Misunderstanding MOC

Recently a valve manufacturer that I respect posted a LinkedIn advertisement for one of their new relief valves. I love new technology so I was really interested in it but noticed something they posted in the graphic: “No PSM Changes required.” When we are replacing one valve for another and that valve is not an IDENTICAL replacement, this is VERY wrong.

Work through this with me here…

Changing a relief valve to a different type of valve would still require you to evaluate:

  • PHA: Does your PHA anticipate/support the use of this valve? It’s definitely classified as an engineering control (119(e)(3)(iii)) that needs to be part of your PHA.
  • PSI: Does it have the same capacity? Are your relief calculations still accurate?
  • MI/SOP: Is it maintained, inspected, installed and replaced the same way (1910.119(j)(2-5))?
  • Training: Are your people trained to maintain, inspect, install and replace it? (1910.119(j)(5))
  • PSSR: This definitely requires updated PSI (119(i)(1)), so not only does it require an MOC (1910.119(l)(4-5)) it requires a PSSR as well to ensure that the equipment is installed correctly and that:
    • Safety, operating, maintenance, and emergency procedures are in place and are adequate (119(i)(2)(ii))
    • Training of each employee involved in operating a process has been completed. (119(i)(2)(iv))

PHA: This is actually the element that should drive you to look at every other part of your PSM program mentioned here. In your PHA, you likely take credit for an engineered relief calculation (PSI element), a Maintenance Program (MI Element) including written procedures (MI & possibly SOP elements) and Training (Training element)

PSI: Let’s assume you check and it does have the same capacity: Don’t you want to take credit for this work and document it? I’ve never seen a relief calculation that didn’t show the relief valve model so won’t you want to update that as well? Do you have the new cut-sheet in your PSI IOM binder(s) and have you made your people familiar with it?

MI/SOP: Does the current MI schedule work for the new valve? Do the current maintenance, inspection, installation and replacement procedures work for the new valve? Again, even if they do, don’t you want to document that you looked?

Training: Have you conducted training on any differences you found in the elements above?

PSSR: Have you documented a PSSR that shows that the program has been updated, an MOC conducted (and closed out), written procedures provided and that training has been completed?

I am guessing they are trying to call this a Replacement in Kind but that is pretty sloppy thinking even if it were still the 90’s. Let me remind you of my favorite MOC guidance from the old OSHA PSM directive:

The standard requires that an MOC procedure be completed, regardless of whether any safety and health impacts will actually be realized by the change. The intent is, in part, to have the employer analyze any potential safety and health impacts of a change prior to its implementation. Even if the employer rightly concludes there would be no safety and health impacts related to a change, 1910.119(l)(1) still requires the employer to conduct the MOC procedure. The MOC requirements are important because many large incidents have occurred in the past when changes have been made and the employer either did not consider the safety and health impacts of the change, or did not appreciate (wrongly concluded) the potential consequences of the change before it was too late. Therefore, it is not only required, but important that the employer conducts an MOC procedure on each change, even those changes the employer believes will have no safety or health impacts.

Posted in Compliance, Good Engineering Practices, Management of Change | Tagged , , | Leave a comment

What the Ammonia refrigeration industry can learn from West, TX

Last night I attended the CSB Public Meeting in Waco, TX concerning the 2013 West, TX Ammonia Nitrate explosion. The purpose of the meeting was to release their report on the incident.

The explosion resulted in 15 fatalities and 260 injuries. When the incident first occurred, the media blamed the co-located Anhydrous Ammonia for the explosion. No knowledgeable person that saw the video of the explosion thought this was an ammonia fire. What you are witnessing below is not a deflagration (from Ammonia) but a detonation from Ammonia Nitrate.

During a break, I asked one of the investigators “How quickly did you know this wasn’t an Anhydrous Ammonia explosion?” His answer, “On day one!” Yet, still today we have articles blaming this explosion on Anhydrous Ammonia. I know several refrigeration plants that were inspected by OSHA and told that their inspection was caused by the incident in West, TX.

During the public comment period at the end of the night, Dr. M. Sam Mannan from the Mary Kay O’Connor Process Safety Center at Texas A&M delivered some great remarks.

“Unless we learn to make these changes happen, that is capture the lessons learned into our practices and activities, I am afraid that these well done and thoughtful investigation reports will not yield any beneficial outcome. The same is true with incidents involving other chemicals. Very few incidents involve unknown root causes or lessons learned. In fact, there is a sameness of all incidents and it seems to me that we are watching the same basic set of circumstances over and over again. The systematic root causes and lessons learned from all incidents are more or less the same. Right after any incident there is a big push to learn from the incident, and then quickly everything is forgotten and we resume business as usual.”

So, even though this wasn’t an Anhydrous Ammonia incident, what can the Ammonia refrigeration industry learn from West, TX? Here are my thoughts:

  • Understand that your RAGAGEP (Recognized and Generally Accepted Good Engineering Practices) evolves and so should your process.
  • Don’t leave recommendations from previous audits / inspections unaddressed.
  • Take the time to develop a relationship with your emergency responders and drill on the incidents you could face together.

