CSB Releases Safety Video on 2009 Fatal Blast at NDK Crystal – Animation Depicts Stress Corrosion Cracking; Vessels Were Not Inspected or Tested

Today the CSB issued a report on a 2009 vessel failure that it blamed on Stress Corrosion Cracking. There are some interesting lessons to be learned about incident investigation in this report since the mechanism that led to the vessel’s failure was identified years before due to a smaller failure in the vessel lid.

Since this is actually an issue for Ammonia Refrigeration Systems, I wouldn’t be surprised if this means the Stress Corrosion Cracking issue comes back into the revolving Chemical NEP questions.

You can learn more about SSC in IIAR2 Appendix J, which defines it as follows:

Stress corrosion cracking (SCC) is a generic term describing the initiation and propagation of cracks that can occur in metals when subjected to stress in the presence of an enabling chemical environment. The stress can originate from an externally applied force, thermal stress, or residual stress from welding or forming.

You should read the entire appendix, but one thing you want to do for sure is ensure that oxygen is not available inside your system. You can do this through proper evacuation during commissioning / maintenance and checking for non-condensables routinely. It also recommends that your vesels are post-weld heat treated, but that’s something you can’t do after they are installed.

Link to the CSB report: http://www.csb.gov/assets/1/19/CSB_CaseStudy_NDK_1107_500PM.pdf

Link to the CSB video: http://www.youtube.com/embed/uo7H_ILs1qc

Crossposted to ChemNEP.com

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EPA goes after a cold storage, the real estate agent AND the customer leasing the space!

Complainant issued a Compliance Order to Respondent, and also to Quirch Foods Caribbean, Corp., and Caparra Realty Associates, LLC ( “the Order”) pursuant to Section 1 13 of the Act regarding the Facility. The Order required these parties to perform certain activities at the Facility including the performance of repairs to the ammonia equipment. Complainant issued a Compliance Order to Respondent,and also to Quirch Foods Caribbean, Corp., and Caparra Realty Associates, LLC ( “the Order”) pursuant to Section 1 13 of the Act regarding the Facility. The Order required these parties to perform certain activities at the Facility including the performance of repairs to the ammonia equipment.


Essentially, they issued general duty citations to the company that was actually operating the facility, but they also ordered the Real Estate company and the CUSTOMER of the cold storage (that was leasing the cold space) to ensure that they fixed the compliance issues.

I would imagine this will increase the customer oversight of Regulatory Compliance quite a bit.

Here’s the actual settlement agreement.

A tip of the hat to Bryan Haywood for covering this on his site.

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NRC Call – When is it necessary? When is it a good idea?

Most people involved with Ammonia Refrigeration understand that if we have an unintentional release of ammonia in excess of 100 pounds over a 24hr period, we have to report it to the National Response Center (among others) immediately or face substantial fines. These fines can be very large

Because of this, I’m getting reports that some companies are requiring their employees to report EVERY release, no matter how small. Usually this is in response to a citation at one of their facilities for not reporting a release that was clearly over 100 pounds in a timely manner.

While I’ve long counseled that companies should report EVERY release that the REASONABLY believe is near 100 pounds, I think the idea of reporting nuisance leaks (packing leaks for example) that are CLEARLY below 100 pounds, is unwise and it’s very possible that someone is going to ask: “Why is ABC company having so many leaks?” followed shortly thereafter by “Perhaps we should send a referral to the EPA or OSHA to make sure everything is OK!”

Reporting leaks that clearly are not going to involve a release of 100 pounds over a 24 hour period is just asking for trouble. Companies with these policies should reconsider them.

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Paying for PSM, California Style

The state of California is having some trouble funding their oversight of their state PSM rule: CalARP. Don’t worry though, they have a solution…

The Department of Industrial Relations, Division of Occupational Safety and Health (DOSH) is proposing to adopt emergency regulations to implement a methodology for determining and collecting an annual assessment to fund the DOSH Process Safety Management Program (Labor Code sections 7855 – 7870). —DOIR

Their intent is to levy a pro-rated “assessment” (read that as “fee”) on the oil refineries in the state to fund their operations. It will be interesting to see if this works well for them. If it does, I would expect a program like this to roll out across the state plans and perhaps even at the federal level.

