Coors Ammonia Leak

In the news today: Part of Coors facility evacuated due to ammonia leak. This is something no ammonia refrigeration operator wants to happen on their watch. Thankfully it appears to have only affected the facility and not the neighborhood around it. An unintentional “Community Involvement Day” is to be avoided at all costs!

Thankfully the Coors employees do not appear to be seriously injured. The fact that an incident occurred doesn’t mean the good people at Coors weren’t necessarily doing things the right way; It’s just an opportunity to improve.

Incidents can happen to anyone – all we accomplish with Process Safety is minimizing the frequency and impact of those events. Nothing is perfect but that shouldn’t stop us from trying. When I was a volunteer firefighter I came up with a slogan for our crew:

“Perfection is our goal. Excellence will be tolerated.”

It’s the attitude we should all have. In my experience, there are a hell of a lot of professional refrigeration personnel out there who are always looking to improve their systems.

Update 01-07-11: Looks like OSHA got around to issuing a citation that resulted from this leak:

The U.S. Department of Labor’s Occupational Safety and Health Administration has cited MillerCoors LLC of Golden, Colo., with 10 alleged serious violations of OSHA standards following the July 2010 release in excess of 2000 pounds of anhydrous ammonia at its Golden brewery. Proposed fines total $63,500.

OSHA’s investigation found that two employees working on the ammonia system narrowly escaped serious injury when an uncontrolled release occurred during maintenance operations.

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Actual OSHA Citations

Here’s a summary of two recent collections of proposed fines from OSHA. I’m not in any way affiliated with either of these facilities; I was just fortunate enough to get copies of the citations. There are plenty of things in this list to check on in your own facilities so I want to pass them on to you; it’s rare that we get to look at these without being the target! Ideally OSHA would make proposed fines public so EVERYONE could improve their compliance.

You’re going to see a lot of things that are painfully obvious to the seasoned PSM/RMP practitioner. I would like you to take notice how many of the high value fines fall into these two categories:

Not following through on observations of deficiencies: Whether they are observed in a walk-through or recorded as a suggestion on a mechanical integrity, PHA or PSM audit, you MUST follow up and correct these issues. A list of deficiencies from your audits is a goldmine for compliance officers; you’ve already done much of their work for them!

Calibrate instruments you rely on for process safety: Gauges, pressure transducers, thermometers – whatever instruments you rely on for process safety have to be regularly calibrated. You are relying on the data these instruments provide and it needs to be accurate. An example: Most facilities outsource their vibration analysis. That’s fine – but you need to qualify those contractors to ensure they are capable of performing the job including requiring calibration certificates from them. If you do vibration analysis in house you need to document the training of your technicians and ensure calibration based on the manufacturer’s recommendations. My understanding is that, since the vibration equipment wasn’t calibrated, all the tests that were conducted were voided in the Seafood Processing Facility.

First we have a Seafood processing facility and then a Cold Storage.

Region #1 – New Hampshire – Seafood Processor

$2,000 (SERIOUS) Ladder rung obstructed: Clearance behind a ladder rung. OSHA requires 7” of clearance. The ladder provided access to an evaporative condenser. Where the ladder and the condenser platform met there was a pipe running between the ladder and the condenser limiting clearance to 4”.

$7,000 (SERIOUS) Process Safety Information missing:

  • No information on pipe specifications or minimum acceptable thickness.
  • No U1A reports for five vessels.
  • No vibration analysis
  • No information on thermometers and gauges

$7,000 (SERIOUS) The employer did not document that the equipment in the process complied with recognized and generally accepted good engineering practices:

  • Lines not properly labeled
  • Pipe color did not match the color specified for service. (The company had specified all high pressure ammonia liquid lines were orange and a portion of a line was painted red during touch-up)
  • Where ammonia lines passed through walls, the penetrations were not tightly sealed as required.
  • Ice buildup on insulated portions of compressors and pumps.
  • Ice buildup on insulated lines in cold storage areas.
  • Condenser relief valves released at a working platform.
  • Relief valves for receiver did not release 15’ above the adjacent grade.
  • Compressor room exit door partially blocked.
  • King valve not accessible without portable ladder.

