Learning from Failure

“Failure is only opportunity to begin again. Only this time, more wisely.” –Henry Ford

We often push PSM practitioners to perform Incident Investigations for fairly minor events in the hopes that the lessons learned from those minor incidents will stop the larger incidents from happening. This is, in part, due to CCPS (Center for Chemical Process Safety) guidance that, for every single catastrophic accident, there are typically nearly 9,900 minor issues / process upsets and 99 near misses.

So, if you only investigate the catastrophic incidents, then you are only acting on 0.010% of the opportunities available to you to improve your control over the process.

OSHA has promoted this idea as far back as a decade ago…

OSHA and industry have found that when major incidents have occurred, most of these incidents have included precursor incidents. Additionally, OSHA and industry (See CCPS [Ref. 41], Section 5, “Reporting and Investigating Near Misses” have concluded based on past investigations, that if employers had properly responded to precursor incidents, later major incidents might not have occurred. Consequently, anytime an employer has an “opportunity” to investigate a near-miss/precursor incident (i.e., an incident that could reasonably have resulted in a catastrophic release) it is important that the required investigation is conducted and that the findings and recommendations are resolved, communicated, and integrated into other PSM elements/systems so a later major incident at the facility is prevented. …It is RAGAGEP to investigate incidents involving system upsets or abnormal operations which result in operating parameters which exceed operating limits or when layers of protection have been activated such as relief valves. (An example RAGAGEP for investigating incidents, including near-miss incidents is CCPS [Guidelines for Investigating Chemical Process Incidents, 2nd Ed.], this document presents some common examples of near-miss incidents). (OSHA, Refinery PSM NEP, 2007)

Going a step further, it’s often true that you can learn something about managing complex operations from businesses in entirely different fields. One field that I like to follow – in part because it’s endlessly re-inventing itself – is information technology.

Google recently published an article on their Post-Mortem culture, with a farcical worked-example that includes the movie “Back to the Future” and a newly discovered sonnet by Shakespeare. The practice of learning from their failures is actually part of their Sight Reliability Engineer handbook and you can read the entire chapter if it appeals to you.

“Failures are an inevitable part of innovation and can provide great data to make products, services, and organizations better. Google uses ‘postmortems’ to capture and share the lessons of failure…

… For us, it’s not about pointing fingers at any given person or team, but about using what we’ve learned to build resilience and prepare for future issues that may arise along the way. By discussing our failures in public and working together to investigate their root causes, everyone gets the opportunity to learn from each incident and to be involved with any next steps. Documentation of this process provides our team and future teams with a lasting resource that they can turn to whenever necessary.

And while our team has used postmortems primarily to understand engineering problems, organizations everywhere — tech and non-tech — can benefit from postmortems as a critical analysis tool after any event, crisis, or launch. We believe a postmortem’s influence extends beyond that of any document and singular team, and into the organization’s culture itself.”

Google’s Pre-Mortem Tool – Anticipating what can go wrong.

Google’s Post-Mortem Tool – Dealing with what actually went wrong.

Posted in Culture, General Information, Good Engineering Practices, Incidents, OSHA, System Optimization | Tagged , , , , , | Comments Off on Learning from Failure

What you need to know about Repeat Citations

First, what is a Repeat Citation? Here’s what OSHA has to say about it in their Field Operations Manual or FOM:

An employer may be cited for a repeated violation if that employer has been cited previously for the same or a substantially similar condition or hazard and the citation has become a final order of the Occupational Safety and Health Review Commission (OSHRC). A citation may become a final order by operation of law when an employer does not contest the citation, or pursuant to court decision or settlement. The underlying citation which the repeated violation will be based on must have become a final order before the occurrence or observation of the second substantially similar violation. (OSHA FOM Chapter 4, Section VII(A)(1). Pg. 4-21&4-22)

A Repeat violation is essentially exposing your employees to the same (or substantially similar) conditions or hazards after your company has previously been cited for the same (or substantially similar) conditions or hazards. Note that this is about your company and not your facility. If you are working for Billy Bob’s Cold Storage and they have four facilities, you may well be subject to a Repeat citation based on a citation issued at one of the other facilities. For Federal OSHA, the citation must have been made by Federal OSHA, not a state plan:

Federal Repeat Citations cannot be based on prior citations from State Plans (OSHA FOM Chapter 4, Section VII(A)(2). Pg. 4-22)


OSHA needs to establish three things to establish a Repeat violation:

  • That the underlying condition or hazard is the same or substantially similar to one used as the basis for a previous citation.
  • That the previous citation has been finalized – it can not be used to establish a Repeat violation if it is still being contested.
  • That you actually came into compliance after the original citation.