RAGAGEP – In this incident, there were consensus standards that provided safer practices for storing the ammonia nitrate. The facility believed themselves “Grandfathered” and ignored evolving, improved practices that would have almost assured this incident couldn’t have happened. Takeaway question for you: When is the last time you updated and looked at your IIAR Ammonia Refrigeration Library?

Recommendations – The insurance carrier for the facility made several recommendations over a period of years and didn’t receive much response to them. After several years of difficulties, the insurance carrier dropped them as a client. That’s a red flag that you have some cultural problems! While none of the recommendations the insurance carrier made were likely to have directly prevented the incident, it is likely that the culture developed from fixing known problems would have led to fixing the previously mentioned RAGAGEP issues. Takeaway question for you: When is the last time you looked through your Compliance Audits, PHA, MI, Incident Investigations, etc. to make sure there aren’t some open items you could address?

Emergency Responders – There was essentially no communication to the emergency responders about the detonation hazards of ammonia nitrate. They had knowledge of the Anhydrous Ammonia and had even drilled on dealing with it, but they were completely unprepared for the possibility of an ammonia nitrate explosion. Takeaway question for you: When is the last time you had the local emergency responders out to your site for a tour and a discussion on the hazards they COULD face in an emergency?

Please consider these three things above at your facility. Your efforts could mean we get to avoid going to a future CSB event concerning your facility.

On a personal note: The couple sitting directly in front of me lost their son, a volunteer firefighter, to the blast. One of the CSB investigators came over to talk with the family and spent a few moments discussing who he was as a person. It was a very emotional thing and I applaud the investigator for taking a little bit of time last night to acknowledge the victims as people, not just as statistics. The board started the meeting with a moment of silence for the victims, which was also appropriate and appreciated.

The CSB has had a rough few years, but what I saw last night gave me renewed hope.

Link: Photos from last night

Link: Previous post on the incident including photos of the damage.

Update: Link to new CSB Video that provides a nice overview

Posted in Community Involvement, Compliance, CSB, Culture, Good Engineering Practices, Incidents | Tagged , , , | Leave a comment

A little memo with some very big implications

 

Memo of Understanding between the DOL and DOJ:

The U.S. Department of Labor (DOL) and the U.S. Department of Justice (DOJ), recognizing the importance of ensuring the health and safety of America’s workforce, enter into this memorandum of understanding (MOU) to provide for coordination of matters pertaining to worker safety that could lead to criminal prosecution by DOJ. This MOU establishes a process and framework for notification, consultation and coordination between DOL and DOJ to aid both agencies in more effectively implementing our nationa l workplace statutes.

That means, that employers now face prison terms of up to 20 years instead of the paltry 6 months for OSHA violations if they are convicted of certain crimes that contribute to the deaths of employees.

More from the memo to US Attorneys:

Prosecutors can make enforcement meaningful by charging other serious offenses that often occur in association with OSH Act violations – including false statements, obstruction of justice, witness tampering, conspiracy, and environmental and endangerment crimes. With penalties ranging from 5 to 20 years’ incarceration, plus significant fines, these felony provisions provide additional important tools to deter and punish workplace safety crimes.

Below is the actual Memorandum of Understanding between the DOL and DOJ as well as the Memo explaining the initiative to the US Attorneys.

Links:

EHS Article

Memo to US Attorneys re Worker Endangerment Initiative

Memorandum of Understanding between DOJ and DOL re Worker Safety

 

Posted in Community Involvement, Compliance, OSHA | Tagged | Leave a comment

OSHA fines to rise 80%?

OSHA Defense Report says that the  “Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015,” gives OSHA the green light to increase penalty amounts to catch up with cost of living adjustments since the last time OSHA’s civil penalties were raised (1990).

The changes would bring the maximum  fines to $12,000 for a Serious Violation and $120,000 for a Repeat or Willful violation.

I’d like to think that the safety of employees & the public was enough to ensure compliance, but the reality is that even these fine structures are probably too LOW to motivate recalcitrant employers.

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OSHA Memo on RAGAGEP

Link to OSHA publication – Highlights (underline) are mine. Note that they reference the CCPS again. The really good stuff is at the bottom in the notes to the inspectors.

 

MEMORANDUM FOR: REGIONAL ADMINISTRATORS AND STATE PLAN DESIGNEES
THROUGH: DOROTHY DOUGHERTY
Deputy Assistant Secretary
FROM: THOMAS GALASSI Director
Directorate of Enforcement Programs
SUBJECT: RAGAGEP in Process Safety Management Enforcement

This memorandum provides guidance on the enforcement of the Process Safety Management (PSM) Standard’s recognized and generally accepted good engineering practices (RAGAGEP) requirements, including how to interpret “shall”  and “should”  language in published codes, standards, published technical reports, recommended practices (RP) or similar documents, and on the use of internal employer documents as RAGAGEP.  Enforcement activity, including the Petroleum Refinery Process Safety Management National Emphasis Program (Refinery NEP), and requests for assistance from the field, revealed the need for guidance on the PSM standard’s RAGAGEP provisions.

