But once we get past that obvious issue, things get a bit more complicated.

Let’s be honest here, if things are running well; you have a good history with compliance audits, inspections, incident investigations, etc. and a low MI backlog, you’re probably not asking this question. If you are asking this question, it is probably due to an event related to a PSM/RMP element.

Let’s look at the kinds of element events that typically lead to this question.

  • Employee Participation
  • Mechanical Integrity
  • Incident Investigations
  • Management of Change / Pre-Startup Safety Review
  • Process Hazard Analysis
  • Emergency Action and Response Plans

 

Employee Participation: Look, everyone feels over-burdened at work, especially in the modern “Do MORE with LESS” era. But, if you pay attention to it, and look at these other elements, this employee feedback can provide valuable insights into the adequacy of your staffing.

 

Mechanical Integrity: What we’re looking for here is to understand if you have the skill sets and staffing to adequately maintain your refrigeration system. Whether you do everything in-house, or have a small in-house small crew performing basic rounds and contract out all the rest of the maintenance, inspections, and tests, is it adequate?

Here’s some MI related questions you might ask to help you determine if your staffing is adequate:

    • Are we properly implementing our Line & Equipment Opening (sometimes known as line break) procedures?
    • Are we caught up on ITPMR’s (Inspection, Test and Preventative Maintenance Reports) or work orders?
    • Is the documentation of ITPMR’s, Work orders, Oil Logs adequate?
    • Are we performing our scheduled walk-through’s and documenting them properly?
    • Are we addressing MI recommendations in a timely manner?
    • Are there indications that maintenance of the facility and system are being conducted properly and required repairs aren’t being delayed?
    • Are there no indications in the written MI records, or in your observations, that the system is running outside the written operating limits?

 

Incident Investigations: A review of incident investigation history can tell us a lot if the facility has a good process safety culture. But if they don’t have the right culture, and /or they don’t have any documented incidents, you’re going to have to do a little detective work and interview plant employees to find out if incidents are occurring that aren’t being recorded. Remember to spread your net wide here because incidents can happen at any time, not just on day-shift: Backshifts, weekends, holidays, etc. there’s no time immune to a possible incident.

You may also find indications of incidents occurring in walk-through logs, communications logs, ITPMRs, work orders, etc.

Here’s some II related questions you might ask to help you determine if your staffing is adequate:

    • Are incidents being reported, conducted, and documented? If not, is this a culture issue or a staffing issue?
    • Are incidents and incident report findings & recommendations being addressed, communicated, and followed to their conclusion?
    • Are there incidents that could have avoided with proper staffing?
    • Are there incidents that would have their severity reduced with proper staffing?
    • Are there incident investigations with recommendations that could be addressed with proper staffing?

 

Management of Change / Pre-Startup Safety Review: Properly implementing the MOC and PSSR elements takes a lot of time! We often find that these two elements are amongst the first to “fall behind” in suboptimal staffing situations. Here’s some MOC/PSSR related questions you might ask to help you determine if your staffing is adequate:

    • Have MOCs / PSSRs been conducted when they were supposed to be?
    • Were the MOCs / PSSRs conducted adequately to properly manage the hazards related to the change and the new systems?
    • Is the documentation of MOCs / PSSRs complete?
    • Are there any open items or recommendations from MOCs, PSSRs, or project punch lists?

 

Process Hazard Analysis: The PHA and open PHA recommendations can also help us understand if our staffing levels are appropriate. There may also be indications in the PHA itself. There’s a portion of the PHA that deals with staffing directly, but we’ll deal with that in the Building a defensible case on staffing section of this article.

Here’s some PHA related questions you might ask to help you determine if your staffing is adequate:

    • Are the PHA recommendations being addressed, communicated, and followed to their conclusion?
    • Is the facility provided with modern controls, alarm systems and equipment? (Newer, modern facilities often have significantly lower staffing needs than older ones)
    • Has the PHA been updated / validated as required by MOC activities and the 5yr schedule?

 

Emergency Action and Response Plans: Whether we’re looking at the plan(s) themselves, or analyzing an after-action report, a there can be a lot to learn here concerning proper staffing levels. Obviously, the required staffing levels for Emergency Response facilities is going to be higher, but that doesn’t mean there is no staffing requirement for Emergency Action plans.