Condition Substantially Similar:

They are issued based on similar conditions or hazards, not based on identical OSHA standard (OSHA FOM Chapter 4, Section VII(B) & VII(B) Pg. 4-22)

They CAN be issued for General Duty Citations (OSHA FOM Chapter 4, Section III(E). Pg. 4-18)

The key to understanding this is that it is NOT based on the particular OSHA Standard or Rule, it is based on the conditions / hazards. This is particularly important under PSM because a single condition or hazard may be cited under several different portions of the PSM Standard or Rule. As an example, let’s say that you were previously cited under PSM 29CFR1910.119(l)(5) for lacking an SOP for a new piece of equipment that was installed. The condition or hazard is not providing an SOP for a piece of equipment that operators are expected to operate. However, it’s important to note that the same condition or hazard could have been cited under 29CFR1910.119(e)(1), 29CFR1910.119(e)(3)(i), 29CFR1910.119(f), 29CFR1910.119(f)(2), 29CFR1910.119(f)(3), 29CFR1910.119(g)(1)(i), 29CFR1910.119(l)(2)(iii), 29CFR1910.119(i)(2)(ii), etc. Remember, it’s about the condition or hazard, not the individual OSHA rule.


Previous Citation is Final:

… the citation has become a final order of the Occupational Safety and Health Review Commission (hereafter,OS&H Review Commission). A citation may become a final order by operation of law when an employer does not contest the citation, or pursuant to court decision or settlement. The underlying citation which the repeated violation will be based on must have become a final order before the occurrence or observation of the second substantially similar violation. (OSHA FOM Chapter 4, Section VII(A)(1). Pg. 4-21&4-22)

While that seems like a minor legalistic issue, it’s one of extreme importance if you have been cited for an OSHA violation. Let’s imagine a situation where your facility is cited for a training issue. While you certainly want to address that issue as soon as possible, it may be wise to delay the settlement of the OSHA violation until you can address the same issue in your sister facilities as well. Settling quickly with OSHA may expose those sister facilities to Repeat violations.


You actually came into compliance after the first citation:

They are different from “Failure to Abate” citations. If an employer never came into compliance after an initial OSHA’s initial inspection / citation, that is a “Failure to Abate.” If the violation was corrected, and then later reoccurs, that is a Repeated violation. (OSHA FOM Chapter 4, Section VII(F) Pg. 4-23)

This is only really a matter of the associated fine. If the citation is Repeat, the fine is capped at about $129k. If the citation is actually a Failure to Abate, the fine is capped at $12.9k a day for up to 30 days or $387k.


Why are we seeing more Repeat citations?

Inspectors are being told to specifically look for these issues:

During inspections, CSHO’s must pay particular attention to identifying instances of Repeated violations from season to season or past occupancy. (OSHA FOM Chapter 12, Section II(F)(3) Pg. 12-3)

During the course of the ChemNEP inspection, the CSHO shall review abatement for all PSM citations issued within the previous six years to determine whether the hazard still exists. (OSHA CPL 03-00-021, Section XI(E)(10) Pg. 31)


What are the ramifications of a Repeat citation?

The fines can be up to $129,336 for each Repeated citation. (OSHA Act of 1970, Section 17) (OSHA Website on Penalties)

A single Repeat citation involving a fatality can place you in the Severe Violator Enforcement Program (SVEP). Two or more Repeat citations can place you in the SVEP if you have a “High Emphasis Hazard” as outlined in CPL 02-00-149 (which includes PSM facilities) (OSHA FOM Chapter 11, Section II(M)(2)(a) Pg. 11-13)

SVEP cases often spread to the entire region or even the entire country if the facility has sister facilities in other areas. OSHA may choose to inspect those other facilities or issue an abatement demand for ALL the sister facilities based on conditions found at SOME of them. Furthermore, OSHA “shall consider going beyond the subject of the citations to include additional safety and health program enhancements,” even for items that were not cited during the inspection. (CPL 02-00-152)

No reduction shall be given for repeated violations. If a repeated violation is found, no reduction for good faith can be applied to ANY of the violations found during the same inspection. (OSHA FOM Chapter 6, Section III(B)(3)(a) Pg. 6-7)

Each repeated violation is evaluated as serious or other-than-serious, based on current workplace conditions, and not on hazards found in the prior case. (OSHA FOM Chapter 6, Section V(A)(1) Pg. 6-11)

Repeat violations can be the basis of 11B enforcement action where the US Court of Appeals is asked to enforce the order. (OSHA FOM Chapter 15, Section XIV(B)(3) Pg. 15-14)

Obviously, there’s a lot of dollar signs involved, but that’s just the start of the possibilities. The real damage can come from becoming enrolled in the Severe Violator Enforcement Program or SVEP.  The SVEP program is a nightmare that you want to avoid. I really can’t summarize it better than Eric Cohn did at OSHA Defense Report.

