Text For Citation: 01 Item/Group: 004 Hazard:

29 CFR 1910.119(l)(1): The employer did not implement procedures to manage changes to process chemicals, technology, equipment, and procedures, and changes to facilities that affect a covered process: (a) When the Maximo system was replaced by the SAP system, on or around August, 2016, for scheduling and tracking mechanical integrity inspections and preventative maintenance of Ammonia Refrigeration equipment, this change affected the content and maintenance of some of these inspection/maintenance records. The employer did not implement procedures to manage these changes. For example, some of the inspection records generated after August, 2016 have a Maximo number: - Annual Inspection record for the Viking Pump performed on 12-5-2016 (Maximo #4900), - Annual Inspection record for Evaporator WPE-71 performed on 11-4-16 (Maximo #4894) Also the SAP Maintenance Work Order for "Compressor General Service - All compressor receive inspection and routine service" was not consistent in its content with the employer's established Mechanical Integrity Program for Compressors. For example, on or around June 6, 2017, a Refrigeration Operator utilized SAP work order #400735218 to perform 6 month (Biannual) inspection and service on East Ammonia Compressor #3. The SAP work order did not cover Items Requiring Attention as listed in the employer's Mechanical Integrity Program for Compressors, Condensers, Pumps, Evaporators and Motors. According to the specific Mechanical Integrity procedure for Vilter Compressors (including East Ammonia Compressor#3), Bi Annually an Operational Inspection must include Lubricate as directed (bearings requiring grease), and Bi Annually a Major Inspection must include All safety cutouts. However, the SAP work order neither covered lubrication nor safety cutouts. (b) In 2016 there were four (4) Refrigeration Operators, whereas during 2017 the number of Refrigeration Operators was reduced to two (2). This reduction in staffing potentially impacted the employer's ability to perform necessary mechanical integrity inspections of process equipment and piping. Also this reduction in staffing potentially affected the employer's ability to investigate ammonia releases which may occur and to perform activities such as line breaking and isolating process equipment. No management of change has been performed to evaluate and manage the effects of this change in staffing.