Here’s some EAP/ERP related questions you might ask to help you determine if your staffing is adequate:

    • In the event of an incidental release of ammonia, do you have adequate staffing to investigate and respond?
    • In the event of an emergency response, even if you are not a “responding” facility, do you have adequate staffing to ensure that the equipment is properly shut down?
    • If you are a “responding” facility, do you have enough adequately trained personnel to staff your response team including an Incident Commander, safety officer, decontamination personnel, two entry teams, etc.
    • If you bring key staff back on-site to deal with emergencies, are they close enough to respond in a timely manner, or do you need to increase the size of your trained response team?

 

Building a defensible case on staffing

Ok, we’ve answered our questions and gathered a good impression of where we stand – and where we should stand. Maybe we need to adjust our staffing levels and/or increase the amount of services we ask contractors to complete for us. Where should we document this? In our opinion, the place in the system where the facility already had the opportunity to address this issue, was in the PHA. So, let’s go back to the PHA, end see if our results match the PHA team’s.

You are going to be looking for the following two questions (or their equivalents) from the standard Human Factors section of the IIAR What-If /Checklist worksheets:

HF14.37 – What if an employee is stressed due to shift work and overtime schedules?

HF14.38 – What if there are not sufficient employees to properly operate the system and respond to system upsets?

During the PHA, the facility should have answered those in a way that says they have adequate staffing or recommended that staffing be increased. Let’s say you decided that you had adequate staffing based on your answers to the questions above. If that’s the case, we’d expect to see something like the following:

 

If, however, we found some areas for improvement, we might expect something like this:

 

Closing Thoughts: We hope you didn’t start reading this hoping for an easy answer, but we’re fairly certain – now that you understand the full scope of the question being asked – that the answer doesn’t need to be easy, it needs to be correct and defensible.

You can build a much better understanding of your staffing needs by looking at the existing elements in your Process Safety program. Any decent Compliance Audit would cover this same ground, if staffing is an area of concern for you, make sure to bring it up.

P.S.  from Victor: Some facilities might try and get more value from a security guard on off shifts or holiday coverage to make roving patrols and report abnormal conditions and alarms? Sure, but that also means that guard has to be trained to identify what the alarms mean, how to identify an abnormal condition, and that they know what to do to either immediately correct the deviation or immediately contact someone that can (on call techs or service providers). By the time you have invested this much into a guard, you could have paid for a well-qualified operator.

My advice to any organization when making these decisions is to evaluate the above and take into consideration the attracting well rounded operators with the skill sets and experience often sought is more often through word of mouth about how the organization projects their Process Safety culture.

How to hire operators? Well, that sounds like a good subject for a future article!

What is the best way to train my ammonia refrigeration operators?

Nearly 3 years ago we posted an answer to the question “What training does my refrigeration operator need?

In our experience, to get a good understanding of the Overview of ammonia refrigeration – the fundamentals of how it works – facility provided one-on-one hands-on training is the most effective training approach. This is the approach used for the vast majority of the skilled trades and it is proven effective. Unfortunately, if you don’t already have in-house expertise, there’s nobody to provide the training! A facility lacking on-site talent to act as trainers is when 3rd party providers can provide some value.

We’ve been getting a lot of questions lately centered around getting the best “bang for your buck” when using outside training providers. This post is solely about operator training. That is, the training we need to provide for our refrigeration operators that can be done by outside training providers – Process Safety training will be addressed briefly at the end.

If you don’t already understand that the training these providers offer is usually only going to address a small portion of the overall PSM training requirements, please read “What training does my refrigeration operator need?” before proceeding. I’ll reinforce a key point from that post though: The standard classes offered by most ammonia “schools,” even if they are done properly, only address a portion of the training burden – a small piece of the Overview of the Process requirement. You cannot send your personnel off to some 4-day class and get a qualified operator in return. (Buying a laminating machine doesn’t give you any authority to certify operators, but that’s another post. If you want credentials that matter, go to RETA)

We’re going to answer this question in three parts:

  • What kinds of programs are there?
  • What are the benefits and drawbacks of each training approach?
  • What training approach do we recommend?

 

What kinds of programs are there?

Broadly speaking, the available options break down into three groups:

  1. Self-directed
  2. Instructor based ON-site
  3. Instructor based OFF-site

Self-directed: You give your employee access to refrigeration books (such as the excellent RETA series) and they teach themselves the topic. You might also supplement this with online training which provides feedback and automated testing such as the RETA online training.