An employer is entered into SVEP at the outset of an OSHA case, prior to an opportunity to defend itself and prove wrong OSHA’s alleged violations. Notwithstanding this end run around Constitutional Due Process, once in the program, SVEP employers are immediately subject to:

  • Public shaming by OSHA through both an inflammatory, embarrassing, and one-sided press release detailing the alleged violations and by posting the employer’s name on a Severe Violator list on OSHA’s public website;Severe Violator Image
  • Mandatory follow-up inspections at that cited facility and up to ten sister facilities within the organization; and
  • More expansive settlement terms than ever before, including corporate-wide requirements.


How far back can OSHA look for a previous citation to use as the basis for a Repeat?

Short answer – As long as they want. Long answer:

Although there are no statutory limitations on the length of time that a previously issued citation can be used as a basis for a repeated violation, it is OSHA policy that they are only to be issued withing five years of the final order date of the previous citation or within five years of the final abatement date, whichever is later, or five years from the issue of a final order from the OS&H Review Commision or final mandate from the US Court of Appeals. (OSHA FOM Chapter 4, Section VII(E)(1) Pg. 4-23)

  • Recent Court rulings have shown that since there are no statutory limitations on the Look-Back period, OSHA could issue Repeat citations based on citations older than five years. (OSHRC Triumph Construction)

  • Under OSHA Commission precedent, the “time between violations does not bear on whether a violation is repeated.” (OSHRC Hackensack Steel)

This long reach means that you need to know your history – and the history of your sister facilities.


Sources: OSHA FOM, CPL 02-00-149 (SVEP), CPL 02-00-152, CPL 03-00-021, OSHA Act of 1970 (Judicial Review), OSHA Website on Penalties, OSHRC Triump Construction, OSHRC Hackensack Steel.

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General Duty vs. PSM/RMP: Is there a benefit to dropping below the 10,000lb threshold?

Several times a year I get a phone call or an email from a client that wants to lower the NH3 inventory below the federal 10,000lb threshold so they are no longer subject to the PSM/RMP rules. It’s a conversation I’ve had nearly a hundred times over my career, so I thought it would be worth writing down my thoughts on this subject for posterity. The factors break down into three categories: Logistical, Regulatory and Safety.

Logistical: If you’re close to the 10,000lb threshold, you may be able to reduce the NH3 inventory below the regulatory line of 10,000lbs., but there are some things worth considering:

Is it safe? A system operating below the level it was designed to operate is often called starved. Starved systems can be unsafe due to the increased rates of vapor propelled slugging and low vessel levels causing pumps to cavitate. This isn’t something you want to do without consulting a design engineer.

Can I keep it at this level? If we dropped our system inventory to 9,900lbs., we are going to have to ensure it stays below the 10,000lb threshold or we can end up in a regulatory nightmare. Future charges (to replace losses) will require careful calculation to ensure that we stay on the right side of the threshold. This can be done through a good inventory management program, but it’s something you’re going to want to plan for.

Regulatory: If we drop below the 10,000lb threshold, we can remove ourselves from the federal RMP & DHS registries, but we will still have to meet the OSHA and EPA General Duty requirements for our NH3 refrigeration system.

To quote OSHA:

“Employers can be cited for violating the General Duty Clause if there is a recognized hazard and they do not take reasonable steps to prevent or abate the hazard.”

When we discuss things like “recognized hazard” we are discussing the things that are outlined in appropriate RAGAGEP. What would be RAGAGEP for an NH3 refrigeration system below 10,000lbs? At a minimum, ALL the IIAR standards & bulletins as well as the IIAR ARM (Ammonia Refrigeration Management) program. What does that mean?

  • The system design still has to comply with IIAR 2 Standard for Safe Design of Closed-Circuit Ammonia Refrigeration Systems
  • The installation still has to comply with IIAR 4 Installation of Closed-Circuit Ammonia Refrigeration Systems
  • The startup and commissioning still has to comply with IIAR 5 Start-up and Commissioning of Closed-Circuit Ammonia Refrigeration Systems
  • The process safety information and maintenance program still has to comply with IIAR
    • Bulletin 108 Guidelines for: Water Contamination in Ammonia Refrigeration Systems
    • Bulletin 109 Minimum Safety Criteria for a Safe Ammonia Refrigeration System
    • Bulletin 110 Guidelines for: Start-Up, Inspection and Maintenance of Ammonia Mechanical Refrigerating Systems
    • Bulletin 114 Guidelines for: Identification of Ammonia Refrigeration Piping and System Components
    • Bulletin 116 Guidelines for: Avoiding Component Failure in Industrial Refrigeration Systems Caused by Abnormal Pressure or Shock
    • The upcoming IIAR Standard 6 Inspection, Testing, and Maintenance of Closed-Circuit Ammonia Refrigeration Systems which will replace all the above bulletins
  • The operating procedures still has to comply with IIAR 7 Developing Operating Procedures for Closed-Circuit Ammonia Mechanical Refrigerating Systems
  • The overall system safety management program will have to comply with the IIAR ARM program which is about 90% of the paperwork burden of a full PSM/RMP program.