Background on Recognized and Generally Accepted Good Engineering Practices

The PSM Standard, 29 CFR 1910.119, directly references or implies the use of RAGAGEP in three provisions:

  • (d)(3)(ii):  Employers must document that all equipment in PSM-covered processes complies with RAGAGEP;
  • (j)(4)(ii):  Inspections and tests are performed on process equipment subject to the standard’s mechanical integrity requirements in accordance with RAGAGEP; and
  • (j)(4)(iii): Inspection and test frequency follows manufacturer’s recommendations and good engineering practice, and more frequently if indicated by operating experience.

In addition, (d)(3)(iii) addresses situations where the design codes, standards, or practices used in the design and construction of existing equipment are no longer in general use.

The PSM standard does not define RAGAGEP. However, the Refinery National Emphasis Program (CPL 03-00-010) references the definition found in the Center for Chemical Process Safety’s (CCPS)Guidelines for Mechanical Integrity Systems:

“Recognized And Generally Accepted Good Engineering Practices” (RAGAGEP) – are the basis for engineering, operation, or maintenance activities and are themselves based on established codes, standards, published technical reports or recommended practices (RP) or similar documents. RAGAGEP detail generally approved ways to perform specific engineering, inspection or mechanical integrity activities, such as fabricating a vessel, inspecting a storage tank, or servicing a relief valve.

As used in the PSM standard, RAGAGEP apply to process equipment design, installation, operation, and maintenance; inspection and test practices; and inspection and test frequencies.  RAGAGEP must be both “recognized and generally accepted” and “good engineering” practices.

The PSM standard allows employers to select the RAGAGEP they apply in their covered processes .

Primary Sources of RAGAGEP

  1. Published and widely adopted codes

    Certain consensus standards have been widely adopted by federal, state, or municipal jurisdictions.  For example, many state and municipal building and other codes incorporate or adopt codes such as the National Fire Protection Association (NFPA) 101 Life Safety and NFPA 70 National Electric codes.  Such published and widely accepted codes are generally accepted by OSHA as RAGAGEP, as are Federal, state, and municipal laws and regulations serving the same purposes.

  2. Published consensus documents

    Certain organizations like the American Society of Mechanical Engineers (ASME) follow the American National Standards Institute’s (ANSI) Essential Requirements: Due process requirements for American National Standards (Essential Requirements) when publishing consensus standards and recommended practices.  Under the ANSI and similar requirements, these organizations must demonstrate that they have diverse and broadly representative committee memberships.  Examples of published consensus documents include the ASME B31.3 Process Piping Code and the International Institute of Ammonia Refrigeration’s (IIAR) ANSI/IIAR 2-2008 – Equipment, Design, and Installation of Closed-Circuit Ammonia Mechanical Refrigerating Systems.  Published consensus documents are very widely used as RAGAGEP by those knowledgeable in the industry, and are accepted as RAGAGEP by OSHA.

  3. Published non-consensus documents

    Some industries publish non-consensus engineering documents using processes not conforming to ANSI’s Essential Requirements.  For example, the Chlorine Institute’s (CI) “pamphlets” focus on chlorine and sodium hypochlorite (bleach) safety.  Where applicable, the practices described in these documents are widely accepted as good practices and used in industries handling these materials.  Similarly, CCPS publishes an extensive set of guideline books, some, but not all, of which deal with process equipment specific topics, e.g., the Design Institute for Emergency Relief Systems’ technology for reactive and multi-phase relief systems design1.  Peer-reviewed technical articles addressing specific hazards may also fall into this category and may be considered when published standards or recommended practices are not available or are not adequate to address specific hazards. OSHA may accept such materials as RAGAGEP where applicable and appropriate.

    Note that 29 CFR 1910.119(j)(4)(iii) also recognizes applicable manufacturer’s recommendations as potential sources of RAGAGEP.

“Appropriate Internal Standards”

The preamble to the PSM standard recognizes that employers may develop internal standards for use within their facilities. The preamble states, in relevant part:

The phrase suggested by rulemaking participants: “recognized and generally accepted good engineering practices” is consistent with OSHA’s intent. The Agency also believes that this phrase would include appropriate internal standards of a facility . . .2 [emphasis added].

The preamble, however, does not imply that employers may disregard applicable published RAGAGEP.3  Internally developed standards must still represent “recognized and generally accepted good engineering practices.”

Facility internal standards can serve a number of legitimate purposes, including:

  1. Translating the requirements of published RAGAGEP into detailed corporate or facility implementation programs and/or procedures.
  2. Setting design, installation, maintenance, inspection, and testing requirements for unique processes, equipment, and hazards for which no published RAGAGEP exists.
  3. Supplementing (or augmenting) published RAGAGEP that only partially or inadequately address the employer’s processes, occupancies, conditions, and hazards. In this situation OSHA (and often the publisher) expect employers/users to supplement the published RAGAGEP with their own applicable practices, protocols, and procedures to control hazards.4
  4. Controlling hazards more effectively than the available codes, standards, or practices.
  5. Addressing hazards when the codes and standards used for existing equipment are outdated and no longer describe good engineering practice.

Employers’ internal standards must either meet or exceed the protective requirements of published RAGAGEP where such RAGAGEP exist.  OSHA has rejected employer standards that deviated from published RAGAGEP where the deviations were less protective than the published requirements.