The refineries have quite a bit of political pull though, so I would also expect this burden to be spread a little bit to all covered processes, not just the refineries.

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How do I deal with recommendations to my program?

You should frequently get recommendations for improving your PSM program through the PSM elements of Employee Participation, Process Hazard Analysis, Incident Investigations, Mechanical Integrity audits, Compliance Audits. Often, these recommendations are worthwhile improvements to your system that are worthy of your consideration. Eventually (and as soon as reasonably possible) you should “resolve” the recommendation. How do you go about that? OSHA’s CPL 2.2-45A offers some excellent guidance:

OSHA considers an employer to have “resolved” the team’s findings and recommendations when the employer either has adopted the recommendations, or has justifiably declined to do so. Where a recommendation is rejected, the employer must communicate this to the team, and expeditiously resolve any subsequent recommendations of the team.

An employer can justifiably decline to adopt a recommendation where the employer can document, in writing and based upon adequate evidence, that one or more of the following conditions is true:

  1. The analysis upon which the recommendation is based contains material factual errors;
  2. The recommendation is not necessary to protect the health and safety of the employer’s own employees, or the employees of contractors;
  3. An alternative measure would provide a sufficient level of protection; or
  4. The recommendation is infeasible.

Leaving open recommendations in your program is nothing less than providing a road-map to OSHA and the EPA for citations.

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Do your Emergency Shut-down and Ventilation switches comply with IIAR2-2008b/IIAR5-2013, Appendix B?

IIAR5 was released just recently and a surprising number of people think that it introduces new requirements for emergency switches. The requirements themselves don’t differ from IIAR2-2008b – they are just laid out a little clearer in IIAR5, Appendix B:

B.3.1.ii: …provide a manually operated tamper proof switch immediately outside of the principle entrance. Switch(es) shall initiate visual and audible alarms inside and outside of the area as well as initiate automatic equipment de-energization.

B.4: The ventilation system shall also be capable of manual activation through an independent emergency control switch outside and near the principle machinery room door (with another at ground level if the machinery room is not at ground level). This switch is separate from the equipment shut-down switch described in B.3.1. In addition to the manually operated switch described above, an additional manual on/off/auto tamper proof switch shall be located remotely (as agreed upon with local authorities having jurisdiction) for use by emergency responders who may wish to start or stop the ventilation system depending on circumstances.

Most of us already have an equipment shut-down switch and the ventilation switch because it’s been required for a very long time. The additional manual on/off/auto tamper proof switch that is located remotely for the ventilation is something that wasn’t required by IIAR2 until 2008.

Failing to adhere to (or address) RAGAGEP (Recognized and Generally Accepted Good Engineering Practices) are the cause for most PSM citations. Those who attend the PSM or NEP classes I teach at GCAP receive copies of our custom checklists for common RAGAGEP including:

  • IIAR2-2008a
  • IIAR2-2008b
  • IIAR-Bulletin 110
  • IIAR-Bulletin 114
  • IIAR3-2012
  • IIAR5-2013
  • ASHRAE15-2010

These custom checklists turn every requirement of the RAGAGEP into a PHA-like What If/Checklist question in a format that allows you to specify how you address each requirement.

Update 9/27/13 : Just got off the phone with the IIAR to clear up some confusion between IIAR 2 and IIAR 5. The intent is that the switches above are placed near the door that goes from the outside of the building into the machinery room.

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FUD in the news!

PSM people love their acronyms and we all have our favorites. One of mine is “FUD” or Fear, Uncertainty and Doubt. I generally use this acronym when discussing how the media reports stories about topics I am familiar with. It seems odd that whenever the media discusses a topic I understand well, they almost always get it wrong. It makes you wonder if maybe they are equally as wrong when it comes to topics I haven’t researched.

In any case, today’s issue comes from an Ohio radio station regarding a minor leak at a local cold storage. I was willing to let the wrong word use (Censor v. Sensor) slide. The issue I took umbrage at was paragraph 5 which read:

“The compound has been cited by experts as a possible culprit for the massive fertilizer plant explosion in West, Texas last year, which flattened homes, killing 14 people and injuring 200 others. That plant was also storing ammonium nitrate. Investigators have been unable to determine an exact cause for the explosion.”

