Historical Perspective

1. Historical Perspective • Marriage between Safety and Engineering (good engineering practice) • Involved Corporate Engineering and Plant Engineers • Training, Training, and more Training • Initial training of PSM Implementers (Primatech) • Use of checklists that clarify what progress really is • Operator training on Ammonia Systems (IIAR/RETA) • Training Engineers on MOC with Ammonia CER’s

2. Historical Perspective • Keeping PSM on the Front Burner • Quarterly progress reports on PHA and CA • Deficiencies (signed by plant manager) • Facility safety reviews • Monthly conference calls • Auditing, Auditing, and more Auditing • Plants performed self-audits per CPL checklist • Corporate Safety and Engineering did PSM audits • Third party audits

3. Historical Perspective • OSHA PSM Inspections • Wallace, NC was first on 1/96 by State OSHA • Turlock, CA was second on 1/97 by State OSHA • Kansas City, KS was third on 5/97 by Federal OSHA

4. The Inspection Process

5. Kansas City, KS • Processed meats facility producing: • Deli products • Sliced luncheon meat • Breakfast strips • Sausage franks • Lunchmakers® • Constructed 1979, addition 1996 • 225,000 square feet • 55,000 pound ammonia system • Four system operators

6. Original Complaint Investigation January 8,1997 • “The ammonia piping and valves on the manufacturing floor of the plant are deteriorated and in very dangerous condition exposing employees to injury.” • Very brief inspection • No review of PSM • No interviews • No citations issued

7. Second Complaint Investigation April 9, 1997 • “Manufacturing floor, evaporative units 1 through 6 have valves that are deteriorating, stems that are 1/3 their original size, and have severe corrosion problems.” • “Some pipes in the engine room are schedule 40 rather than standard schedule 80.” • “Pipes and pressure vessels are welded on by non-certified welders.” • “Pipes in the facility are not tested for corrosion.”

8. Initial Inspection • One inspector from Overland Park office • Minimal visits to inspect physical conditions • takes video and still pictures • Requests and receives numerous documents including: • pipe inspection report • mechanical integrity program • process hazard analysis and status report • completed compliance audits • Interviews operators • interviews each operator for up to four hours

9. Salt Lake City Inspection Team • Four inspections • original inspector (Safety Engineer) • Assistant Regional Director (Industrial Hygienist) • Salt Lake City inspectors: • Mechanical Engineer (PE/Industrial Hygienist) • Industrial Hygienist (CIH)

10. Team Inspection Process • Request and receive numerous additional documents • inspectors pair up to focus on specific elements • continue interviews with operators • group interview with management • several tours to view engine room, roof, and pipe runs

11. Documents Furnished • All PSM program elements and supporting information including: • all Management of Change forms • equipment manuals • all PSM incident investigation reports • all employee training records for operators • ancillary programs (LOTO, PPE, confined space, etc.) • ConAgra Annual Report

12. Additional Issues • Asbestos survey • PSM consultant • Pipe radiography • Pipe replacement • Full corporate safety and health compliance audit

13. Inspection Management • Request all documents in writing • 24 hour time to respond • Log all documents given • name of document • file number • double copy

14. KANSAS CITY, KANSAS - PSM INSPECTION AREA OF CITATION # ITEMS CITED Employee Participation 2 Process Safety Information 3 Process Hazard Analysis 3 Operating Procedures 7 Training 2 Contractors 2 Pre-Startup Safety Reviews 4 Mechanical Integrity 7 Management Of Change 4 Incident Investigation 3 Compliance Audits 3 Total PSM 40

15. KANSAS CITY, KANSAS - PSM INSPECTION AREA OF CITATION # ITEMS CITED Related H&S Programs OSHAct General Duty - Section 5 (a)(1) 1 Emergency Action Plans - 1910.38 1 HAZWOPER - 1910.120 1 Personal Protective Equipment - 1910.132 1 Respiratory Protection - 1910.134 2 Control of Hazardous Energy (Lockout) - 1910.147 4 Employee Alarm Systems - 1910.165 1 Electrical Safety - 1910.303, 304, & 305 2 Total Related H&S Programs 13 TOTAL ITEMS CITED 53

16. PreCitation Settlement • Potential for megafine and negative publicity • Interest by OSHA • leverage inspection • avoid potential conflict with VPP Partnership Initiative • save resources • UFCW informed and cooperative