If you are looking at that list and thinking “There’s almost no benefit to dropping below the 10,000lbs mark from a regulatory standpoint” you aren’t wrong. There is ONE and it’s fairly minor: Generally speaking, your potential fines for violating OSHA’s or EPA’s General Duty clause are smaller than those for violating PSM/RMP. I say generally, because that’s not always the case. As an example, here’s a consent agreement for a $185,000 fine under the EPA’s General Duty clause.

Let me summarize the regulatory situation of a General Duty NH3 refrigeration facility in a single sentence: A General Duty NH3 refrigeration system is going to have 95% of the regulatory burden of a PSM/RMP facility (and thus have to do the same things as a PSM/RMP facility would) but you won’t have the well-understood PSM/RMP structure to help manage that regulatory burden.

Safety: In theory, any inventory reduction provides some small measure of reduced risk. In practical terms, though, there is usually very little effect. Often, due to the way our systems are designed (and the way the RMP scenarios are calculated) there is no change at all in the calculated area of effect of a release scenario*. Also, it’s important to keep in mind that very small amounts of NH3 can pose a danger to your personnel – it doesn’t matter that you’ve reduced your inventory from 11,000lbs to 9,900lbs when a release of 5lbs can pose mortal danger to a technician.

In my experience though, the real danger of reducing your inventory below the threshold is that facilities that do so almost always give their General Duty compliance a lower priority than they gave to their PSM/RMP compliance. These facilities become less safe because they believe that they are less exposed to OSHA and the EPA.

Conclusion: Yes, lowering your inventory can produce a slight increase in inherent safety and a lower regulatory exposure, but in practice, it usually does very little other than give the facility an excuse to de-prioritize safety and compliance.

I work with many companies with National and International brands. Nearly ALL of these companies treat their General Duty facilities as if they have over the 10,000lb threshold, for the same reason: Brand protection – You never want to be in a position where you are making the argument that you didn’t provide the highest level of safety to your employees and your community because you didn’t have to by law!

* No, Worst-Case and Alternate release scenarios are not required by General Duty plants, but I always calculate and map them so the facility understands the possible ramifications of a release on their community.

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IIAR 7 update now open for Public Review

November 10th, 2017
To: IIAR Members
Re: First (1st) Public Review of Standard BSR/IIAR 7-201x, Developing Operating Procedures for Closed-Circuit Ammonia Refrigeration Systems.
A first (1st) public review of draft standard BSR/IIAR 7-201x, Developing Operating Procedures for Closed-Circuit Ammonia Refrigeration Systems is now open. The International Institute of Ammonia Refrigeration (IIAR) invites you to make comments on the draft standard. Substantive changes resulting from this public review will also be provided for comment in a future public review if necessary.

BSR/IIAR 7-201x, defines the minimum requirements for developing operating procedures applicable to closed-circuit ammonia refrigeration systems. It presupposes that the persons who use the document have a working knowledge of the functionality of an ammonia refrigeration system(s) and basic ammonia refrigeration practices and principles. This standard is intended for those who develop, define, or review operating procedures, or a combination thereof, for closed-circuit ammonia refrigeration systems. This standard shall apply only to stationary closed-circuit refrigeration systems utilizing ammonia as the refrigerant. It supplements existing general refrigeration standards issued by IIAR and other organizations such as ASHRAE, ASME, and ANSI. It is not intended to supplant existing safety codes (e.g., model mechanical or fire codes).

IIAR has designated the draft standard as BSR/IIAR 7-201x. Upon approval by the ANSI Board of Standards Review, the standard will receive a different name that reflects this approval date.

We invite you to participate in the first (1st) public review of BSR/IIAR 7-201x. IIAR will use the American National Standards Institute (ANSI) procedures to develop evidence of consensus among affected parties. ANSI’s role in the revision process is to establish and enforce standards of openness, balance, due process, and harmonization with other American and International Standards. IIAR is the ANSI-accredited standards developer for BSR/IIAR 7-201x, and is responsible for the technical content of the standard.

This site includes links to the following attachments:

The 45-day public review period will be from November 10th, 2017 through December 26th, 2017. Comments are due no later than 5:00 pm Eastern Standard Time (EST) on December 26th, 2017.

A quick review of the update shows no significant changes are necessary to the current stock templates.

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RAGAGEP Hierarchy in Application – A worked example

RAGAGEP (Recognized and Generally Accepted Good Engineering Practices/Principles) is extremely important to our Process Safety programs as it helps define the boundaries of what is (and isn’t) acceptable in our processes and our management of them. There seems to be some confusion in a significant portion of the industry as to how to practically apply RAGAGEP* so I thought a brief discussion (and worked example) might be useful.