Instructor based On-site: Various training providers offer classes taught by an instructor at your facility.  These classes usually run 8-10 hours a day for 3-5 days.  With your approval, the class can use your refrigeration system for any illustration or “hands-on” purposes. If you have enough students, you can make these classes private – meaning only students from your company attend. This allows you to customize the content to reflect your policies. It also allows you to be a little more open about your practices and shortcomings in class discussions.

Instructor based Off-site: Various training providers offer classes taught by an instructor at the training companies “school.” These classes usually run 8-10 hours a day for 3-5 days.  Some of these training providers have built small refrigeration systems (“labs”) that they use to illustrate concepts during “hands-on” sessions. Like the on-site classes, if you have enough students, you can make these classes private.

 

What are the benefits and drawbacks of each training approach?

Program Type Pro Con
Self-directed
  • Lowest cost
  • Flexible scheduling (can be done during low demand times and in off hours)
  • Self-paced
  • Students can pick-and-choose relevant topics and avoid things that don’t apply to your system.
  • Online versions offer good documentation and testing feedback.
  • Bad fit for people that aren’t self-starters
  • Requires above-average reading comprehension skills
  • Questions need to be directed to on-site resources so if you don’t have them, you must reach out to contractors or industry colleagues.
Instructor based ON-site
  • Lower cost compared to Off-site because you avoid lodging, travel, travel time, and most meal expenses.
  • You can set up the class time block for a time convenient to your operations. Many facilities choose to schedule these classes during an off-season.
  • Students are available on-site in case of actual facility emergencies.
  • Instructor-based training can be more responsive and open to questions.
  • “Hands on” and procedural training can be done with your actual equipment and procedures & policies.

 

  • Higher cost compared to self-directed
  • While you can schedule the instruction for any convenient time block, once you have the time locked in, students need to be able to stay in the class during the entire time block.
  • Usually the minimum class size is 8-10 people, so you have to pull a lot of talent into this class or open it up to others. Once you open it up, you also lose the ability to customize the class.
  • There is a tendency to pull students out of the class during the instruction for maintenance “emergencies” more than is actually necessary.
  • Class pace is dictated by the class schedule and tends to move at the pace of the slowest learner in the group. 
  • Many facility’s lack adequate training classrooms. At a minimum, you need a quiet, comfortable space with a projector and screen.
  • Content is usually set, and your students may learn about a lot of equipment and technologies that aren’t applicable to your system. If you are performing a sole-company class, the content can be customized to your needs and equipment, but this may cost extra.
Instructor based OFF-site
  • Students are off-site and can’t be pulled for emergencies.
  • Instructor-based training can be more responsive and open to questions.
  • Most training providers provide clean, comfortable training classrooms.
  • Highest cost when you factor in travel costs, travel time, lodging, meals, etc.
  • You must arrange to meet the schedule of the training provider.
  • Your students are off-site and not available for any facility emergencies.
  • Even though the students are off-site, they will probably be pulled away for endless phone calls and teleconference meetings.
  • Class pace is dictated by the class schedule and tends to move at the pace of the slowest learner in the group. 
  • “Hands on” and procedural training are not done with your equipment and procedures & policies.
  • Content is usually set, and your students may learn about a lot of equipment and technologies that aren’t applicable to your system. If you are performing a sole-company class, the content can be customized to your needs and equipment, but this may cost extra.

 

What training approach do we recommend?

Unless your operators are natural autodidacts (PSM people often prefer learning out of books, for example) self-directed training is not a good fit for most operators. For most organizations, your best bet is instructor-based learning.

As with any training, the more relevant you can make it to your day-to-day operations, the more effective it will be. When you don’t have the on-site expertise to provide training, we think Instructor based ON-site training is the best choice for most organizations. It tends to be more focused on your equipment, procedures & policies and it is more cost effective than off-site training.

One last note: Be extremely mindful of your selection of a 3rd party provider for ANY training, because the instructor’s attitude and knowledge may well affect your safety culture.

PSM-ONLY Note: if you are looking for PSM training – training on how to be a PSM coordinator, or simply to better understand Process Safety systems – then we’d recommend the same as for operator training. But, most organizations don’t have someone sufficiently skilled to provide one-on-one training, so we’re left to seek a 3rd party. Unfortunately, most facilities don’t have enough people for a full class either, so you either need to combine with other facilities in your company (which allows you to have customized training on your policies & procedures) or combine with other organizations to get enough people for an in-house class. Because this is difficult to do, the Instructor based OFF-site option becomes the only one available. While we don’t provide Operator Training, we do offer PSM training.