“Shall” and “Should” in RAGAGEP

“Shall,” “must,” or similar language used in published RAGAGEP reflects the developer’s view that the practice is a mandatory minimum requirement to control a hazard.  Similarly, “shall not,” “prohibited,” or similar language references or describes unacceptable approaches or practices.  If an employer deviates from “shall” or “shall not” requirements in the employer’s adopted RAGAGEP (or applicable RAGAGEP if the employer has not specified RAGAGEP), OSHA will presume a violation.

Use of the term “should” or similar language in the RAGAGEP reflects an acceptable and preferred approach, in the view of the publishing group, to controlling a recognized hazard.  If a selected RAGAGEP provision is applicable to the covered process or particular situation, OSHA presumes that employer compliance with the recommended approach is acceptable.

If an employer chooses to use an alternate approach to the one the published “should” RAGAGEP says applies, the CSHO should evaluate whether the employer has determined and documented that the alternate approach is at least as protective, or that the published RAGAGEP is not applicable to the employer’s operation.  In the absence of such documentation, the CSHO should examine documents, such as relevant process hazards analyses (PHAs) and management of change procedures (MOCs), to determine if the employer’s approach is as protective as the published RAGAGEP and is a good engineering practice. This may require consultation with Regional resources or the OSHA National Office (see below).

“Should not” or similar language describes disfavored or less than fully protective practices.  Following such disfavored practices is presumed to be violative.

For technical help, consult with your Regional PSM Coordinator, technical support engineer, or contact the PSM group at OSHA’s Directorate of Enforcement Programs – Office of Chemical Process Safety and Enforcement Initiatives at 202-693-2341.

“Normative” and “Informative” Requirements.

Published codes and consensus documents frequently contain appendices or annexes that provide supplemental information and/or requirements.  The content of these appendices or annexes may be “normative” or “informative.”   “Normative” sections generally explain how to comply with the published code and/or consensus document requirements and may contain both “shall” and “should” language.  As discussed above, “shall” denotes the developer’s view that the normative statement is mandatory, while “should” indicates an acceptable or preferred approach.  “Informative” sections generally provide background and reference information with respect to the published code and/or consensus document requirements but may also identify and/or address hazards or acceptable means of abatement. Again, for technical help, CSHOs should consult their Regional PSM coordinator, technical support engineer, or the Office of Chemical Process Safety and Enforcement Initiatives.

Other Uses of RAGAGEP Materials in PSM

Only the three sections of 1910.119 referenced above require compliance with RAGAGEP. However, RAGAGEP can also provide useful background and context, and can help CSHOs identify and document hazards and feasible means of abatement when reviewing other aspects of the employer’s PSM program and covered equipment.

Enforcement considerations

In accordance with 1910.119, employers select the RAGAGEP with which their equipment and procedures must comply.  In evaluating RAGAGEP compliance, CSHOs should be aware of a number of potential issues:

  1. There may be multiple RAGAGEP that apply to a specific process.  For example, American Petroleum Institute (API), RP 520 Sizing, Selection, and Installation of Pressure-Relieving Devices in Refineries Part II – Installation, and International Standards Organization, Standard No. 4126-9,  Application and installation of safety devices, are both RAGAGEP for relief valve installation and contain similar but not identical requirements.  Both documents are protective and either is acceptable to OSHA.
  2. Employers do not need to consider or comply with a RAGAGEP provision that is not applicable to their specific worksite conditions, situations, or applications. 
  3. Some employers apply RAGAGEP outside of their intended area of application, such as using ammonia refrigeration pressure vessel inspection recommended practices in a chemical plant or refinery process.  Use of inapplicable RAGAGEP can result in poor hazard control and can be grounds for citations.
  4. There may be cases where fully applicable RAGAGEP do not exist to control hazards in an employer’s covered process.  As discussed in “Appropriate Internal Standards”, above, the employer’s internal standards (guidance and procedures) are expected to address the process hazards.  Whether the internal standards are adequately protective should be reviewed on a case-by-case basis.
  5. An employer’s internal standards may be more stringent than the relevant published RAGAGEP.  More-stringent standards may be needed to adequately control hazards due to the unique characteristics of the employer’s process.  This should be documented.  Employers that meet published RAGAGEP requirements, but that fail to comply with their own more stringent internal requirements, may be citable under other PSM provisions:
    • If there is a failure to follow more stringent internal Inspection & Test (I&T) procedures, consider citations under 1910.119(j)(2) for failure to implement their written I&T procedures
    • Process equipment may be outside acceptable limits defined in the employer’s PSI.  If so, consider citations under 1910.119(j)(5).
    • Additional or more stringent equipment safeguards may be specified by employers based on findings and recommendations from PHAs and supporting documents, such as Layers of Protection Analyses, siting studies, human factors studies, Quantitative Risk Assessments, and similar risk management activities, as well as Incident Investigations, or Management of Change procedures. Failure to implement or complete documented actions-to-be-taken may be cited under the relevant section of the Standard (e.g., 1910.119(e), (l), or (m)).
  6. Selectively applying individual provisions from multiple RAGAGEP addressing similar hazards might be inappropriate.  Standard writing organizations develop their requirements as packages and mixing-and-matching provisions from multiple sources could result in inadequately controlled hazards.  This situation should be evaluated on a case-by-case basis. Consult the regional PSM Coordinator, regional engineering support, or the Office of Chemical Process Safety and Enforcement Initiatives if you are uncertain how to proceed.
  7. The PSM standard requires employers to document that their inspection and testing of equipment, required under 1910.119(j)(4)(ii) and (iii), is in accordance with their selected RAGAGEP, (e.g., as referenced in the written procedures required by 1910.119(j)(2)).  Failure to do so is citable.
  8. In accordance with 1910.119(d)(3)(ii), employers must document that their covered process equipment and equipment whose operation could affect that process equipment comply with RAGAGEP (equipment built to older standards may come under 1910.119(d)(3)(iii), see paragraph 10 below).  Equipment that does not comply with RAGAGEP cannot be documented as compliant.  Therefore, both the failure to document compliance and the deviations from compliance with RAGAGEP can be cited under (d)(3)(ii).