Let’s say that we have multiple possible RAGAGEP’s for a single item – such as relief valve replacement schedule. Those multiple RAGAGEP’s may well have differing requirements so we will need to rank them to understand what we actually need to do. Here’s an example RAGAGEP listing from OSHA:

  1. Codes adopted by the AHJ (Authority Having Jurisdiction) such as IMC/UMC
  2. Consensus Standards such as IIAR or ASHRAE
  3. Non-consensus documents such as Pamphlets / Bulletins from industry organizations
  4. Internal Standards such as your corporate policy

What isn’t on that list is manufacturer’s recommendations and there’s a reason why. The things listed above set the RAGAGEP and the manufacturer’s recommendations can modify it.**

There are generally two ways to modify something: make it more or less restrictive.

More: In the event that the manufacturer gives you a recommendation that is more restrictive (conservative) than the RAGAGEP, you must*** accept that more restrictive recommendation.

Less: If the manufacturer gives you a recommendation that is less restrictive than the RAGAGEP, you can accept that less restrictive recommendation, but you will need to document why you believe that the manufacturer’s recommendation is superior to the existing RAGAGEP.

In a recent article on RCE-Chill, we discussed the replacement schedule for a relief valve that relieves back into the system. The codes reference the consensus standards, which in turn reference some non-consensus bulletins. The bulletin in question, IIAR B110 says that these valves are not subject to the 5yr changeout frequency that other relief valves are. Yet, we have an email from Cyrus Shank’s engineering department that still recommends the 5yr changeout schedule.

In this case, we have a disagreement between the non-consensus bulletin and the manufacturer’s recommendation. Put another way, we have a generic recommendation on relief valve changeout versus a manufacturer specific recommendation. Obviously, the manufacturer’s specific recommendation on their valves overrides the generic recommendation about all relief valves. Therefore, as long as we are going to use these specific valves, we need to follow the manufacturer’s recommendation. ***

*It’s important to understand that we’re talking about what RAGAGEP decision is the most defensible during an inspection / audit.

** In 1910.119(j)(4)(iii) manufacturer’s recommendations are explicitly called out in conjunction with good engineering practices to set inspection/testing frequency, but the point still holds true.

*** It’s theoretically possible that you can make the engineering case that you know more about the manufacturer’s equipment as it operates in your process than they do, so you can override their recommendation. One method that’s routinely used is to choose an alternative way to achieve the same goals – one where you can show the engineering rationale to prove your alternative is as safe or safer. A common example of that would be replacing the oil based on regular oil analysis rather than changing it out at a specific hour interval. Of course, such a change would have to be thoroughly documented through your Management of Change procedure.

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PHA Worksheets Template updated

The Template What-If / Checklist worksheet used to guide PHA Studies has been modified.

  1. The Identification and Review of Past Incidents section has been renumbered with some new questions concerning the performance of the Incident Investigation element added before the example / industry What-If incident questions.
  2.  We’ve added a new 57-question Revalidation Considerations Checklist to the current list of What-If questions. This new section is to be used as an additional check on PHA revalidations.

These changes are available immediately to anyone using the Google Shared Drive.

Note: These additions are partially based on an EPA-provided example of typical questions asked during a PHA revalidation. It has always been our practice to FULLY revalidate the PHA by reviewing all the previous answers; however, during a revalidation, this new section should help highlight areas of the existing PHA study that demand extra attention.

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Why we changed our element “Guidelines” to be called “Written Plans”

In mid-february we changed every reference to Guideline in the example templates to Written Plan. This change was made to the Google Drive and logged on 2/3/17.

Although I have used guideline for a very long time, it was really just out of habit – it’s not an accurate reflection of the intent of those documents.

First: Where did this Guideline idea come from?

Well, it all started back in the Employee Participation element which requires you to have a document that explains how you intend to comply with certain requirements.

1910.119(c)(1) – Employers shall develop a written plan of action regarding the implementation of the employee participation required by this paragraph.

Over time we realized that these written plans of action were very useful and wrote them for every single PSM/RMP element. For whatever reason, the very first program I ever worked on called this the “Guideline for Employee Participation” and I just stuck with that wording for well over a decade.

Ok, so why call it a Written Plan rather than a Guideline? 

Well, let’s look at definitions:

A dictionary definition of guideline is:

“General rule, or piece of advice”

The word plan defined in that same dictionary:

“a detailed proposal for doing or achieving something;” 

“an intention or decision about what one is going to do.” 

The word plan is really what we are going for: A decision about what the facility is going to do. The intent of these documents, whether they are called Written Plan or Guidelines, was always to document the detailed plan that the facility intended to follow in achieving compliance.

Anything else?

Actually, yes. Over the years we had to explain the above to several different inspectors: our Guidelines were actually our written plans. Frankly, it just got annoying explaining the same concept over and over again – especially when they had a point: Rightly understood the documents really are the written plan and general guidance usually used the guidelines terminology such as the IIAR Compliance Guidelines and the CCPS Guidelines for Safe Process Operations and Maintenance.

