The “PSM Lessons Shared” project

Recently, during a PSM class, I had a student with an all-too-common issue: How do I change the incident reporting culture at my facility? As a new PSM coordinator he was struggling because he couldn’t get his operators to report any incidents or near-misses that occurred on the process. We discussed it as a group for a while because changing safety culture is one of the most difficult things you will ever attempt.

It helps if we start with a common definition of culture. “A way of thinking, behaving, or working that exists in a place or organization” is the Merriam Webster dictionary definition that seems to apply best to safety culture. When dealing with culture, it’s good to keep in mind this Tony Robbins quote as well: “It’s not what we do once in a while that shapes our lives, but what we do consistently.”

Your safety culture is the result of the consistent actions and experiences that your company has provided for its employees. This kind of deeply established culture isn’t going to change just by issuing a new corporate policy. It’s likely that your safety culture has built up over years.  Culture has inertia and you shouldn’t expect to counter-act that overnight. If you are to have any chance of changing it, you have to first understand what has caused this culture to form.

In this particular case, it became clear that the culture of not reporting incidents was due to a past practice of criticizing and punishing anyone who reported an incident. It’s a fundamental principle of human nature that we get more of something we reward and less of something we punish. The culture of not reporting incidents can only be changed by changing the perception that negative things will occur if you share your incident with your colleagues and management.

It’s going to take time and careful attention to change such a culture.  For this case, he wanted something low key – something that wouldn’t seem like an overt attempt at changing culture because the employees were instinctively resistant to any type of direct change. How could we begin to change the culture for this student? We decided to attempt to change the culture – not by changing the culture directly – but by changing the perceptions and values of the employees through consistent action on the part of the PSM coordinator. He is going to share incidents from other facilities in the hopes that they start a conversation about similar situations in the plant. If such discussions do occur, he is going to focus the conversations ONLY on the lessons we can learn from the incidents, rather than trying to assess blame or fault.

This is such an interesting idea to me that I decided to help him out. Over the next year, I will provide a monthly post about a single incident relevant to Ammonia PSM so that they can discuss it and learn from it. We’re hoping that just the act of discussing these situations will make the facility more comfortable with the failings of human nature. Hopefully, they will begin to understand the value of incident investigation and the reporting rate will naturally change in response to the changing perception of the value of incident investigation.

If you have any PSM incidents that you would like to share (even anonymously) please email them to me at

Look for the first of these monthly incident posts in the next few days. I look forward to the reports concerning the culture change (if any) over the next year and I will keep you updated as well.

Posted in Culture, General Information, Incidents | Tagged , , | Leave a comment

Should you challenge OSHA citations?

Will Kramer has written an excellent article on why you should challenge OSHA citations.

Based on an analysis of the more than 57,000 citations listed in OSHA’s public inspection databases in 2012, employers achieved an average penalty reduction of 49% by negotiating their citations with OSHA at informal conferences. Of the 33,765 citations of this type, 7% were deleted entirely. This is a victory as the complete elimination of a citation is typically an employer’s primary goal, since that effectively clears the employer’s record in the event of future inspections, which could otherwise result in costly repeat citations.

I’ve had very good luck with informal conferences. Be prepared. Know the law. Know the RAGAGEP.

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

GCAP files FOIA Exemption Appeal

Over at the GCAP I’ve been working on an interesting FOIA request for OSHA’s coursebook on class 3430: Advanced Process Safety Management in the Chemical Industries. This is the class an OSHA inspector takes as part of becoming NEP qualified.

You can read more about it at

Posted in Compliance, NEP, OSHA | Tagged , | Leave a comment

H.R.1648 – Protecting America’s Workers Act

Rep. Miller, George [D-CA-11] has introduced legislation to revise the OSHA penalty structure. There are some interesting changes in this legislation:

  • Repeat Violations – Increased from $70,000 to $120,000
  • Serious Violations – OSHA has requested increase from $7,000 to $12,000.
  • Built in inflation adjustment for penalty amounts
  • Requirement of reporting of fatalities and hospitalizations of 2 or more employees (currently 3)
  • 5 years imprisonment for a 1st offence violation that causes or contributes to serious bodily harm to any employee but does not cause death to any employee – 10 years for subsequent offences
  • 10 years imprisonment for a 1st offence violation that causes or contributes to the death to any employee – 20 years for subsequent offences
  • Increases federal oversight of state OSHA plans
  • Increases whistle-blower protection
  • Allows multiple general duty citations – one for each affected employee

These would be massive changes to the enforcement of the OSHA rules.

You can read the bill at this link.

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

IIAR 2 and IIAR 4 up for public review

IIAR Standard 2 (Safety Standard for Equipment, Design, and Installation of Closed-Circuit Ammonia Mechanical Refrigeration Systems) and IIAR Standard 4 (Installation of Closed-Circuit Ammonia Mechanical Refrigeration Systems) are available for public review on the IIAR website.

While being an IIAR member is always a good idea, you do not have to be a member to download or comment on these proposed standards.

Posted in Good Engineering Practices | Tagged | Leave a comment

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:

Link to the CSB video:

Crossposted to

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

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.

Posted in Compliance, EPA, General Information, Inspections | Tagged , , | Leave a comment

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.

Posted in Community Involvement, Compliance, EPA, Incidents | Tagged , , | Leave a comment

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.

Posted in General Information, Oddities | Tagged , , | Leave a comment

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.

Posted in Compliance, Incidents, OSHA | Tagged , , , , , | Leave a comment