    When writing 1910.119(d)(3)(ii) RAGAGEP-related citations, always cite the employer for failing to document compliance with recognized and generally accepted good engineering practices, describe the hazard, e.g., exposure of employees to fire, explosion, or toxic hazards, and reference the RAGAGEP selected by the employer.  If the employer has not specified an applicable RAGAGEP, use “such as” language to reference an applicable published RAGAGEP.

  9. Equipment covered under PSM’s Mechanical Integrity provisions (listed in 1910.119(j)) that is outside acceptable limits, as defined by the process safety information (including RAGAGEP), is deficient under 1910.119(j)(5).  Employers are required by this provision to correct deficiencies before further use or in a safe and timely manner when necessary means are taken to assure safe operation in the interim.  If an employer fails to correct the deficiency before further use, or fails to implement adequate interim measures and to schedule a permanent correction timely, the failure may be cited under 1910.119(j)(5).  If an employer has implemented interim measures and scheduled correction, additional investigation may be required to determine whether the interim measures are adequate and the scheduled correction is timely. 1910.119(d)(3)(ii) and (j)(5) citations are often grouped.  Consult your Regional OSHA support staff and/or SOL if you are uncertain if grouped citations are appropriate.

    Note, in the case where an employer is operating deficient equipment based on the use of interim safeguards pending final correction of the deficiency, 29 CFR 1910.119(l) requires that the employer develop and implement a management-of-change procedure for the continued safe operation of the equipment.

  10. Older covered equipment may not have been designed and constructed under an applicable RAGAGEP because none existed at the time of design and construction. Alternatively, the equipment may have been designed and constructed under provisions of codes, standards, or practices that are no longer in general use.  In such cases, 29 CFR 1910.119(d)(3)(iii) requires employers to determine and document that the equipment is designed, maintained, inspected, tested, and operating in a safe manner.  Failure to do so may be cited under 1910.119(d)(3)(iii).

    When writing 1910.119(d)(3)(iii) citations, always cite the employer for failing to determine and document that the relevant equipment design, maintenance, inspection and testing, and/or operation ensure the safety of the equipment.

    If the employer has adopted an appropriate internal standard applicable to such older equipment, 29 CFR 1910.119(d)(3)(ii) requires the employer to document that the equipment complies with the internal standard.  Failure to do so may result in a citation under 29 CFR 1910.119(d)(3)(ii).

  11. When a 29 CFR 1910.119(d)(3)(ii) or (iii) citation is under consideration, it is important to establish and to document the age and installation date of the relevant process and equipment, and the dates and extent of process and equipment modifications, as well as the exact RAGAGEP selected by the employer, including the edition and publication date.
  12. Organizations that publish RAGAGEP may update them based on newly identified or recognized hazards; improved understanding of existing hazards; industry operating experience; and/or incidents indicating that more stringent hazard control is needed. If the updated RAGAGEP explicitly provides that new clauses or requirements are retroactive, OSHA expects employers that have selected that RAGAGEP to conform to those provisions. Where RAGAGEP are updated to be more protective but are not explicitly retroactive, PSM does not mandate that employers upgrade their equipment, facilities, or practices to meet current versions of their selected RAGAGEP.  However, OSHA does expect employers to address issues raised by or identified in the updated RAGAGEP in accordance with 1910.119(d)(3)(iii) by determining and documenting that their equipment is designed, maintained, inspected, tested, and operating in a safe manner. This can be accomplished through a variety of approaches, such as but not limited to the PHA revalidation and management of change (MOC) processes, or through corporate monitoring and review of published standards. Citations for 29 CFR 1910.119(d)(3)(iii), either stand-alone or grouped with, for example, (e)(3) or (l)(1), may be appropriate if the employer fails to address the issues (see item 8 above).
  13. Notify the Office of Chemical Process Safety and Enforcement Initiatives if you encounter RAGAGEP that appear to have changed to be less protective or that are being interpreted by employers in a manner that is less protective. In the past, OSHA determined that specific provisions in published guidance documents were not RAGAGEP (i.e., OSHA believed that some written practices provided inadequate protection and were not good engineering practices; therefore, the specific practices in question could not be RAGAGEP).  Such determinations should only be made in consultation with the Office of Chemical Process Safety and Enforcement Initiatives.
  14. When writing 1910.119(j)(4)(ii) citations, always cite the employer for failing to follow RAGAGEP in its inspection and testing procedures, and reference the relevant RAGAGEP adopted / recognized by the employer.  If the employer has not specified an applicable RAGAGEP, use “such as” language to reference an applicable published RAGAGEP.  When the employer’s I&T procedures comply with RAGAGEP, but are not implemented or followed, consider 1910.119(j)(2) citations.
  15. When writing 1910.119(j)(4)(iii) citations, always cite the employer for not inspecting and/or testing process equipment at frequencies consistent with applicable manufacturers’ recommendations and good engineering practices, or more frequently if indicated by prior operating experience, i.e., based on the condition of the equipment when previously inspected or tested.
  16. When writing RAGAGEP-related citations when the employer has not specified a RAGAGEP, CSHOs should be careful to reference in the citation’s alleged violation description only RAGAGEP that are actually applicable to the equipment and process being inspected.  CSHOs have sometimes referenced inapplicable API relief valve RAGAGEP in citations involving ammonia refrigeration processes.