Do I have to change my documents if I use the templates?

Well, no you never really have to update your program to reflect our changes. That said, Should you? Yes, you should make the change whenever you update your program to the latest templates.

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What training does my refrigeration operator need?

Note: this article focuses only on the PSM/RMP training burden that is unique to PSM/RMP. Furthermore, it does not address the requirements of training documentation.

Understanding the requirements of PSM/RMP training for Operators

The Training element in PSM (1910.119(g)) and RMP (40CFR68.71) requires that your process operators involved in operating a process receive certain training. For me, the key word for our understanding is Operator which means to control the functioning of a machine, process or system. If they turn valves, operate physical or electrical controls, etc. they are likely Process Operators. It is important to remember that the term Process Operator is not a title – it is a function. A management employee that turns refrigeration valves, or restarts equipment after a power failure is a Process Operator by function even if their title is “Director of Warehousing.” This concept is so important, that it is one of our PSM Golden Rules:

8. Treat people by their function within the process, not their title.

This means that in facilities where Contractors are actually the Process Operators, this Operator Training section must apply to them – just as it would a similarly situated direct-hire employee. OSHA made this clear in 1992:

…should a contract employer provide employees to operate a process, then those employees would obviously have to be trained to the same extent as the directed hire employees “involved in operating a process” under paragraph (g) of the final standard.

Generally speaking, all OSHA standards cover all employees including contract employees. In something of a break with tradition, the process safety management rule has separate provisions covering the training of contract employees. This was done primarily for emphasis since contract employees make up a significant portion of some segments of industries covered by the final rule. This is not to say, however, that paragraph (h) is the only section of the process safety rule that applies to contractors. As already indicated, under appropriate circumstances, all of the provisions of the standard may apply to a contractor (i.e., a contractor operated facility). After all, employees of an independent contractor are still employees in the broadest sense of the word and they and their employers must not only follow the process safety management rule, but they must also take care that they do nothing to endanger the safety of those working nearby who work for another employer. Moreover, the fact that this rule has a separate section that specifically lays out the duty of contractors on the job site does not mean that other OSHA standards, lacking a similar section, do not apply to contract employers. (OSHA, PSM Preamble, 1992)

Training in this element that training is broken into two categories: Initial and Refresher.

Initial Training

Initial training is 1910.119(g)(1)(i) – “Each employee presently involved in operating a process, and each employee before being involved in operating a newly assigned process, shall be trained in an overview of the process and in the operating procedures as specified in paragraph (f) of this section. The training shall include emphasis on the specific safety and health hazards, emergency operations including shutdown, and safe work practices applicable to the employee’s job tasks

Initial Training is meant to cover the things Process Operators need to know to be involved in the covered process. It needs to cover an Overview of the Process as well as any specific Operating Procedures that the Process Operator is expected to perform.

One component of the Overview of the Process. Overview of the Process is simply how the covered process works. This understanding can be very basic or in-depth based on how much the Process Operator needs to know to safely perform the tasks assigned to them. This is the only component of the operator training requirements that is addressed by attending 3rd party classes (usually titled Refrigeration Operator) at a one-week school. I’m not discounting their value – I’m just pointing out that these schools do nothing to meet the other requirements of the training element. (Any honest school offering these classes will tell you this!)

This operator training must include a focus on:

  • Specific Safety and Health Hazards of the process and work on the process.
  • Emergency Operations and Shutdown.
  • Safe Work Practices (Like LEO & LO/TO) applicable to the employee’s job tasks.

It’s important to emphasize that this training is conducted before the operator actually performs these tasks independently. For a typical Ammonia Refrigeration Process Operator, these requirements would lead us to train, at a minimum, in the following areas:

  • Routine refrigeration system operation; an overview of the process.
  • Ammonia properties, safety and health hazards
  • SOP awareness including the requirement to follow written SOPs
  • Specific training in any SOP they are expected to perform such as the Overall System Operation SOP(s), which includes emergency and normal refrigeration system operation procedures.
  • Their individual role in the emergency response plan

In many programs, this is a level of Process Operator called Entry Level. Due to the increased use of Contractors in most Ammonia Refrigeration processes, many, if not most, Process Operators are never trained to reach higher levels of operator classification.

Refresher Training

1910.119(g)(2) – “Refresher training shall be provided at least every three years, and more often if necessary, to each employee involved in operating a process to assure that the employee understands and adheres to the current operating procedures of the process. The employer, in consultation with the employees involved in operating the process, shall determine the appropriate frequency of refresher training.” Note that this training is meant to reinforce the earlier emphasis on SOPs.

Refresher or Ongoing Training is a collection of activities designed to reach a certain Performance-Based goal: …To assure that the employee understands and adheres to the current operating procedures of the process.

