prevention program for level 2 processes - us epa · piping, electrical, ... • prevent...

66
Prevention Program Program Level 2 Processes The heart of the Risk Management Program Prevention Program 1 CAA 112(r)

Upload: doandien

Post on 20-Apr-2018

218 views

Category:

Documents


1 download

TRANSCRIPT

Page 1: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Prevention ProgramProgram Level 2 ProcessesThe heart of the Risk Management Program

Prevention Program 1CAA 112(r)

Page 2: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Prevention Program

Program 2

• Safety information• Hazard review• Operating procedures• Training• Maintenance• Compliance Audits• Incident investigation

Program 3

• Process safety information• Process hazard analysis• Operating procedures• Training• Mechanical integrity• Compliance audits• Incident investigation

• Pre-startup review• Management of change• Employee participation• Hot work permit• Contractor accountability

Prevention Program 2CAA 112(r)

Page 3: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Safety InformationSafety information is the foundation of a good

prevention program

Prevention Program: Safety Information 3CAA 112(r)

Page 4: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Guidelines and Best Management Practices

• One of the most important parts of the regulation relates to “recognized and generally accepted good engineering practices” 40 CFR 68.48(b)

• When it comes to the Risk Management Program and chemical safety in general (General Duty Clause), the strict interpretation of “grandfather clauses” ended on June 21, 1999

CAA 112(r) Prevention Program: Safety Information 4

Page 5: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Purpose of RequirementSafety Information

• Ensure understanding of safety-related aspects of equipment, processes, and chemicals

• Know limits those aspects place on operations• Adopt accepted standards and codes• Most program elements depend on the accuracy and thoroughness of

information required by this element• Especially important for the hazard review

CAA 112(r) Prevention Program: Safety Information 5

Page 6: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Up-to-date Safety Information Requirements for Program 2 Processes

• Hazardous/regulated substances• SDS – current, from actual chemical supplier

• Processes• Maximum intended inventories• Safe upper and lower limits for temperatures, pressures, flows, compositions

CAA 112(r) Prevention Program: Safety Information 6

Page 7: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Up-to-date Safety Information Requirements for Program 2 Processes (cont.)

• Equipment Specifications• Account for upper and lower temperatures and pressures• Use of schedule 40 pipes• Pressure vessel rating vs. codes/standards

• Codes/standards used to design, build, and operate• Compliance with good engineering practices• Update when major change makes information inaccurate

CAA 112(r) Prevention Program: Safety Information 7

Page 8: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Common Codes and Standards for Program 2 Processes

CAA 112(r) 8

Organization Codes IncludePiping, electrical, power wiring, instrumentation, lighting, product storage and handling, insulation and fireproofing, painting and coating, ventilation, noise and vibration, fire protection equipment, safety equipment, pumps, compressors, motors, refrigeration equipment, pneumatic conveyingPower boilers, pressure vessels, piping, compressors, shell and tube heat exchangers, vessel components, general design and fabrication codesWelded tanks, rotating equipment, bulk liquid storage systems

Fire pumps, flammable liquid code, liquid natural gas storage and handling, plant equipment and layout, electrical system design, shutdown systems, pressure relief equipment, venting requirements, gas turbines and engines, cooling towers, storage tanksInspection and testing, noise and vibration, materials of construction, piping materials andsystems, instrumentationChlorine handling, inspections, testing, equipment integrity

Page 9: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Common Deficiencies

• Safety information incomplete, not current, or inaccurate• Maximum inventories• Safe operating control limits not specified in written documents

• No or outdated SDS/MSDS• Obsolete equipment or design with no plans to change and no

documentation to show still safe• Good engineering practices/industry standards not followed

• Examples: anhydrous ammonia vessels with rust, no traffic barriers around piping

CAA 112(r) Prevention Program: Safety Information 9

Page 10: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Rust – the cancer of steel

CAA 112(r) Prevention Program: Safety Information 10

Page 11: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Saddles Fit Poorly

CAA 112(r) Prevention Program: Safety Information 11

Page 12: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Saddles Not Designed to Prevent Movement

