Text For Citation: 03 Item/Group: 018 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 November 2009 to March 2010, Silver Eagle Refining Inc., 2355 South 1100 West, Woods Cross, UT, 84087. During a review of incident reports dated 2006 to present (85+ incident investigation reports), only 4 were found to have any documentation indicating that the recommendation is being addressed. The employer did not demonstrate that a system has been established to consistently ensure that these recommendations are addressed. By not establishing and implementing a system to promptly address and resolve incident report findings/recommendations, critical causal factors can be overlooked and left uncorrected, exposing employees to serious injury or death. This may be a system-wide occurrence that requires evaluation of all incident reports and recommendations throughout the facility.