$2,500 (SERIOUS) Written procedures for vibration analysis did not exist

$7,000 (SERIOUS) Inspections and tests were not performed on equipment to maintain its mechanical integrity:

  • Vibration testing was not conducted on reciprocating compressors
  • Autopurger not inspected for excess vibration.
  • Vessel thicknesses not checked.
  • Piping under compromised insulation not inspected.

$2,500 (SERIOUS) Mechanical Integrity of Control Valves: “Each ammonia shut-off valve was not cycled at least once every six months.”

$7,000 (SERIOUS) Items identified in mechanical integrity inspections were not addressed:

  • Ice buildup on insulated portions of compressors and pumps.
  • Ice buildup on insulated lines in cold storage areas.
  • No U1A reports for five vessels.
  • Torn insulation on a compressor
  • Unidentified ammonia piping

$7,000 (SERIOUS) Employer did not certify 3 year PSM audits.

$70,000 (WILLFULL) Piping inspections did not occur where observation showed evidence of failure or breakdown of insulation.

$70,000 (WILLFULL) Ice formations had been noticed in 1997 audit and not completed as of December 2009. Items observed in April 2008 mechanical integrity inspection were not completed as of December 2009.

  • Pipes marked as “severely rusted and pitted”
  • Pipes marked as “not within acceptable limits”
  • Pipes marked as “rusty” or “extensive corrosion”
  • Relief valves on condensers were directed towards the workways.

$25,000 (REPEAT) A device used for vibration analysis was not calibrated as required.

Region #10 – Idaho – Cold Storage

$2,500 (SERIOUS) Exit door in compressor room not clearly visible in normal light and during a power outage and marked “Exit”.

$7,000 (SERIOUS) Intercom system used as alarm system did not have a battery backup and would not function during a power outage.

$7,000 (SERIOUS) The employer did not document that the equipment in the process complied with recognized and generally accepted good engineering practices:

  • Ammonia Compressor Room – Emergency remote ventilation controls are not located outside the compressor room.
  • Where ammonia lines passed through walls, the penetrations were not tightly sealed as required.
  • Pipe labeling inadequate.
  • High pressure receiver located in enclosed separate structure without ventilation.

$7,000 (SERIOUS) The Process Hazard Analysis must address the engineering and administrative controls applicable to the hazards and their interrelationship.

  • High Pressure Receiver safety relief valve discharge is 2’ above roof level and 8’above adjacent ground exposing employees to potential exposure.
  • Evaporator safety relief valve discharge is 2’ horizontally and 3’ vertically from the ladder to a platform exposing employees to potential exposure.
  • Oil Pot safety relief valve discharge is 4’ from the platform exposing employees to potential exposure.
  • Low Pressure Receivers are not protected from forklift traffic

$7,000 (SERIOUS) The employer must establish a system to ensure the Process Hazard Analysis team’s recommendations are resolved in a timely manner. A 2008 PHA states that mechanical ventilation in the compressor room is inadequate. The target completion date was April 2009 and still requires implementation.

$7,000 (SERIOUS) Inspections and tests were not performed on equipment to maintain its mechanical integrity: 57 pressure relief valves in use beyond their five year service life.

$2,500 (SERIOUS) Respirators: Respirators with canisters that list expiration date of 2004.

$2,500 (SERIOUS) Horizontal shafting must be protected by stationary casing: 3 rotary compressors lack guards.

$12,500 (REPEAT) Open sided platforms 4’ or more above adjacent ground must be guarded by standard railings or the equivalent.

$35,000 (REPEAT) The facility lacked a complete set of Piping and Instrumentation Diagrams (P&IDs).

$35,000 (REPEAT) Mechanical Integrity Procedures not established:

  • For insulated and uninsulated anhydrous ammonia pipes. For vessels and heat exchangers. Specifically check for wall thickness.
  • For ammonia pumps to be inspected annually
  • For pressure gauges to be calibrated annually
  • For temperature gauges to be calibrated annually

$35,000 (REPEAT) Electrical Equipment: Since ventilation is inadequate, the equipment located in the engine room and high pressure receiver enclosure must be intrinsically safe.