The “understands” portion of the performance basis should have been handled by our Initial Training. The real question then is how we ensure Process Operators adhere to current operating procedures of the process. This is called Operational Discipline. Much of what we call Refresher Training is just reminding Process Operators about the importance of this Operational Discipline. An example Refresher Training schedule is below:

In addition to the above regularly scheduled and event-driven training, there should be some sort of verification that process tasks are being completed in accordance with the written procedures of the process. On a regular basis (usually at least annually) the Responsible Person should verify that qualified operators are adhering to the SOPs. This verification usually takes the form of observations while the operator performs their assigned work. These observations should be done without prior notification of the operator being evaluated.

While there is a requirement that Refresher Training occur at least every three years, and that the frequency of the training be decided in consultation with the Process Operators, an effective PSM/RMP Program is continuously Training and seeking consultation.

Employers, in consultation with employees, shall determine the appropriate frequency, which may be based on consideration of such factors as deviations from standard operating procedures, recent incidents, or apparent deficiencies in training. (OSHA, CPL 2-2.45A, 1994)

Mechanical Integrity (Maintenance) Training

1910.119(j)(3) – “Training for process maintenance activities. The employer shall train each employee involved in maintaining the on-going integrity of process equipment in an overview of that process and its hazards and in the procedures applicable to the employee’s job tasks to assure that the employee can perform the job tasks in a safe manner.”

In this section they are referring not to the SOPs so much as the written procedures required in 1910.119(j)(2) – “Written procedures. The employer shall establish and implement written procedures to maintain the on-going integrity of process equipment.”

The rule requires that there be written procedures on maintaining the integrity of the covered process and that the personnel performing these procedures be trained in those procedures. Most chemical and petroleum plants have one set of personnel to operate the plant and another to maintain it. Nearly all Ammonia Refrigeration systems have the same personnel operate and maintain the process, so most plants in our position combine these training requirements with the Operator Training requirements.

As OSHA indicated in the preamble, paragraph (j)(3) requires that employers provide maintenance employees with “on-going” or “continual” training adequate “to assure that they can perform their jobs in a safe manner.” In this regard, the paragraph clearly contemplates that new maintenance employees be trained before beginning work at the site, and all maintenance employees receive additional training appropriate to their constantly changing job tasks. (OSHA, CPL 2-2.45A, 1994)

Appendix C to the rule notes that the “employer needs to develop procedures to ensure that tests and inspections are conducted properly and that consistency is maintained even where different employees may be involved. Appropriate training is to be provided to maintenance personnel to ensure that they understand the preventive maintenance program procedures, safe practices, and the proper use and application of special equipment or unique tools that may be required. This training is part of the overall training program called for in the standard.” (OSHA, 29CFR1910.119, 1992)

Note that this includes contractors that are performing MI tasks on the covered process:

This training requirement applies to both host employer’s and contractor employer’s employees performing MI procedures. CPL 02-02-045, Appendix B, pg. B-27, states, “If contract employees are involved in…maintaining the on-going integrity of process equipment, then they must receive training in accordance with specific training requirements set forth in paragraphs (g) and (h), respectively”). (OSHA, Refinery PSM NEP, 2007)

What does a successful training program look like?

A successful Operator Training element will be one that:

  • Ensures the operators are aware of the procedures and will consistently apply those written procedures resulting in fewer process deviations.
  • Ensures the operators understand the process and the procedures so they are able to quickly correct those few deviations that do occur.

“An effective training program significantly reduces the number and severity of incidents arising from process operations, and can be instrumental in preventing small problems from leading to a catastrophic release.” (OSHA, CPL 2-2.45A, 1994)


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Management Of Change (MOC) for Personnel

In response to a recent LinkedIn forum post, here’s a short discussion on why MOC should be implemented for some personnel changes.


The employer shall establish and implement written procedures to manage changes (except for “replacements in kind”) to process chemicals, technology, equipment, and procedures; and, changes to facilities that affect a covered process.

Certainly, a change to certain personnel can be a change that affects a covered process and OSHA has cited this before when key players have changed such as the PSM coordinator, Maintenance Manager or Safety Director.

To make life simpler, I use the “Management System” rule of thumb. If the person is listed as a “Responsible Person” in the RMP Management System then they are covered in the MOC procedure.

Here are my MOC/PSSR Written Plan (a.k.a. Guideline) section for MOC regarding personnel.

Note that Operators that have no other role in the Management System are not covered under this procedure as they are already covered in the Training element. Here is the form the above procedure is referencing:

Every program I’ve written and PSM class I’ve taught over the last five years uses some variation of this procedure/form.

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Outsourcing your Contractor Selection Process – Can it be done?

Over the past few years we’ve seen an increase in the number of companies that use a 3rd party service to qualify their contractors. Often, these services screen the prospective contractor for their safety record / programs, insurance history / coverage, and financial stability. It’s common to see facilities believe that these contractor qualification services are covering their PSM/RMP Contractor obligations, but this is rarely the case. Let’s review the PSM/RMP requirements regarding Contactors – starting with the facility obligations – to see why:

1910.119(h) Contractors.