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Change is coming to the Industrial Refrigeration world…

I have seen the future and it is going to mean some very large changes for the Industrial Refrigeration industry. As always, I want to talk about something else, before I get to my point…

I want to talk about Cold Storage / Distribution Warehouses. My first refrigeration job was in an Ice Cream plant that had the traditional, old-school distribution model. People placed packages on pallets manually, picked up the pallets with lifts, put them in racks, and recorded it on a log. Later, when the product was needed, they pulled the pallets down with a lift, took off the packages they needed and placed them on a separate pallet. Forklift drivers took the finished pallets and put them on trucks. It was very labor intensive, required the people to work in brutal environments (-20f at the warmest) and was a little hit-and-miss when it came to inventory tracking. Still, it worked and many people had been doing it their whole careers.

A few years down the road I was at a grocery distribution warehouse. They had added some fancy computer tracking system that told them through a headset what rack to go to. All the packages were scanned when they were put on a pallet or taken off. Still, it was very labor intensive and still awfully cold for the employees.

A few years ago I was at a restaurant supply distribution warehouse that was nearly fully automated. Pallets came off the trucks, were moved to racks by robots. When the pallet was needed for an order, it was removed from the racks by a robot and then put on the floor so people could pick the package they needed. It removed a lot of the labor and nearly all of the rack damage.

A few weeks ago I was in a distribution warehouse for a major retailer. Thousands of SKU’s. Robots did it all. People took the pallets off the trucks and scanned them – from there the robots stored them, picked packages from them, even created the pallets for shipping. Hell, the thing arranged the packages on the pallet so that the employee at the store could pick from the top down and only have to travel one way at the store to re-stock the shelves. The only people left in the operation were the people who unloaded the original pallets from the trucks, loaded the finished picked pallets on the trucks, and the people who maintain the robots.

Check out this video from EDNA International to see how this sort of system works:

Amazing isn’t it? Now think about how many people aren’t needed in these distribution warehouses due to these robots. About 95% of the people that used to work in this warehouse aren’t needed anymore. The few jobs that remain are extremely low-skilled (janitorial, pallet jack operator) and extremely high-skilled such as PLC programmer, electrician, maintenance. All the middle-skill jobs are gone. The sorters, pickers, supervisors, lift operators – They’ve all been replaced by automation.

Ok, now let’s get back to Ammonia refrigeration. I was talking with a colleague about a month ago that was struggling with operating his refrigeration systems. Not because they were problem systems, but because he didn’t have the people he needed to operate them the way they had traditionally operated them. They weren’t available at the wage his employer was willing to pay. He thought that something was happening with wage growth for refrigeration operators.

Traditionally, the refrigeration system was operated by skilled technicians – usually the best the maintenance department had to offer. You trained these already good people in the art & science of refrigeration and they were the caretakers of the system. Then something interesting happened as the equipment and the system design became more complex. The job got harder in some ways and easier in others. Refrigeration system automation made running the systems easy, and fixing them really tough. There were completely new skills needed and those skills were in very high demand.

It reminded me of what happened to the car industry. It used to be that anyone with a bit of sense could maintain a vehicle. With a little trial and error and a Chilton’s manual, you could learn to fix it. As those cars got more complex, the job got beyond the skill and training that the normal person has. The job market for auto mechanics lost the middle. There are jobs to drain oil and they don’t pay enough to make ends meet. At the other end of the spectrum there are jobs that require computer skills, electrical troubleshooting, advanced diagnostics, etc. and those jobs pay very well because there aren’t many people that possess all those skills.

While I was standing in this amazing automated warehouse, watching the robots whir around me at unbelievable speed, I had a moment when some things clicked in my head. I think the days of the blue collar refrigeration mechanic are almost over. It pains me to say this, because I’ve come to love and admire this workforce over the past decade, but I think the writing is on the walls. Like in auto mechanics, and distribution warehouses, the middle in the refrigeration industry is being hollowed out. I’m not particularly happy about it, but I don’t think it’s avoidable.

So, what does the future look like? Here’s my guess:

  • Very automated computer-controlled refrigeration systems with redundant capacity and safeties.
  • Low-skill (and sadly, low-wage) employees that monitor that system and perform walk-through’s to observe its operation.
  • A small, very high-skill, very high-wage group of employees (or contractors) that troubleshoot and maintain the system.