Does any of this look familiar to you?

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EPA settles with Pacific Seafood Group

EPA extracted a $35,000 penalty for not complying with the Emergency Planning and Community Right to Know Act.

In the agreement, EPA alleges that Pacific Seafood failed to immediately notify emergency response entities after the ammonia release occurred and they failed to submit a completed Emergency and Hazardous Chemical Inventory Form. The federal Comprehensive Environmental Response, Compensation and Liability Act and the Emergency Planning and Community Right-to-Know Act require that releases of hazardous substances such as ammonia above a reportable quantity be immediately reported to federal, state and local emergency responders.

Are your facility staff trained to notify the appropriate authorities immediately when an incident occurs?

A little good will can go a long way. Have you taken the initiative to establish good relations with your neighbors, first responders and Local Emergency Planning Committee before an incident occurs?

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OSHA vs. EPA

If you are covered under OSHA’s PSM regulation you know that you are covered under the EPA’s RMP regulation as well. I understand why most people focus on the PSM regulations – they are used to dealing with OSHA regulations that cover everything from PPE to Lockout/Tagout. Furthermore, if you follow the PSM regulations to the letter, you are essentially covering every single element of the RMP requirements but one.

What amazes me is the general lack of interest, or at least the minor importance that is usually placed by most safety professionals on the Risk Management Plan that is unique to the EPA regulations.

Here are the requested budgets for OSHA and the EPA for fiscal year 2009:

OSHA $501.7 million
EPA $7.14 billion

Now that you see the EPA has nearly 14 and a half times the budget, ask yourself a question: Which one of these agencies is more likely to have the resources to make my life miserable?

Please, take some time to review your EPA required Risk Management Plan.

Here are some things to think about:

Is your RMP management system up to date and are those managers keeping up with their responsibilities under the plan? Has this been audited and documented?

Has every incident that could have resulted in a catastrophic release been investigated and documented?

Have you updated your five year accident history?

Has anything happened that would alter the consequences or likely frequency of your catastrophic release scenarios?

Is your currently filed RMP up to date?

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Learning Industrial Ammonia Refrigeration

Lets say that you are new to industrial refrigeration, or refrigeration in general. What is the easiest way to get up to speed on this rather counter-intuitive topic?

Well, I read quite a few books on the subject but honestly nothing really clicked for me until I read the RETA 1 & RETA 2 books.

I pick up information fairly quickly and within 30 days of study and application of these texts I was able to troubleshoot about 95% of the industrial refrigeration problems I came across. It turns out that many people who work in industrial refrigeration simply do not understand the theory behind refrigeration.

I’ve even had long-time operators explain to me that “Theory is fine, but it just doesn’t work in the real world.” This kind of operator has usually been left to their own devices to limp along a system that just barely works. Worse yet, since they are constantly having to adjust and “fix” the system they are viewed as heroes by many in the organization.

Well, here is the truth: If your experience is that the theory isn’t applicable, then you do not understand the theory well enough.

Buy yourself a copy of the RETA 1&2 books. For a real treat, see which (if any) of your operators can pass the tests that come with the books.

When you feel you’ve got a good grasp on the information in them then you should consider attending a hands-on school like those offered by WMI or GCAP.

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What’s all this, then?

I work for a fairly large company implementing a Process Safety Management / Risk Management Program for four separate facilities with Ammonia refrigeration systems.

I also operate a consulting service on PSM / RMP including writing complete programs for them.

I have experience with ISO & SQF systems as well as Lean/Six Sigma methodology and use those skills to continuously improve existing PSM/RM Programs.

There are not a whole lot of people who work in this field and I thought that there might be some use in posting the information, strategies, observations and ideas I come across that are applicable to the PSM/RMP compliance community.

If you are not in this field, there isn’t much of interest you will find here… Unless of course you have trouble sleeping.

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