Let me go ahead and rewrite that to make it factually accurate and a little more to the point:

“Ammonia was erroneously cited by wildly speculating so-called experts  as a possible culprit for the massive fertilizer plant explosion in West, Texas last year, which flattened homes, killing 14 people and injuring 200 others. Investigators have been unable to determine an exact cause for the explosion; however that plant was also storing massive quantities of ammonium nitrate (a known explosive) which is now believed to have caused the destruction.”

There have been no ties to refrigeration grade ammonia and the West, Texas explosion since the horrible reporting and speculation of the first few days. Neither the CSB, ATF or the President of the United States in referencing the tragedy have spoken of a cause other than ammonium nitrate.

Frankly, there is nothing tying this story to West, Texas at all. In my opinion, the only reason to include the paragraph referencing it is that the reporter is trying to add FEAR, UNCERTAINTY and DOUBT in hopes that the article goes viral.

Note: There was a previous article on West, Texas as well as some photos I took of the devastation on my Google+ page.

Also, for reference, if you know of anyone else in the media thinking about writing an article concerning ammonia, please consider pointing them to my article “A reporters guide to Ammonia

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OSHA is going to have a field day in 2016

The IIAR released two new standards today which you can download (if you are a member) or purchase from their website:

IIAR5 – Start-up and Commissioning of Closed Circuit Ammonia Refrigeration Systems

IIAR7 – Developing Operating Procedures for Closed-Circuit Ammonia Mechanical Refrigerating Systems

I believe these standards are going to result in significant OSHA general duty and PSM citations for Ammonia refrigeration systems starting in 2016. Why 2016? It’s just how this has worked in the past – when a new standard comes out, OSHA starts enforcing RAGAGEP compliance to it hard and heavy about three years after it has been published.

The IIAR5 standard is ready-made with requirements and checklists that will result in non-compliance issues for nearly every facility whether they meet the PSM threshold quantity or not.  Much of IIAR5 seems sensible on first review though, so those of you who are planning on starting a new process or modifying an existing process need to read this standard and take appropriate steps to come into compliance.

The real problem I think we’re all going to have is IIAR7 concerning operating procedures. First, in my opinion, the IIAR has no business whatsoever developing standards on PSM practices. There’s already an organization for that and it’s called the CCPS. The Center for Chemical Process Safety already has guidance on writing effective operating and maintenance procedures. The guidance is excellent and it’s been referenced by nearly every PSM citation concerning SOPs I’ve seen over the last five years. It’s even directly quoted in the published Refinery PSM NEP.  I’ve discussed this guidance before and my SOPs for the past few years have been written with it in mind.


You’re going to want to acquire a copy of IIAR7, if for no other reason, to explain in your SOP guidelines why you choose not to follow it. I have already re-written my example SOP guidelines to address some of the issues caused by this standard (and explain that my RAGAGEP of choice for SOPs is the CCPS, not the IIAR) and I imagine they’ll be more revisions to come.

What the IIAR has done in IIAR7 is muddy the water. They’ve sewn confusion on the operating phases and what they mean. They appear to have completely ignored CCPS guidelines and published OSHA NEP guidance and this confusion will result in hundreds of citations if people don’t rewrite their SOP guidelines or their SOPs to take this standard into account.

*I’ll be putting together checklists for these two standards to go with the existing RAGAGEP checklists that are provided in the PSM classes I teach. Look for updates on this subject at www.chemnep.com in the coming weeks.

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OSHA to revise Palmer guidance on Hydrostatic Trapping

OSHA and the IIAR have not seen eye to eye on the issue of Hydrostatic trapping since 2006 when OSHA issued the Palmer interpretation letter which said the following:

If a liquid expansion hazard exists and the only safeguard to protect against this hazard is the use of trained operators/technicians, then OSHA would not consider this hazard to be adequately controlled, as required by 1910.119(e). After addressing the liquid expansion hazard in the PHA, the employer must address and resolve any of the PHA team’s findings and recommendations [1910.119(e)(5)]. Employers could abate this hazard and address and resolve the PHA finding/recommendation by installing the hydrostatic relief device(s) required by ANSI/IIAR 2 — 1999, Section 7.3.4(a)