 

Bonus editorial content: How important is “hands-on” training?

For the purposes of these classes, it is my opinion that the “hands-on” portion of these classes, as it is usually provided, is of little to no value. WHAT!? Allow me to explain:

  • Learning Styles: “But my operators all claim to prefer a ‘hands-on’ learning style!” or “Our operating staff are tactile learners” you say. The idea of learning styles is most likely a “neuromythology” – a popular idea that endures despite having little evidence to support it. In any case, these classes usually don’t really let them “operate” the system in any meaningful way so the “benefit” of “tactile” learning due to “hand-on” training is minimal…
  • “Hands-On”: I used to be an instructor in an organization that provided a lot of classes in the on-site and off-site instructor-based model. The organization provided a lab with “live” ammonia refrigeration systems. Typically, the students spent about a third of their time in this lab, in a group setting. In my opinion, this lab time had very little value for most students. Again, these classes usually don’t really let them “operate” the system in any meaningful way so they are just turning a few valves and conducting exercises in locating valves on PIDs. Certainly, you can manage that level of “hands-on” training at your facility! (I’m sure you can understand why: the liability in letting students operate equipment is HUGE.)

Furthermore, this lab equipment is not the same equipment in your facility, and I can assure you (unless you are woefully non-compliant with General Duty, General Industry standards and PSM/RMP) that their procedures & policies are not YOUR facilities procedures & policies. Most of the benefit that can be gained from “hands-on” training should be done at YOUR facility with YOUR equipment using YOUR procedures and policies. This is how and where the vast majority of your training should actually happen.

IIAR 2 202x Public Review 1

The IIAR has released a proposed draft of IIAR 2 Safety Standard for Design of Closed-Circuit Ammonia Refrigeration Systems for public review. Here’s the notice:

March 20th, 2020

To:

IIAR Members

Re:

First (1st) Public Review of Standard BSR/IIAR 2-202x, Safety Standard for Design of Closed-Circuit Ammonia Refrigeration Systems.

A first (1st) public review of draft standard BSR/IIAR 2-202x, Safety Standard for Design of Closed-Circuit Ammonia Refrigeration Systems is now open. The International Institute of Ammonia Refrigeration (IIAR) invites you to make comments on the draft standard. Substantive changes resulting from this public review will also be provided for comment in a future public review if necessary.

BSR/IIAR 2-202x specifies the minimum safety criteria for design of closed-circuit ammonia refrigeration systems. It presupposes that the persons who use the document have a working knowledge of the functionality of ammonia refrigerating system(s) and basic ammonia refrigerating practices and principles. This standard is intended for those who develop, define, implement and/or review the design of ammonia refrigeration systems. This standard shall apply only to closed-circuit refrigeration systems utilizing ammonia as the refrigerant. It is not intended to supplant existing safety codes (e.g., model mechanical or fire codes) where provisions in these may take precedence.

IIAR has designated the revised standard as BSR/IIAR 2-202x. Upon approval by the ANSI Board of Standards Review, the standard will receive a different name that reflects this approval date.

We invite you to participate in the first (1st) public review of BSR/IIAR 2-202x. IIAR will use the American National Standards Institute (ANSI) procedures to develop evidence of consensus among affected parties. ANSI’s role in the revision process is to establish and enforce standards of openness, balance, due process and harmonization with other American and International Standards. IIAR is the ANSI-accredited standards developer for BSR/IIAR 2-202x, and is responsible for the technical content of the standard.

This site includes links to the following attachments:

The 45-day public review period will be from March 20th, 2020 to May 4th, 2020. Comments are due no later than May 4th, 2020.

Thank you for your interest in the public review of BSR/IIAR 2-202x, Safety Standard for Design of Closed-Circuit Ammonia Refrigeration Systems.

There are MANY proposed changes. I’ll include a full list of the proposed changes at the end of the post, but here are some highlights:

  • Requirements for System Signage became a little simpler
  • Ammonia detection requirements have changed
    • Most installations now need two detectors in a machine room
    • Installation & Testing for detectors outside machine rooms now refer to external RAGAGEPs.
    • “Level 1” detection now requires liquid & hot gas shutoff at 150ppm
    • Requires AHJ approval if not installing ammonia detection in “Areas Other than Machinery Rooms”
  • New requirements for permanently installed Hoses and Corrugated Metal Fittings to ensure they meet ISO 10380 or ARPM IP-14

 

It’s important that YOU read these changes and make your voice heard if you have any input on them. 

