Text For Citation: 03 Item/Group: 009E Hazard: REFINERY

29 CFR 1910.119(e)(3)(vi) The process hazard analysis shall address: Human factors. A. The employer did not ensure the process hazard analysis (PHA) addressed human factors specifically considering the lack of clearly visible, understandable, exit route signs and instructions. This violation was identified during inspections of the facility from November 2009 to March 2010. Review of the #2 Crude Unit 2005 PHA, #5 Reformer Unit 2009 PHA, #5 Naphtha/HDS 2008 PHA, and #3 MDDW 2009 PHA did not indicate that exit signage and instructions were considered. Onsite review of refining units showed clearly visible exit signs were not present. Employee interviews stated that if exit routes were reviewed, it would be included on the PHA checklist. Documents provided by the employer did not show the lack of clearly visible, understandable, exit route signs and instructions was assessed. Silver Eagle's 2009 PSM Compliance Audit identified that human factors were not considered in the PHA's. By not addressing clearly visible, understandable exit signs, employees and contractors may be unable to locate exit routes in the event of an emergency. Such oversight can lead to employees being exposed to hazardous situations that can cause serious injury or death. This may be a system-wide occurrence that requires evaluation of all applicable areas throughout the facility. B. The employer did not ensure the process hazard analysis (PHA) addressed human factors specifically considering and evaluating all situations where field employees must close isolation valves during emergencies and where doing so would expose them to hazardous situations. This violation was identified during inspections of the facility from November 2009 to March 2010. Review of the #2 Crude Unit 2005 PHA, #5 Reformer Unit 2009 PHA, #5 Naphtha/HDS 2008 PHA, and #3 MDDW 2009 PHA did not indicate that the PHA team evaluated situations where field employees closing valves during an emergency would expose them to hazardous situations. Documents provided by the employer did not demonstrate evaluation of closing valves during hazardous situations was assessed. In addition, Silver Eagle's 2009 PSM Compliance Audit identified that human factors were not considered in the PHA's. In the event of an upset, employees can be required to enter hazardous environments which can expose them to serious injury or death. This may be a system-wide occurrence that requires evaluation of all applicable areas throughout the facility. C. The employer did not ensure the process hazard analysis (PHA) addressed human factors specifically considering the possibility of human error when equipment described in a written procedure is not labeled or marked with that same identifier in the field. This violation was identified during inspections of the facility from November 2009 to March 2010. Review of the #2 Crude Unit 2005 PHA, #5 Reformer Unit 2009 PHA, #5 Naphtha/HDS 2008 PHA, and #3 MDDW 2009 PHA did not indicate that the PHA team evaluated differences and scenarios where markings differed between written procedures and in the field. Noted during onsite inspections were missing car seals & P&ID discrepancies which could cause confusion in the field. Documents provided by the employer did not demonstrate evaluation of human error in the PHA. By not ensuring markings are the same on paper as in the field, confusion could result and incorrect changes or adjustments can occur. Such oversight can lead to employees being exposed to hazardous situations that can cause serious injury or death. This may be a system-wide occurrence that requires evaluation of all applicable areas throughoutthe facility. D. The employer did not ensure the process hazard analysis (PHA) addressed human factors specifically considering when control room operators perform calculations during situations such as upset conditions, system failures, or emergency conditions. This violation was identified during inspections of the facility from November 2009 to March 2010. Review of the #2 Crude Unit 2005 PHA, #5 Reformer Unit 2009 PHA, #5 Naphtha/HDS 2008 PHA, and #3 MDDW 2009 PHA did not indicate that the PHA team evaluated events in which calculations must be made by operators. Operators stated that in some cases, they are required to perform manual calculations. Documents provided by the employer did not demonstrate evaluation of manual calculations in the PHA. Such oversight can lead to employees being exposed to hazardous situations that can cause serious injury or death. This may be a system-wide occurrence that requires evaluation of all applicable areas throughout the facility.