Text For Citation: 01 Item/Group: 009 Hazard:

29 CFR 1910.119(e)(3)(vi):The process hazard analysis did not address human factors. a) On or about May 12, 2021 at Limetree Bay Refining, LLC., Delayed Coker Unit (DCU) - The employer's 2020 UNIT 8500 Coker Unit Re-do Process Hazard Analysis Final Report failed to evaluate human factors when the human-machine interface (HMI) part of the distributed control system (DCS) was inadequately designed such that safety-critical alarms were indistinguishable and not prioritized. Failure to evaluate human factors in the design of the HMI DCS system can confuse operators during an emergency event when several thousand alarms may be reported at the console simultaneously without any prioritization scheme, delaying operator intervention/prompt action to an emergency, exposing employees to fire and toxic exposure hazards. b) On or about May 12, 2021 at Limetree Bay Refining, LLC., Delayed Coker Unit (DCU) - The employer's 2020 UNIT 8500 Coker Unit Re-do Process Hazard Analysis Final Report failed to evaluate human factors when process equipment - pressure vessels, pipes, valves, instruments, and controls were not labeled. During the P&ID walk down of the Coker Unit, OSHA observed pressure vessels (Coker Drums, Blowdown Tower, Fractionation Tower, etc.), piping, pumps, control valves (MOV), emergency isolation valves, manual valves including car seal/locked open valves, and instruments were not labeled. Failure to properly label process equipment can lead to inadvertent operation of equipment such as opening the incorrect valve or errors with Coke Drum switching, exposing employees to fire, explosion, and toxic release hazards. c) On or about May 12, 2021 at Limetree Bay Refining, LLC., Delayed Coker Unit (DCU) - The employer's 2020 UNIT 8500 Coker Unit Re-do Process Hazard Analysis Final Report did evaluate human factors in the initial Coker PHA related to hiring and retaining experienced personnel due to the remote location of the facility. Failure to have appropriate staffing and experienced operators can create worker fatigue and unsafe operations, exposing employees to fire, explosion, and toxic release hazards. d) On or about May 12, 2021 at Limetree Bay Refining, LLC., Delayed Coker Unit (DCU) - The employer's 2020 UNIT 8500 Coker Unit Re-do Process Hazard Analysis Final Report did not evaluate human factors when the operating procedures, Coke Drum Preparation, Switching, Drum Quenching, Drum Draining, and Drum Unheading (DCU-OP-401) were too long, unclear, not concise, and inaccurate. Failure to develop clearly written operating procedures can increase the likelihood of an error when using the procedure, exposing operators to fire and toxic hazards.