 

Full change list of the normative sections of the standard below…


Continue reading

IIAR releases new ANSI/IIAR 9 standard

What you need to know about the new standard IIAR 9

IIAR 9-2020 has been officially released.

This is a new standard and it will require you to do certain things differently going forward.

 

What is it?

This document is a standard for minimum system safety requirements for existing closed-circuit ammonia refrigeration systems. The safety focus is on persons and property located at or near the premises where the refrigeration systems are located…

This standard provides a method to determine if existing stationary closed-circuit refrigeration systems using ammonia as a refrigerant comply with minimum system safety requirements.

For practical purposes it’s a way to deal with a system designed under an older RAGAGEP that doesn’t necessarily require you to update to the latest version of IIAR 2.

 

What’s the problem it’s solving?

How do you build a defensible case that your system built to an older code or standard is still designed, maintained, inspected, tested, and operating in a safe manner if it doesn’t meet the current code or standard? In PSM I refer to this issue as the d(3)(iii) trap. Here’s the relevant law:

1910.119(d)(3)(iii) For existing equipment designed and constructed in accordance with codes, standards, or practices that are no longer in general use, the employer shall determine and document that the equipment is designed, maintained, inspected, tested, and operating in a safe manner.

The way we traditionally did this is in the PHA where we either recommended the facility upgrade to conform to the latest version of the code or standard, OR has the PHA team build a defensible case that the alternative arrangement in the as-built / existing system was at least as safe as meeting the new code or standard. As you can imagine, this was not an easy thing to do.

 

How does this new standard affect me?

First, if you are already compliant with the current RAGAGEP (such as IIAR 2-2014a) then nothing much changes for you. If you are not compliant with the current IIAR 2 then it provides a different fallback position, because if you meet the requirements in IIAR 9, you now have an ANSI certified RAGAGEP that helps you defend the decision not to update to the current code or standard. Put another way: If your system is designed to IIAR 2-1999, then you might be able to use IIAR 9-2020 as an alternative to compliance with IIAR 2-2014a. 

Put in a flowchart, it looks like this:

Please note: this does not change NEW additions and systems – they are evaluated under current RAGAGEP. 

 

Is there anything else it requires?

The new standard requires an initial evaluation for IIAR 9 compliance within 5 years. It also requires that you re-evaluate that IIAR 9 compliance every 5 years thereafter.

 

How should I comply?

As with all compliance topics, there are lots of ways to get from here to there. I’m going with the EASIEST method which is: incorporate this analysis in your PHA. The requirements for evaluation methodology allow for a semi-quantitative technique for risk-ranking which is what you are already doing if you are using traditional IIAR PHA What-If / Checklist methodology.

To that end, I’ve converted every requirement in IIAR 9-2020 to a Checklist and included that checklist in with the existing PHA checklists for IIAR 2 compliance.

So, the next time you revalidate your PHA, if you use the new PHA templates you will automatically be performing this new required IIAR 9 evaluation. I’ve updated the PHA report template, the PHA worksheets, the PSI RAGAGEP letter templates, and the MI-EL1 to reflect these changes as well. Check the template change-log for details. 

A little help can go a long way!

Sometimes a little extra can go a long way to improve the effectiveness of your compliance efforts. I would like to show you how we used two simple, inexpensive laminated cards to improve the effectiveness of our APR inspections and Incident reporting / reactions.

APR Card

First, the APR issue:1910.134 has some requirements on inspections, cleaning, fit-check, etc. We require our service technicians to wear APR’s during Line-Opening. I created a small laminated card (about 5″x8″) that fits in their APR bag. With the included permanent marker, we can track the APR inspections for a year. The card also provides convenient information on the “Fit-Check” and “Monthly Inspection” procedures. Here’s the WORD document if you want to modify it for your use.

 

Leak Investigation / Incident Reporting

Our technicians are often called to look into reported ammonia odors. We’ve established a policy on doing this in compliance with 1910.119(n) concerning “handling small releases.” We also conduct Incident Investigations to meet the requirements of 1910.119(m). Again, I created a small laminated card (about 5″x8″) that fits in their APR bag.  It provides a quick-reference to the investigation procedure, as well as reminders of the information we’ll be asking them for. Contact numbers for company safety/compliance resources are also included. Here’s the WORD document if you want to modify it for your use.

