Text For Citation: 01 Item/Group: 005 Hazard:

29 CFR 1910.119(m)(5): The employer shall establish a system to promptly address and resolve the incident report findings and recommendations. Resolutions and corrective actions shall be documented. (a) The incident report for the release of anhydrous ammonia on or about November 4, 2016, involving the IMECO Evaporative Condenser EEC-03 in the East Plant did not include documentation of resolutions and corrective actions completed. For example, the following incident report findings and recommendations were not addressed and resolved: * Root/Basic Cause(s): Possible equipment failure and deviation from response procedure * Review manual purger manufacture's manual for troubleshooting * Review condenser JTP for winter mode operations * Re-train how to respond to an ammonia release (b) The incident report for the release of anhydrous ammonia on or about November 30, 2017 involving the Viking Pump in the West Plant did not adequately address and resolve incident report findings and recommendations. For example, the following incident report findings and recommendations were not addressed and resolved: * Determine if new transfer pump is needed * Ammonia pipe needs to be extended * Create task procedure for checking proper rotation of pump 1 (d) On or about November 4, 2016, in the East Plant, an incident occurred involving an over-pressure release from one of the dual pressure relief valves provided for the IMECO Evaporative Condenser. Following this incident, the dual pressure relief valves were switched to the alternate side that did not release. However, the relief valve that did release was not replaced at the first opportunity. This was not in accordance with IIAR Bulletin No. 110.