Text For Citation: 01 Item/Group: 012 Hazard:

29 CFR 1910.119(m)(4): An incident report was not prepared at the conclusion of the investigation that included at a minimum, the date of the incident, date the investigation began, a description of the incident, and any recommendations resulting from the investigation: The employer is failing to protect employees engaged in production activities throughout the facility. This was most recently documented where employees were exposed to chemical hazards associated with a catastrophic release of Ammonia in that the incident investigation reports were not prepared to its completeness. a) Incident Investigation Reference No. 2015-September-23, the Close Out Report does not include recommendations regarding the Investigation Review Sessions to address the leaking coil at the AC-4. b) Incident Investigation Reference No. 2015-March-29, the Close Out Report does not include recommendations regarding the Investigation Review Sessions to address the leaking coil at the AC-8. c) Incident Investigation Reference No. Iola 2015-January-29, the Close Out Report does not include recommendations regarding the Investigation Review Sessions to address the leaking at the economizer valve packing on RC-1 Ammonia compressor. Reference number on the last page has the wrong date. d) Incident Investigation Reference No. Iola 2015-January-18, the Close Out Report does not include recommendations regarding the Investigation Review Sessions to address the leaking coil on the gasket in hot gas valve for the evaporators. e) Incident Investigation Reference No. Iola 2014-March-12, the Close Out Report does not include recommendations regarding the Investigation Review Sessions to address the Ammonia vapor release on a shaft seal on Ammonia compressor RC-5. Date and time team commenced investigation is not completed to show that the investigation started within 48 hours of the incident. There are no signatures of the submitter or the receiver for approvals, follow-up and reviews. There are no signatures of the team leader and the approver to close-out the incident investigation report. f) Incident Investigation Reference No. Iola 2013-May-16, date and time team commenced investigation is not completed to show that the investigation started within 48 hours of the incident. The form is not signed by the team leader. g) Incident Investigation Reference No. Iola 2010-August-1, the Close Out Report does not include recommendations regarding the Investigation Review Sessions. Date and time team commenced investigation is not completed to show that the investigation started within 48 hours of the incident. The form is not signed by any of the management team. The form is marked as DRAFT - Document for development and review only. h) Incident Investigation Reference No. Iola 2010-June 18, the Close Out Report does not include recommendations regarding the Investigation Review Sessions. Date and time team commenced investigation is not completed to show that the investigation started within 48 hours of the incident. The form is not signed by any of the management team. The form is marked as DRAFT - Document for development and review only. i) Incident Investigation Reference No. Iola 2010-January 14, the Close Out Report does not include recommendations regarding the Investigation Review Sessions. Date and time team commenced investigation is not completed to show that the investigation started within 48 hours of the incident. The form is not signed by any of the management team. The form is marked as DRAFT - Document for development and review only. 29 CFR 1903.19(d)(1) requires certification and documentation that the abatement of the above violation is completed.