Thankfully the IIAR was adamant in their resolve which resulted in the following letter:

OSHA agrees that this revised language addresses the concerns expressed in our response to question 10 in Palmer by clarifying that engineering controls, e.g., hydrostatic relief devices or expansion compensation devices must be used when liquid filled equipment or piping can be automatically isolated under either normal or abnormal operating conditions. We also agree that “trained technicians” acting in accordance with the requirements of 29 CFR 1910.147 (lockout/tagout) can safely perform manual isolation of potentially liquid filled equipment and piping. e.g .. to prepare equipment or piping for maintenance…

OSHA intends to revise Palmer by striking all or part of the reply to question 10 and adding either an explanatory note or footnote referencing the revised language in ANSI/IIAR 2-2008


You can read the full letter here: http://issuu.com/iiarcondenser/docs/osha_hydrostatic?e=8262184/4645894


Note: Using administrative controls was always how I taught this in PSM classes. While OSHA didn’t care for it, there was no way they could uphold a citation for it and I can’t find a single time when they even tried in the last five years. Of course, they could always cite you saying the administrative control was ineffective but that was only post-incident.

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OSHA to focus on difficult inspections (like PSM) in 2014


With the agency now in its fifth decade, OSHA finds itself at a crossroads concerning how it will direct its enforcement resources. OSHA has always operated under the assumption that “more inspections are better” as the more establishments inspected, the greater OSHA’s presence, and hence the greater the agency’s impact. Consequently there has always been pressure on the agency to conduct more inspections than it did in the previous years. The problem with this model is that not all inspections are created equal as some inspections take more time and resources to complete than the average or typical OSHA inspection, such as those dealing with process safety management (PSM), ergonomics, complicated electrical and machine guarding; or industrial hygiene inspections dealing with unknown or unique chemicals.

… Under the current system, the only incentive for a compliance officer is to meet the inspection goals as there is no incentive for them to do the larger more complicated inspections. It is important to encourage enforcement staff to pursue more resource and time-intensive inspections for several reasons. As a compliance officer is deployed to conduct a PSM inspection, ergonomics inspection, or industrial hygiene inspection, the agency will see a more effective application of its limited resources… In FY 2014, the agency intends to explore an inspection weighting approach in order to direct inspections to high hazard operations – including inspections of refineries and chemical plants, emerging chemical and health issues and workplace violence – operations that require much more time and complexity than the average OSHA inspection. For example, a construction inspection taking 10 hours from start to finish is ranked the same as a process safety management inspection taking over 300 hours to complete. By utilizing this approach the Agency slightly fewer inspections overall, but will focus inspections on areas that require more attention.

As I read that, it seems OSHA realizes it needs to provide an incentive for its CSHOs to perform the more intensive and difficult PSM type inspections. There are other sections in the document where they claim that the number of overall inspections next year will decrease, but the audits conducted will be more intensive. This is an inspection priority that places quality over quantity.

Further trouble may lurk ahead for the Chemical NEP…

The Petroleum Refinery PSM NEP, which took effect in August 2007, was effectively completed in September 2011 after OSHA inspected every non-VPP petroleum refinery under federal OSHA jurisdiction. OSHA is conducting a thorough evaluation of the 2007 NEP. Since 2009, OSHA has had a pilot program for a PSM Covered Chemical Facilities NEP. The permanent Chemical NEP took effect in FY 2012. In FY 2013, OSHA began evaluating the effectiveness of this NEP, in light of the Refinery NEP evaluation, to develop options for implementing a new enforcement strategy that may target both PSM covered refineries and chemical facilities under the same emphasis program.

There aren’t a whole lot of differences between the two programs as they stand now, but placing them under the same umbrella may well result in even more of the line-blurring we see between Refinery RAGAGEP and Ammonia Refrigeration RAGAGEP.

I am teaching a ChemNEP class at GCAP on September 23-26 with Josh Latovich. If you haven’t attended one of these seminars, they focus not only on the ChemNEP protocol but on many of the “secret questions” that are asked during the inspection. Follow the link above or call GCAP at 620-271-0037 directly for more information.

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