 

Little items like this can reinforce your training. The easier “being compliant” is, the more likely it is to happen in the field! 

p.s. The Word documents are meant to be printed double-sided. I use 32# paper, trim, then seal with 5mil clear laminating envelopes. 

Why use the “buddy system” during Line Openings?

Most LEO (Line & Equipment Opening) policy a.k.a. “Line Break” policies require a second person away from the work but in the immediate area. It is reasonable to ask why the procedure demands this.

Put as simply as possible:

  1. PSM/RMP and IIAR 7 require procedures for Line & Equipment Openings. (or IIAR 7 alone if you have under 10k pounds)
  2. The PHA asks questions that identify hazards which result in administrative controls aka procedures. Those procedures will have to control the unique hazards identified in the PHA.
  3. RAGAGEP for procedures (such as IIAR 7) require the buddy system be addressed in Line & Equipment Opening procedures.
  4. HazMat & Firefighting history show it is useful.
  5. Human Nature tells us that people tend to hold each other accountable.

 

Let’s work through this step-by-step

1. PSM/RMP requires us to have a procedure:

1910.119(f)(4) The employer shall 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.

Put another way: We have to develop a written procedure on Line & Equipment Openings which everyone must follow.

 

2. Hazards identified during a PHA are often controlled with Administrative controls, such as SOPs. SOP content therefore must address the hazards identified in the PHA. Some examples:

…the Ammonia exposure increases while the operator is using an APR/SCBA? (II.8) This is what makes us mandate the use of a personal NH3 detector during line openings and leak investigations.

…there is inadequate isolation prior to maintenance? (HF.3) …the Ammonia pump-out for a length of piping or for a piece of equipment is incomplete? (PO.1) This is why SOPs include a pressure check to confirm pumpdown. This is also why the LEO procedure (and permit) require a written SOP & permit to check the effectiveness of the procedure.

…an injured worker is unable to summon assistance? (HF.56) This (among other reasons) is why we require a Buddy System. The LEO policy, in the General Precautions section, states “A buddy-system is used for all LEO procedures. The second person must be trained to initiate emergency action and must be stationed close enough to observe the activity but far enough away to ensure that they would not be endangered by an accidental release.”

 

3. The RAGAGEP for procedures IIAR 7-2019 has this requirement:

4.4.2 Buddy System. Operating procedures shall indicate when the buddy system shall be practiced in performing work on the ammonia refrigeration system

A4.4.2-The buddy system should be practiced for operations where there is the potential that ammonia could be released, for example, operations which involve opening ammonia refrigeration equipment or piping. The buddy system should also be practiced during emergency operations involving ammonia releases.

 

4. HazMat & Firefighting history: Hazardous Materials teams and Firefighters have long used a 2-person team for increased safety. To some degree, this is enshrined in OSHA rules in 1910.134(g)(3)…

1910.134(g)(3) Procedures for IDLH atmospheres. For all IDLH atmospheres, the employer shall ensure that:

1910.134(g)(3)(i) One employee or, when needed, more than one employee is located outside the IDLH atmosphere;

1910.134(g)(3)(ii) Visual, voice, or signal line communication is maintained between the employee(s) in the IDLH atmosphere and the employee(s) located outside the IDLH atmosphere;

While we don’t INTEND to work inside a IDLH atmosphere during a LEO procedure, the possibility certainly exists if something goes wrong. The “buddy system” allows the person performing the LEO to focus on the work while the second person remains in the area situationally aware and ready to respond in the event that the situation changes or something goes wrong.

 

5. Human Nature: The LEO policy is written around accountability. The policy requires that we demonstrate to a second person that we’ve followed the policy and adequately prepared for the work before the LEO occurs.  The “buddy system” tends to keep the actions “in-line” during the actual work.

Note: While it’s certainly possible  – from a regulatory view – that you could have certain specific LEO procedures that did not require a “buddy,” you would have to be able to document how you managed to address all of the issues outlined above without the second person.

Thanks to Bryan Haywood of SaftEng.net and Gary Smith of ASTI (Ammonia Safety Training Institute) for their time and thoughts in helping review this post.

OSHA fines getting more expensive again!

The Obama administration signed the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 which requires OSHA to adjust their fine amounts for inflation. 2020’s numbers are in: OSHA will adjust the fines by the  Consumer Price Index cost-of-living adjustment multiplier of 1.01764 which turns into a $230 increase for Serious and a $2300 increase for Willful / Repeat. The table below shows the new penalty amounts.