CAA 112(r) Prevention Program: Safety Information 12

Page 13: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Vehicular Barriers Absent or Inadequate

CAA 112(r) Prevention Program: Safety Information 13

Page 14: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Tanks On/Near Ground

CAA 112(r) Prevention Program: Safety Information 14

Page 15: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Inadequate Bulkheads

CAA 112(r) Prevention Program: Safety Information 15

Page 16: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Common Deficiencies

• Other examples of good engineering practices/industry standards not followed include

• Anhydrous ammonia pipes not marked throughout the entire facility • Markings not readily readable from any vantage point• No emergency water near the ammonia loading area

CAA 112(r) Prevention Program: Safety Information 16

Page 17: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

New Standard Released

• Make sure to consider new standards once they are released• There is no “grandfathering” of old standards• ANSI/CGA K61.1 (1999) superseded by CGA G-2.1 (2014) “Requirements for

the Storage and Handling of Anhydrous Ammonia” 6th Ed.

CAA 112(r) Prevention Program: Safety Information 17

Page 18: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Hazard ReviewDetermining what could lead to problems

CAA 112(r) Prevention Program: Hazard Review 18

Page 19: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Overview

• Identify potential for chemical releases• Incorporate safety information• Findings used to develop operating procedures, training programs,

emergency response programs• Many options – checklists, HAZOP, fault-tree, etc.

• If checklist used, should be facility-specific

CAA 112(r) Prevention Program: Hazard Review 19

Page 20: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Definitions

• Hazards:• Unsafe acts or conditions that create potential for accident(s) with

undesirable consequences• Loss of containment of flammable, combustible, highly reactive, or toxic

materials• Uncontrolled electrical hazards or mechanical overpressure

• Accident: unplanned sequence of events that has undesirable consequences• Consequence: impact of accident (i.e., effects on people, property, or

environment)

CAA 112(r) Prevention Program: Hazard Review 20

Page 21: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Definitions (cont.)

• Risk: measure of potential human injury, economic loss, or environmental impact in terms of severity or likelihood

CAA 112(r) Prevention Program: Hazard Review 21

Page 22: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Factors Affecting Risk

• Process materials• Process conditions• Physical design• Equipment• Control system• Operating procedures• Operator training

CAA 112(r) Prevention Program: Hazard Review 22

• Test, inspection, maintenance practices

• Emergency plans• Plant layout• Source siting• Protective measures• Staff attitudes• Management attention

Page 23: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Requirements

• Conduct review to identify• Process and regulated substance hazards• Equipment malfunctions or human errors that could cause release• Safeguards used or needed• Release detection/monitoring used or needed

• May use guides (e.g., checklists)

CAA 112(r) Prevention Program: Hazard Review 23

Page 24: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Requirements (cont.)

• Must document results and resolve identified problems in timely manner• Update review

• At least every 5 years• After major change in process (resolve problems identified before startup)

CAA 112(r) Prevention Program: Hazard Review 24

Page 25: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Common Deficiencies

• Industry standard(s) have not been reviewed since the facility was designed/built (i.e., “grandfathered”)

• Review has not been revised/updated at least every five years• Safety information not up to date, so hazard review not started on time

• Hazard review findings• Not resolved• Not documented• Not tracked – show up in subsequent reviews

CAA 112(r) Prevention Program: Hazard Review 25

Page 26: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Common Deficiencies (cont.)

• Facilities do not look past industry checklist• Commonly missed hazards includes

• Facility located in floodplain• Vessel proximity to

• Railroad or highway• Other vessels with incompatible materials

• i.e. chlorine and anhydrous ammonia• Underground piping

CAA 112(r) Prevention Program: Hazard Review 26

Page 27: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Operating ProceduresMore than just a piece of paper

CAA 112(r) Prevention Program: Operating Procedures 27

Page 28: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Operating Procedures Must Be

• Appropriate for equipment and operations• Complete• Easily understood by facility’s operators• Readily accessible to workers who operate or maintain process• Reviewed/modified as often as necessary to reflect current practices and

process changes

CAA 112(r) Prevention Program: Operating Procedures 28

Page 29: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

RequirementsConsequences of Deviation

• Deviations to address include• High pressure• High or low temperatures• Exceeding capacities• Operating without adequate level• Feeding too fast• And others

• Consequences could be leak, rupture, overflow, explosion, equipment damage, etc.

