Text For Citation: 03 Item/Group: 017A Hazard: REFINERY

29 CFR 1910.119(m)(4)(iv) A report shall be prepared at the conclusion of the investigation which includes at a minimum: The factors that contributed to the incident. A. At the time of the inspection, November 2009 through March 2010, Silver Eagle Refining Inc., 2355 South 1100 West, Woods Cross, UT, 84087, review of incident reports demonstrated that contributing factors were not always included as part of the incident investigation. An example of such includes, but not limited to, incident report #67, dated 2/11/2009; identified no contributing factors or root causes. Incident #67 involved an uncontrolled release of vapors which were identified as "light ends and hydrogen." Incident report #71, dated 3/04/09, states "Root cause is undetermined." By not fully investigating incidents and near misses, critical contributing factors and root causes may not be documented and addressed. Lack of addressing and correcting contributing factors can result in continued employee exposure to known hazards. This may be a system-wide occurrence that requires evaluation of all incident investigation reports throughout the facility.