1910.119(h)(1) Application. This paragraph applies to contractors performing maintenance or repair, turnaround, major renovation, or specialty work on or adjacent to a covered process. It does not apply to contractors providing incidental services which do not influence process safety, such as janitorial work, food and drink services, laundry, delivery or other supply services.

This section covers which contractors are covered under the PSM/RMP rules. Since nearly all of these Contractor Qualification services cover all contractors, you are usually well covered here.

1910.119(h)(2) Employer responsibilities.

1910.119(h)(2)(i) The employer, when selecting a contractor, shall obtain and evaluate information regarding the contract employer’s safety performance and programs.

Every Contractor Qualification service we’ve seen covers this area quite well – in fact, it’s the reason these services exist. 1910.119(h)(2)(ii) The employer shall inform contract employers of the known potential fire, explosion, or toxic release hazards related to the contractor’s work and the process.

1910.119(h)(2)(iii) The employer shall explain to contract employers the applicable provisions of the emergency action plan required by paragraph (n) of this section.

Here we get our first compliance issue. Contractor Qualification services do not possess this information and cannot provide it to the contractor. Let me quote the 2009 Petroleum NEP to show you why this MUST be done by the facility itself:

Compliance Guidance: To assist in determining the applicable known potential fire, explosion or toxic release hazards that the host employer must inform the contract employers about, CSHOs should examine the host employer’s PHA. The PHA must identify the hazards of the process – 1910.119(e)(1) and (e)(3)(i). At a minimum, the hazards identified in the employer’s PHA which are applicable to the contractor’s work must be passed (“informed”) from the host employer to the contract employer – 1910.119(h)(2)(ii). In turn, the contract employer must then instruct its employees on the known potential fire, explosion or toxic release hazards of the process (1910.119(h)(3)(ii)), including, at a minimum, those hazards identified in the host employer’s PHA which are applicable to the contractor’s work.

As you can see, this requires a deliberate and thoughtful analysis of the work the contractor will do and the hazards present by that work – and the area of the process they will be working on. A cookie-cutter Contractor Qualification service cannot provide this service so you need to make sure your program does.

1910.119(h)(2)(iv) The employer shall develop and implement safe work practices consistent with paragraph (f)(4) of this section, to control the entrance, presence and exit of contract employers and contract employees in covered process areas.

Again, a Contractor Qualification service cannot provide this service – this is a facility level requirement that establishes and implements the procedures required under the Operating Procedures element.

1910.119(h)(2)(v) The employer shall periodically evaluate the performance of contract employers in fulfilling their obligations as specified in paragraph (h)(3) of this section.

1910.119(h)(2)(vi) The employer shall maintain a contract employee injury and illness log related to the contractor’s work in process areas.

While a Contractor Qualification service can maintain some general information on the contractor in general such as injury rate and accident history, it will not know about the specific performance of a contractor at your facility – at least not as well as your own people will.

Next, we move on to the PSM/RMP responsibilities of the Contractor…

1910.119(h)(3) Contract employer responsibilities.

1910.119(h)(3)(i) The contract employer shall assure that each contract employee is trained in the work practices necessary to safely perform his/her job.

1910.119(h)(3)(ii) The contract employer shall assure that each contract employee is instructed in the known potential fire, explosion, or toxic release hazards related to his/her job and the process, and the applicable provisions of the emergency action plan.

1910.119(h)(3)(iii) The contract employer shall document that each contract employee has received and understood the training required by this paragraph. The contract employer shall prepare a record which contains the identity of the contract employee, the date of training, and the means used to verify that the employee understood the training.

While a Contractor Qualification service can certainly request this documentation, what’s usually acceptable to the Contractor Qualification service is a generic “statement” on training, not the very specific training required based on the information provided under 1910.119(h)(2)(ii-iii).

1910.119(h)(3)(iv) The contract employer shall assure that each contract employee follows the safety rules of the facility including the safe work practices required by paragraph (f)(4) of this section.

A Contractor Qualification service can certainly ask the contractor to provide a pledge that they will follow the safety rules / practices at the facility, but this can only really be proven through direct on-site examination of the contractor on a regular basis.

1910.119(h)(3)(v) The contract employer shall advise the employer of any unique hazards presented by the contract employer’s work, or of any hazards found by the contract employer’s work.

A Contractor Qualification service will ask the contractor to provide this information, but very often the nature of the work (and the tools used to perform it) change during the project. Again, only direct on-site examination of the contractor on a regular basis can ensure that the contractor is compliant with this requirement.

I hope this review has helped you understand how Contractor Qualification services can be useful to meet some PSM/RMP obligations, while showing you how they cannot replace your entire PSM/RMP Contractor element.

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