 

 

Memo File:  2020 OSHA Annual Adjustments

OSHA Raising Fines Again!

January 15, 2019- The Federal Civil Penalties Inflation Adjustment Act of 1990 as amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (Inflation Adjustment Act) requires the Department to annually adjust its civil monetary penalty levels for inflation no later than January 15 of each year. Adjustments are made by issuing a final rule that is effective on its date of publication in the Federal Register.

Source: https://www.osha.gov/penalties/2019InflationAdjustments.pdf

What can we learn from the Fernie Ammonia fatalities?

The October 17th, 2017 Ammonia release in Fernie, BC resulted in three fatalities:

On October 16, 2017, the curling brine chiller at the Fernie Memorial Arena was put back into operation after a seasonal shutdown. During the shutdown and seasonal maintenance, ammonia had been detected in the curling brine system, indicating that the curling brine chiller was leaking… A total of three people were found deceased in the mechanical room: the director of leisure services, the refrigeration operator, and a refrigeration contractor mechanic.

 

Three people died in a completely avoidable incident. If you want to know the particulars of the incident, I’d recommend you go read the Incident Report itself. While we can’t go back in time and avoid this particular incident, we can extract some valuable lessons from it to prevent a similar incident in the future.

There’s a lot that went wrong, but we’re going to focus on a few key failures in Mechanical Integrity, Process Safety, and Release / Incident Response. We’ll briefly discuss each failure and provide ten opportunities for improving your current Process Safety system.

Note: While this incident occurred in Canada, which does not have robust Process Safety regulation, we’re going to provide our analysis as if it was a PSM/RMP plant. Even if this incident had occurred in the US, the total system inventory was estimated at less than 1,000 pounds, placing it in the General Duty category. Most operators of these General Duty systems do not choose to implement a PSM system – hopefully this incident will cause them to re-evaluate that choice.

 

Equipment Age and installation: In 2011, the facility received a recommendation from their mechanical contractor to replace the chiller due to its age. It had been in service for about 24 years and had a life expectancy of 20-25yrs. (At the time of failure the chiller was in service for approximately 31yrs.) The facility actually budgeted for this replacement, deferred it, and then dropped the idea altogether. The report (and appendices) detail this decision making and indicates that the people making these decisions didn’t understand the underlying safety issues or the possible repercussions of these decisions. In part this was due to management turnover – the people who received the initial recommendation no longer worked at the facility when those recommendations were due to be implemented. Additionally, post-release, it was determined that the failed coupling was not properly supported.

Possible PSM citations: 1910.119(d)(3)(ii) for not installing the coupling per the manufacturers recommendations. 1910.119(d)(3)(ii) for equipment operating outside manufacturer’s recommended lifespan. 1910.119(e)(1) for the PHA not analyzing the hazards associated with operating outside the manufacturer’s recommended lifespan. 1910.119(j)(5) for operating the equipment with a known (service life) deficiency without assuring safe operation. 1910.119(m)(5) for not addressing and resolving a recommendation. (if the recommendation was made due to an indication of NH3 in the brine)

Opportunity #1: When a piece of equipment has a stated service life, you need to either replace the equipment per the recommendation or support your decision to keep it in service with a suitable engineering rationale.

Opportunity #2: When operators & contractors make recommendations, they need to provide CLEAR and defensible reasons for those recommendations.

Opportunity #3: When recommendations are delayed, deferred, or not completed, the operators & contractors need to ensure that the decision makers understand the implications of their decisions.

Opportunity #4: A Pre-Startup Safety Review (PSSR) and ongoing MI tasks need to ensure that equipment is installed correctly and maintained in a safe manner / arrangement.

 

Signs of Failure and Deficiency Response: The facility detected NH3 in the brine (by scent) in April of 2017 and then followed it up with a lab test of the brine showing over 3,000ppm of NH3 in June. The facility decided to continue operating the chiller and “monitor” it. A second test in August showed an NH3 concentration near 2,000ppm. Again, the facility decided to keep “monitoring” the situation. The report indicated that the personnel performing the tests and receiving the results didn’t understand the safety implications of them. Even after receiving the tests showing the chiller had failed, the facility decided to keep operating it. According to the report, there was no evidence the facility understood the hazards associated with a leaking chiller.