I’ve actually talked to a couple people that already run their systems this way. Normal, everyday tasks such as system monitoring is done by low-skill, low-pay employees. They receive enough training to not be a danger to themselves and others, but once they get to an issue they call a regional engineer or an outside contractor. Routine maintenance (draining oil pots, cleaning condensers, calibrating sensors, etc.) is all outsourced to highly skilled contractors.

If you are currently in the middle of the refrigeration workforce, this doesn’t come as good news. You may want to consider up-skilling to grab those high-skill high-pay regional / contractor jobs. I could be wrong, but I think if you discuss this at your next RETA meeting or maintenance get-together, you’ll find out that it’s already happening.

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Interesting link at NPR – Will your job be done by a machine?

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Opinion: Why many Safety Programs fail to get results

The question that vexed me

Over the past few years as a traveling PSM auditor I was exposed to hundreds of different safety programs. There were small, flat organizations with dozens of workers and large international conglomerates with thousands of workers and layer upon layer of bureaucracy. When I started doing audits, I had (erroneously) expected that the large organizations would have better programs than the smaller ones because they had so many resources at their disposal. I had thought that these resources: Time, Money, Experience, etc., would result in a superior program. What I found was something quite different.

Resources are important, and many a program suffers from a lack of them. It turned out though – at least from my observations – that once you had a certain threshold of resources, they were not a determining factor in the success of the programs. Put another way: you needed *enough* Time, Money and Experience to have a successful Safety Program, but having extra didn’t seem to make it better. More often than not, the places I went with large, complex Safety Programs had worse on-the-ground performance than their smaller, relatively resource-poor, counterparts.

Things like this really bug me. When I find something that seems to contradict conventional wisdom it causes a little voice in my head to continuously pester me with “what are we missing?” These kinds of questions lead me to stare into the darkness in many a hotel room pondering “big” questions on Safety Programs.

Summed up it went something like this: If the conventional wisdom of “MORE Resources = MORE safety,” isn’t as big of an issue as I’d assumed, then what else was at play? It’s a questions I asked myself (and any other safety professional that would listen) for years until I stumbled across what I think is the biggest safety issue facing us today.

The stumble

“Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing had happened.” –Winston Churchill

Two experiences set me up for a realization that would totally alter the way I approached safety programs. One was with a young engineer and the other was with a somewhat confused cashier at a rural Kansas Wendy’s.

Wendy’s first: I am a simple man when it comes to my interactions with clerks, fast-food attendants, etc. I figure out what I want from the person, then I turn that thing I want into as few simple words as possible and tell that person those words. In this particular interaction I wanted a Combo #4 with no onions and Diet Coke. The conversation started something like this:

Attendant: Can I help you?

Me: Combo #4 – no onions – with a Large Diet Coke

Attendant: Did you want the sandwich or the meal?

Me: The combo

Attendant: Did you want fries?

Me: Doesn’t the combo come with fries and a drink?

Attendant: You can get other things too. It comes with fries unless you want something else.

Me: Other than the no-onions bit, just give it to me as it comes then.

Attendant: So, yes. You want fries.

Me: …and a Large Diet Coke

Attendant: You want a drink too?

Me: …a Large Diet Coke…

This went on for quite a while. At no point did the attendant look up from her screen and it was obvious that she was struggling with turning what I wanted into the button presses that would tell the ordering system to get it for me. If you have traveled, you know this type of experience from countless rental car, airline and hotel clerks: The system isn’t taking the information the way that the people involved are trying to give it. The clerk is now trying to interpret the real-world information in a way that the system understands it. If I had a dollar for every time I heard “The system isn’t letting me…” I’d be hiring Bill Gates as a clown for my grandkid’s birthday parties.

You see, the system was designed around the needs of the programmer. The programmer had to deal with the needs of the person entering the information, the people making the food, the needs of the accountants, the needs of the inventory system, etc. The easy design choice for the programmer is to come up with a single interface that gives everyone that uses it what they need. Unfortunately, when you design like this you end up with a system that tries to be everything to everyone in the same way at the same time.

This is a broken system – the system for taking information need to be designed around the needs of the person entering it. The system should then translate that information to fit the needs of the person using that information whether they are cooks, accountants or managers.

Which brings me to my young engineer. He had produced a large spreadsheet to validate relief calculations. It was very impressive and just chock-full of numbers. It was also unintelligible to anyone that wasn’t an engineer. I couldn’t make much sense of it and showed it to another engineer who scratched his head, looked at it for a few minutes, and started: “I think what he did here was….”

It turns out the calculations were quite right and very defensible – assuming you had an engineer to translate it. For a compliance/safety document, that’s a bad design! The engineers found the document quite acceptable – it met their needs and provided the engineering basis for their design. What it didn’t do was meet the needs of the people using the document to prove compliance. Working with the engineers, we were able to “pretty up” the spreadsheet so it explained itself. We put another sheet in front of all the calculations that pulled the information from the engineering sheets and put it in a manner that any reasonably competent person could understand.

The false realization

To my mind, these were similar situations. In fact, I actually thought of the Wendy’s conversation while working with the engineers. I wondered, if this was occurring in engineering departments and fast-food places, would it explain the implementation problems I had been seeing nation-wide in Safety Programs?

