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

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 employer did not establish and implement an incident investigation system to promptly address recommendations and resolve incident findings. This violation was identified during inspections of the facility from May 2010 to September 2010, Big West Oil LLC., 333 West Center Street, North Salt Lake, UT, 84054. UOSH reviewed incident reports dated 2009 to present as well as the incident tracking sheet (BWO UOSH-036D). The reports included recommendations but many were found to have no documentation indicating the recommendations were resolved. Examples include, but are not limited to, recommendations associated with a flare piping failure on 03/28/2010. The employer did not demonstrate that a system has been established to consistently ensure that these recommendations are addressed and resolved. Critical causal factors were left uncorrected by not establishing and implementing a system to promptly address and resolve incident report findings/recommendations. By not making the necessary corrections, employees may be exposed to hazardous conditions that could result in serious injury. This may be a system-wide occurrence that requires evaluation of all incident reports and recommendations throughout the facility.