Text For Citation: 01 Item/Group: 010 Hazard:

29 CFR 1910.119(m)(4): A written 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; the factors that resulted from the investigation; any recommendations resulting from the investigation; and the recommendation's resolutions: Employees engaged in operating, inspecting, testing, and maintaining activities at the covered process equipment in the rooftop, and the CP-2 + CP-4 engine rooms were exposed to catastrophic release of ammonia which results in asphyxiation, explosion and flash fire leading to death and injury to persons in and near the facility in that the incident investigation reports were not prepared to its completeness. a) Incident Investigation - Reference No.: K12806-06052016, The Copy Distribution block, Submitted By: Wayne Holub signed with the wrong date 4/5/16, and Received By: James Jackson signed with no date. The Close-Out section, same issue, Submitted By: Wayne Holub signed with the wrong date 4/5/16, and Received By: James Jackson signed with no date. b) Incident Investigation - Reference No.: CP2-12102013 - Replace Hansen Motorized Valves with Danfoss Valves - There was no attached document within the report for indication that an MOC was initiated for this change of valves. There was no document indicating that the PSI and P&ID has been updated to reflect the new valves. c) Ammonia Leak on 2/2/13 - Issues & Concerns regarding this Incident - There was 6 items addressing concerns; but there was no attached document in the report indicating these issues have been addressed. d) Incident Investigation - Reference No.: 111312 - The date of the incident was not filled out on the form at the Date of Incident block. The Close-Out section did not have any management signed off to certify that it is complete and appropriate to close out the investigation. The form stated that Safety Director must sign when completed. e) Incident Investigation - Reference No.: II-03092012 - The date of the incident was not filled out on the form at the Date of Incident block. The Close-Out section was missing from the provided document so OSHA is not able to confirm that there was any management signed off to certify that it is complete and appropriate to close out the investigation. 29 CFR 1903.19(c)(1) requires certification that the abatement of the above violations is complete.