I came up with a little motto that I used for a year or two, thinking that it explained the problem: The systems we are creating are too complex for the people that are implementing them.

Unfortunately, many people took this concept and blamed the PEOPLE. This was not my intent and the results of blaming the people actually made it worse. What management did with this concept was move implementation tasks even further away from the people on the ground. They assigned these programs to ever-higher levels of the company where extremely competent people designed extremely elaborate programs that ultimately further insulated the end user from the Safety Program. Now safety messages, policies and procedures were dictated from on-high. This actually made things far worse.

The realization – Where I went wrong and how it stands now

They were addressing a causal factor – people not understanding the system – rather than the root of the problem which was that the system was poorly designed or explained.

In a moment of brutal honesty, an operator once answered my question about an Emergency Response policy with something along the lines of “You know, they have a lot of these policies. It’s page after page of stuff. I need to make a split-second decision and that binder (referencing a 100+ page Emergency Action / Response program) doesn’t help me. They give a lot of this stuff but I just have to ignore it in an emergency and rely on what I know. ”

We looked through that binder and after about 15 minutes we eventually did find the answer we were looking for. It was buried somewhere in the middle of all these pages that all looked the same. The operator had a point, didn’t he? Do we actually expect an operator responding to an emergency so sit down, pull out a chair and thumb through a binder while the emergency is occurring? An Emergency Response policy that isn’t useful in an Emergency is a system failure.

That’s not the fault of the operator. The problem IS the system. A system that doesn’t meet the needs of the people implementing it is a broken system. Here’s the situation as I explain it now:

The systems we are creating are not providing guidance in a manner that meets the needs of the end-user.

Addressing this problem statement is much more fruitful. Sometimes we get caught up in “compliance” and “policy” and forget that their are real people at the end of that policy.

A function Safety Program is a system.

Design that system so that the people implementing it understand the guidance it provides.

A functional Safety Program has to be relevant to the needs of the implementer.

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Shock to the system

The CSB just released a video on the August 23, 2010 Alabama ammonia release. While not perfect, it is a worthwhile video to watch as it might just make you question how you should deal with the type of power-failure issues that were a part of this release.

In conjunction with the PHA, a properly prepared / followed SOP could easily anticipate these events and mandate safe steps to ensure that these issues could be addressed safely.

I think the recommendations made by the CSB makes are too broad, but you can certainly use this video and the accompanying Safety Bulletin to start a conversation on how these issues can be safely addressed in your facility!

Posted in Community Involvement, Compliance, CSB, Good Engineering Practices, Incidents | Tagged , , , , | Leave a comment

Region 7 Ammonia Safety Day

If you are within a couple hundred miles of Kansas City, Kansas it’s worth attending the 7th annual Region 7 Ammonia Safety Day which is held at the Kansas City Community College on May 28th, 2014.

More information including the schedule and enrollment link can be found at GCAP’s website.

Of special interest this year is a presentation by Lucy Tyler of the CSB on a large NH3 release in Alabama. OSHA and the EPA will be presenting as well.

Posted in Community Involvement, Compliance, CSB, EPA, Operator Training, OSHA | Tagged , , , , , | Leave a comment

Here’s a change that doesn’t require a Formal MOC!

I am sure many of my PSM friends have noticed my lethargic posting rate at the blog over the past year or so. I’ve been running all around the country helping people with their PSM programs through Audits, PHA’s and Training at a breakneck pace during that time as the Director of Compliance for Garden City Ammonia Program.

I have spent four years there working with the fine staff building and improving the PSM program and services they offered. In that time I’ve worked with some wonderful people at GCAP and earlier today, with a heavy heart, we both decided that our future paths were going to diverge.

I wish the best for the GCAP staff as they continue to provide world-class training to operators around the country. It was an honor and a privilege to work with the staff, some of whom I’d like to acknowledge directly:

Randy Williams – A true visionary who has done more for this industry than he’ll likely ever get credit for. The creator of GCAP and a legend in his own time.

Jeremy Williams – A talented and knowledgeable man who, I believe, will grow GCAP into something uniquely his own in the future.

Steve Rucker – The Director of the Boiler division at GCAP that continues to impress us all with his ability to grow and meet challenges. I expect great things from the Boiler division in the future.

Tyler Ramos – One of the most talented instructors I’ve ever met and a genuinely nice guy.

Kristen, Dolly, Amber and Rachel – The office staff that tried to keep me sane when I traveled 40+ weeks a year. They always had my back and I am grateful for their diligent work behind the scenes that makes everyone else look so good.

Bret Geier –  Our maintenance man who keeps his attention on the little things while the instructors get to keep their heads in the clouds.

Working with talented people makes “work” worth doing and I’ve definitely had quite an experience over the past few years. I hope for, and expect nothing less than, continued success for GCAP in the future.

The real joy, of course, was meeting all the students that passed through our classes over that time. I’ve made some great friends and worked with some incredibly devoted and talented colleagues from the world’s best Ammonia Refrigeration users. It was a great honor to be a small part of their careers.

Last, but certainly not least, I’d like to thank my wife Diane who has been enormously patient during this wild ride!

I am not sure where I go from here – but I think a little bit of a vacation is in order. Hope to see you all again soon!

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