17. PreCitation Settlement • OSHA provides draft citation • ASE develops abatement plan • aggressive dates • $500,000 + spent on mechanical integrity and PSM implementation • Abatement plan reviewed with UFCW

18. Citation • 53 serious items: • 40 PSM • $256,650 proposed fine • 3 willful violations avoided • mechanical integrity • pre-startup safety review • process hazard analysis

19. Settlement Agreement Corporate • Region-wide: 5 plants Kansas City, KS Carthage, MO Hastings, NE Omaha, NE Junction City, KS • Citation to be training tool • ASE • ConAgra • Industry groups • Train UFCW • Copies to all ASE facilities

20. Settlement Agreement Kansas City • Full PSM implementation by 7/1/98 • Corporate Safety Department to monitor progress • on-site visits • 60 day monitoring reports • 3rd party audit on or before 7/1/99 • OSHA Institute training

21. Settlement Agreement Kansas City (cont.) • Serve as benchmark • 5-year inspection by 7/1/98 • IIAR Bulletins • ANSI/ASHRAE • Replace piping with wall thickness loss of 50% or greater

22. Settlement Agreement Region VII • Quarterly reports • Compliance by 4/19/98 • employee participation • contractors (except safe work practices) • pre-startup safety reviews • hot work permit • management of change • incident investigations • emergency response

23. Settlement Agreement Region VII (cont.) • Compliance by 10/9/99 • process safety information • process hazard analysis • standard operating procedures • mechanical integrity (except 3rd party visual inspection (6 months)) • compliance audits

24. OSHA’sPress Release • “… employers with ammonia refrigeration PSM related programs are being notified of OSHA’s intent to hold them accountable for complying with the IIAR Bulletins.”

25. EMPLOYEE PARTICIPATION • The facility’s Employee Participation Guidelines did not: • Address employee consultations during PSM program development • Assign responsibility or authority for implementing PSM • Establish methods for soliciting input from contract employees regarding PSM • The facility did not consult with employees on various elements of PSM

26. PROCESS SAFETY INFORMATION • The facilities PSI Information did not include: • A block flow or simplified process flow diagram • The expected maximum inventory of site vessels • Safe upper and lower operating limits for temperature, pressure, etc. • Expected results of deviations from safe upper and lower operating limits • Design codes and standards, materials of construction, etc., used in system design • Complete Process & Instrumentation Diagrams (P&ID’s) • Electrical classification of machine rooms • Information regarding ventilation system design • Information regarding safety systems (e.g. interlocks, cutouts, detection systems)

27. PROCESS SAFETY INFORMATION The facilities PSI Information did not include: • Verification of good engineering practices in ammonia system including: • a) Location of the discharge of pressure relief valves (PRV’s) for new system • b) The size of common vent header for PRV’s • c) Suitability of pipe and vessel insulation materials • d) Installation of PRV’s on appropriate devices (#’s 3 and 25 accumulators) • e) Location of king valves (not operable from floor & no access platform)

28. PROCESS SAFETY INFORMATION • Demonstration of good engineering practice for of electrical classification • a) Engine room not classified • b) No remote emergency stop switches in engine rooms

29. Process Hazard Analysis • The facility’s initial (1994) Process Hazards Analysis (PHA) did not: • Identify, evaluate, and establish controls for the hazards associated with the process • Address previous PSM incidents • Address engineering and administrative controls for the following: • detection methodologies for ammonia nor emergency ventilation • PRV’s or their vent header sizing • emergency isolation (king) valves or compressor emergency cut-off switches • mechanical integrity procedures

30. Process Hazard Analysis (cont.) • Address the consequences of failure of engineering and/or administrative controls • Address facility siting or human factors • The facility’s initial (1994) Process Hazards Analysis (PHA) did not: • Promptly address all recommendations • Discuss recommendations with refrigeration operators

31. Operating Procedures • The facility did not have compete (SOP’s) for the ammonia system • The facility’s written SOP’s did not address: • Normal operating procedures • Temporary operations • Emergency shutdown conditions • Procedures for isolation and control of engine room leaks, including PPE • Operating limits, i.e., flow rates, pressure limits, temperature ranges, etc. • Hazards of the chemicals used in the process • Safety systems and their functions, i.e., emergency stop switches, king valves, etc.

