Text For Citation: 01 Item/Group: 006 Hazard:

29 CFR 1910.119(f)(1): The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process: At the Wichita facility the employer did not develop and implement written operating procedures that provided clear instructions for safely conducting activities involved in each covered process. Employees engaged in repair, replace, inspection and maintenance activities of covered process equipment at the engine rooms, roof top, and the warehouse, freezer areas were exposed to the hazards of inhalation of toxic ammonia, asphyxiation, chemical burns, and fire. The review of the Standard Operating Procedures (SOP) showing some of the following deficiencies: a. The Ammonia Pumps #2 (PP2) Standard Operating Procedure (SOP) was deficient in that the Process Piping & Instrumentation Diagrams (P&ID) was referenced without the ID, the drawing, or the control number. The Technical Operating Specification / Node Description Ammonia Pumps #2 (PP2) - Instrumentation and Safety Systems, Item Number section just listed, stated "See P&ID", therefore, it is not clear with which P&ID they refer to, what the drawing number, control number for the P&ID to review, to take actions in case of emergency. b. The Compressor Vilter #2 (CP2) Operating Procedure, Emergency Shutdown, Step #2, "Follow the procedures for 'normal shutdown' as listed above." There was no mention, no clear instructions of how and when with related to the intended use of the emergency stop devices (the emergency shutdown button) installed outside of the engine room. The employer did not develop a clear instruction in the Compressor Vilter #2 (CP2) Standard Operating Procedure Emergency Shutdown section as to when/what conditions, how and who is authorized to activate the Ammonia Emergency Shutdown procedure. There was no description, provision describing conditions requiring emergency shutdown of the system. c. The Compressor Vilter #2 (CP2) Standard Operating Procedure (SOP) was deficient in that the Process Piping & Instrumentation Diagrams (P&ID) was referenced without the ID, the drawing, or the control number. The Technical Operating Specification / Node Description Compressor Vilter #2 (CP2) - Instrumentation and Safety Systems, Item Number section just listed, stated "See P&ID", therefore, it is not clear with which P&ID they refer to, what the drawing number, control number for the P&ID to review in case of emergency. d. The Condenser #2 (C2) Standard Operating Procedure (SOP) was deficient in that the Process Piping & Instrumentation Diagrams (P&ID) was referenced without the ID, the drawing, or the control number. The Technical Operating Specification / Node Description Condenser #2 (C2) - Instrumentation and Safety Systems, Item Number section just listed, stated "See P&ID", therefore, it is not clear with which P&ID they refer to, what the drawing number, control number for the P&ID to review in case of emergency. e. The Evaporators CD East (AU4) Standard Operating Procedure (SOP) was deficient in that the Process Piping & Instrumentation Diagrams (P&ID) was referenced without the ID, the drawing, or the control number. The Technical Operating Specification / Node Description Evaporators CD East (AU4) - Instrumentation and Safety Systems, Item Number section just listed, stated "See P&ID", therefore, it is not clear with which P&ID they refer to, what the drawing number, control number for the P&ID to review in case of emergency. f. The Exhaust Fan #2 Standard Operating Procedure (SOP) was deficient in that the Process Piping & Instrumentation Diagrams (P&ID) was referenced without the ID, the drawing, or the control number. The Technical Operating Specification / Node Description Exhaust Fan #2 - Instrumentation and Safety Systems, Item Number section just listed, stated "See P&ID", therefore, it is not clear with which P&ID they refer to, what the drawing number, control number for the P&ID to review in case of emergency. g. The LTR #1 (V1) Operating Procedure, Emergency Shutdown Instructions / Required Steps. Step 1. Shut down compressors. The SOP did not list out step by step on how, what are the steps to shut down the compressors such as shut down by the compressor panels inside the engine room or by the emergency stop button outside the exit of the engine room. There was no mention, no clear instructions of how with related to the intended use of the emergency stop devices (the emergency shutdown button) installed outside of the engine room. Step 2. If the emergency is an ammonia leak, turn off all flow promoting equipment then close valves deemed appropriate per the P&ID's. There was no specific of which P&ID to work with in case of ammonia leak. h. The LTR #1 (V1) Standard Operating Procedure (SOP) was deficient in that the Process Piping & Instrumentation Diagrams (P&ID) was referenced without the ID, the drawing, or the control number. The Technical Operating Specification / Node Description LTR #1 (V1) - Instrumentation and Safety Systems, Item Number section just listed, stated "See P&ID", therefore, it is not clear with which P&ID they refer to, what the drawing number, control number for the P&ID to review in case of emergency. The SOP procedural steps instruct employees to verify valve conditions, to open, close, or shut valves during operations, or emergency situations. Because of this reason, the P&ID must be identified in each of the SOP to be able to reference quickly, and to avoid confusion, the instruction steps must be clear. Employees and contractors must immediately know what valves to open and close, which P&ID to review, to identity, to work with, what steps to follow, which one to shut down in case of emergency. Safety systems are critical to ensure that the process remains under control within operating limits, and will shut down under unsafe conditions of temperature, pressure, or flow. The data in the Process Safety Information is essential for the Mechanical Integrity program for the safety equipment.