Text For Citation: 01 Item/Group: 018B Hazard:

29 CFR 1910.119(m)(3): An incident investigation team was not established and did not consist of at least one person knowledgeable in the process involved, including a contract employee if the incident involved work of the contractor, and other persons with appropriate knowledge and experience to thoroughly investigate and analyze the incident. In the mechanical room, employer did not establish an incident investigation team that consists of at least one person knowledgeable in the process involved. Incidents in which ammonia releases were reported were not investigated by an incident investigation team, including but not limited to: a) corrosion of piping liquid line to Offal Cooler Unit 2 resulted in an ammonia vapor release, investigation report indicated only one person participated. investigation team was not identified on the incident summary, therefore qualifications of investigation team were not established. b) inadequate maintenance, administrative controls, procedures, training resulted in loose bolts on the liquid line of Hot Box 3 Unit 15 resulting in ammonia vapor release with liquid spill, investigation did not include contractors involved and report did not provide qualifications of members.