Furthermore, due to a miscommunication, the contractor believed the facility had taken the chiller out-of-service and they were preparing a bid to replace the leaking unit. The contractor’s recommendation to “monitor” the unit was likely meant to monitor it to see if the valves were leaking by, but the facility interpreted it as a go-ahead to continue operating the defective chiller until it could be replaced as long as they “monitored” it.

The contractor had no policy or procedure in place to deal with a failed chiller outside the usual troubleshooting, repair and replace activities. The investigators concluded that none of the people involved with the decision to continue operating the chiller had training or qualifications involving condition/risk assessment.

Possible PSM citations: 1910.119(j)(5) for operating the equipment with a known (integrity) deficiency without assuring safe operation. 1910.119(m)(5) for not addressing and resolving a recommendation. 1910.119(g)(1)(i) for not training personnel of the hazards associated with a leaking chiller.

Opportunity #5: Personnel reviewing test results need to understand the meaning of the test results and the safety implication of those test results.

Opportunity #6: When test results are provided to decision-makers, these results need to provide adequate information so that the decision-makers understand them and their safety implications.

Opportunity #7: When contractors are called to deal with deficient equipment, they will almost always provide guidance / estimates on how to repair / replace the equipment, but facilities should demand a risk assessment on continued operation of the equipment if they intend to continue its operation while planning and preparing for the repair / replacement.

From Appendix V of the report: “In the majority of instances, owner/operators relied heavily on the refrigeration contractor’s assessment of the equipment and evaluation of the NH3 indication in the brine samples. The owner is accountable for the safe condition and operation of the equipment but in some instances, deferment to the refrigeration contractor’s assessment and recommendations for the equipment was observed.”

Opportunity #8: When a facility outsources maintenance work, they often erroneously think that they are outsourcing the responsibility as well. It is important for a facility to understand that this remains their process and their responsibility. Ask tough questions of your contractors to ensure that you understand the condition of your system.

 

Facility and Contractor Incident Release Response: On the day of the release at 03:53 the machine room NH3 alarm registered 300ppm. Responding facility personnel observed the brine expansion tank shaking and spilling brine. At 04:30, the facility personnel shutdown the system and closed the chiller suction valve, observing that the shaking in the brine tank stopped. This should have indicated to the facility personnel that the separation between the brine and NH3 sides was completely compromised and that the brine loop was now full of ammonia. At 05:18 the facility personnel called the contractor to come in and re-configure the system to operate without the brine chiller.

At some point during the work, the personnel isolated the brine chiller, trapping the ammonia-laden brine in the chiller with no outlet available for it. As this ammonia-laden brine warmed up, the pressure inside the brine chiller rose and, at an estimated pressure of 30-150psig, a coupling on the brine-side of the brine chiller failed releasing the contents into the machine room and onto the personnel in the room. The estimated total NH3 release was 22 pounds (9lbs immediately vaporizing) resulting in an immediate concentration in the area of 20,000ppm which dissipated to about 5,000ppm over a period of 5 minutes.

The report uses electricity demand to conclude that the personnel did not attempt a pump-out of the brine chiller. Unlike a CSB report, the report does not go into the fatalities. We have no idea where the personnel were positioned in the room, or what – if any – PPE they were wearing at the time of the release. It can reasonably be surmised that they weren’t wearing any respiratory PPE at all.

Possible PSM citations: 1910.119(g)(1)(i) for not training personnel of the hazards associated with NH3 contaminated brine and the hazards of trapping it. 1910.119(h)(3)(ii) for the contractor not being trained in the hazards associated with NH3 contaminated brine and 1910.119(h)(2)(v) for the facility not ensuring this training occurred. 1910.119(n) for not providing “procedures to handle small releases.” 1910.119(f)(1)(i)(D) for not providing an emergency shutdown procedure. 1910.119(f)(1)(i)(E) for not providing an emergency operations procedure.

Opportunity #9: While we often train on the dangers associated with trapping NH3, the dangers of trapping NH3 contamination in a secondary loop is rarely discussed. Operator training in facilities that utilize secondary cooling loops must address contamination and its possible safety implications.

Opportunity #10: While it’s not possible to know for sure, it is extremely likely that all three of these fatalities could have been avoided if the personnel were wearing full-face APRs at the time of release. Note: They would have to have been wearing them, not have them “near-by.” APR’s aren’t magic.

 

090618 Update: Full WorkSafeBC Incident Report

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