32. Operating Procedure (cont.) • The facility did not perform annual certification of their SOP’s • The facility had not developed and implement safe work practices for: • Contractors entering the facility • Entering process equipment or piping

33. Training • The facility’s PSM training program did not: • Require refresher training at least once every three years • Require consultation with employees regarding the frequency of refresher training • Document employee training on specific SOP’s • Require verification of employee understanding of SOP’s

34. Contractors • The facility’s PSM Contractor Safety Program did not require: • Evaluation of contractor safety performance and programs prior to contract initiation • Periodic review of contractor safety performance • Periodic evaluation of contractor safety training programs • Periodic evaluation of contractor employees understanding safety training

35. Pre-Startup Safety Reviews • The Pre-Startup Safety Review for the new ammonia system failed to confirm that: • construction and equipment of process was in accordance with design specifications • P& ID’s were complete and verified as accurate • Acceptance tests were performed on computer hardware & software, protection devices including alarms, interlocks, cutouts and level controls • Safety, operating, maintenance, and emergency procedures were complete • PHA had been performed • Employee training had been performed and understood

36. Mechanical Integrity • The facility’s Mechanical Integrity Program contained the following deficiencies: • No procedures for repair of process equipment • No procedures for replacement of PRV’s • Inspection and tests were not performed on vessels, piping, PRV’s, emergency shutdown systems, control systems, pumps and compressors

37. Mechanical Integrity (cont.) • No documentation of inspection & tests on process equipment • The facility did not correct known deficiencies in a safe and timely manner • No procedures ensuring that new refrigeration plant was installed to design specifications and manufacturer’s instructions • No procedures to ensure that maintenance materials, spare parts and equipment were suitable for the process applications

38. Management of Change • No requirement to establish and implement written MOC procedures • Numerous changes were implemented without performing MOC’s

39. Management of Change (cont.) • Written MOC procedures did not assure that the following issues were addressed: • Technical basis for proposed changes • Safety & Health considerations • Modifications to operating procedures • Failure to update process information and operating procedures after implementing MOC’s

40. Incident Investigation • Failure to develop an incident investigation procedure that met the requirements of PSM • Failure to investigate numerous PSM related incidents • Failure to train investigation teams in incident investigation techniques • Failure to include at least one member with process knowledge on investigation team • Failure to establish system to promptly address and resolve investigation report findings

41. Compliance Audits • Failure to verify that procedures and practices developed under the standard were being following, i.e., failure to correct PSI issues identified in earlier compliance audits • Failure to include at least one member with process knowledge on the audit team • Failure to develop plan for resolution of compliance audit findings • Failure to resolve compliance audit findings in a timely manner

42. Related Work Practices • OSHAct General Duty - Section 5 (a)(1) • Failure to provide positive securing mechanism for chain hoist on freezer doors • Failure to maintain chain hoists on freezer doors • Emergency Action Plans - 1910.38 • Failure to train employees in changes to site alarm system • Failure to train employees in changes to emergency egress routes

43. Related Work Practices (cont.) • Hazwoper - 1910.120 • Failure to develop an emergency response plan that adequately addressed: • Ammonia release and response criteria • Protocols for Carbon Dioxide or Sulfuric Acid releases • Methods for determining safe distances and places of refuge • Personal Protective Equipment - 1910.132 • Failure to perform workplace hazard assessment for ammonia system repairs

44. Related Work Practices (cont.) • Respiratory Protection - 1910.134 • Utilization cartridge respirators in lieu of SCBA during ammonia releases • No procedures for emergency’s involving sulfuric acid and carbon dioxide • Failure to perform air sampling prior to entering potentially hazardous atmosphere

45. Related Work Practices (cont.) • Control of Hazardous Energy (Lockout) - 1910.147 • Use of tagout procedure in lieu of lockout where lockout was appropriate • No specific lockout procedures for the following equipment: • Shirmatic unit in TRM Stuffing Dept • Cozzini Vacuum Hopper & Mill in TRM Stuffing Dept. • Various pieces of ammonia refrigeration equipment • Transfer of ownership procedures • Failure to perform annual audits of lockout program • Failure to verify employee understanding of lockout program (as evidenced by numerous injuries of employees while performing lockout)

46. Related Work Practices (cont.) • Employee Alarm Systems - 1910.165 • Alarm system was not capable of being heard throughout the workplace • Electrical Safety - 1910.303, 304, & 305 • Electrical services not identified • Live electrical parts (operating above 50 volts) not guarded: • Electrical box in Sizzlean area • Electrical panel in old engine room • Ground pin removed on fan in new engine room • Damaged insulation on electrical cord (TRM Shiramatic) • Receptacle on reeves drive (Sizzlean) not water tight, electrical hazard during clean-up