Text For Citation: 01 Item/Group: 007A Hazard:

29 CFR 1910.119(e)(3)(vi) The process hazard analysis did not address human factors: a) GEA/FES and Frick ammonia refrigeration systems: The employer's PHA failed to address human factors such as, but not limited to, use of an inadequate standard operating procedure when using a propane torch or kerosene heater to melt ice. The standard operating procedure, Ice Melting With A Propane Presto Lite Torch or Turbo Heater, did not include instructions to prevent hydrostatic expansion, on or about 10/10/17. b) Frick ammonia refrigeration system: The employer's PHA failed to address human factors such as the use of inadequate standard operating procedures (SOPs). RESOP-28 Operation of Air Unit EV3 Yeast Cooler did not list the consequences of deviation and the steps to avoid deviation, on or about 10/10/17. d) GEA/FES ammonia refrigeration system: The employer's PHA failed to address human factors such as the use of inadequate standard operating procedures (SOPs). OPS-01 Operation of C1, C2 or C3 FES Ammonia Compressors did not include the personal protective equipment required when conducting certain tasks and the properties and hazards of ammonia, on or about 10/10/17. e) GEA/FES ammonia refrigeration system: The employer's PHA failed to address human factors such as the use of inadequate standard operating procedures (SOPs). OPS-10A Startup, Shutdown and Operation of Spiral Air Units LK 18 and LK 19 did not include when emergency shutdown was required, personnel authorized to conduct emergency shutdowns, the consequences of deviation and the steps to avoid deviation, personal protective equipment required for certain tasks, safety systems and their functions and the properties and hazards of ammonia, on or about 10/10/17. f) GEA/FES ammonia refrigeration system: The employer's PHA failed to address human factors such as the use of inadequate standard operating procedures (SOPs). OPS-04 Operation of Low Pressure Receives VA1 and VA2 did not include when emergency shutdown was required, personnel authorized to conduct emergency shutdowns, personal protective equipment required for certain tasks and the properties and hazards of ammonia, on or about 10/10/17. g) Frick ammonia refrigeration system: The employer's PHA failed to address human factors such as, but not limited to, an evaluation of the access control procedures for the line 5 spiral freezer computer. In November 2017 a production supervisor was able to access the computer and initiate the hot gas defrost cycle for one of the four evaporators while another unit was in already in a defrost cycle resulting in a surge of ammonia back to the LTPR-2 that caused the compressors to freeze, on or about 10/10/17. NOTE: THE EMPLOYER IS REQUIRED TO SUBMIT ABATEMENT CERTIFICATION FOR THIS ITEM. FAILURE TO COMPLY WILL RESULT IN AN ADDITIONAL PENALTY OF $1000.00 IN ACCORDANCE WITH 29 CFR 1903.19.