CAA 112(r) Prevention Program: Operating Procedures 29

Page 30: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

RequirementsSteps to Avoid or Correct Deviations

• Operating instructions to maintain appropriate conditions

• Specific steps to take to correct problems if they occur

CAA 112(r) Prevention Program: Operating Procedures 30

Page 31: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Required Operating Procedures

• Initial startup• Normal operations• Temporary operations• Emergency shutdown• Emergency operations• Normal shutdown• Start-up following a normal or emergency shutdown, or a major change

CAA 112(r) Prevention Program: Operating Procedures 31

Page 32: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Overlooked Procedures Temporary Operations

• Examples: process shutdown, extra capacity needed for limited time

• Need steps to ensure operations function safely

• Documentation must be prepared and training conducted prior to starting temporary operations

CAA 112(r) Prevention Program: Operating Procedures 32

Page 33: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Overlooked Procedures

• Start-up Following Emergency Shutdown• After emergency shutdown, there may be additional steps to ensure process starts

safely (e.g., evaluating equipment status due to potential damage)

• Equipment Inspection• Periodic inspection and surveillance of equipment

CAA 112(r) Prevention Program: Operating Procedures 33

Page 34: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Common Deficiencies

• Failure to have all of the required procedures• Failure to include operating limits and consequences of deviation in

operating procedures• Actual operations are not consistent with operating procedures

• Inspectors spot issues by checking the revision date and visiting with/observing operators to see if implemented procedures match written procedures

CAA 112(r) Prevention Program: Operating Procedures 34

Page 35: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

TrainingA trained workforce is a less-at-risk workforce

CAA 112(r) Prevention Program: Training 35

Page 36: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

40 CFR Part 68 Training Requirements

CAA 112(r) Prevention Program: Training 36

Training Requirement SectionOperating Procedures, Safe Work Practices, Refresher 68.54

Maintenance 68.56(b)Contractors 68.56(c)

Emergency Response 68.95(a)(3)

Page 37: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Training RequirementsOperating Procedures

• Employees trained in operating procedures pertinent to their duties (68.54(a))

• Refresher training required at least every 3 years (68.54(b))• Training required for updated/new procedures prior to startup of process

after major change (68.54(d))

CAA 112(r) Prevention Program: Training 37

Page 38: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Training RequirementsMaintenance

• Training required for employees responsible for process maintenance activities (68.56(b))

• Training must cover• Hazards of process• How to avoid or correct unsafe conditions• Procedures applicable to job tasks

• Maintenance contractor responsible for training employees in facility’s maintenance procedures (68.56(c))

CAA 112(r) Prevention Program: Training 38

Page 39: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Training RequirementsPrior to Start-Up After Major Change

• Ensure personnel know how to do their job before process equipment is restarted

• Changes can include new process equipment and/or introduction of regulated substance(s)

• Training in updated procedures required for• Operators, employees, and contractors (68.54(d))• Those involved in maintaining process equipment

CAA 112(r) Prevention Program: Training 39

Page 40: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Training RequirementsEmergency Response

• Train employees in relevant emergency response program procedures (68.95(a))

• Only required for facilities that will respond to a release of the regulated substance(s)

CAA 112(r) Prevention Program: Training 40

Page 41: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Common Deficiencies

• Training does not address facility-specific operating procedures• Not all employees get refresher training

• Process maintenance and contractor personnel• Multiple shifts

• Lacking documentation of each individual’s training

CAA 112(r) Prevention Program: Training 41

Page 42: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

MaintenanceProperly maintained equipment is less likely to fail

CAA 112(r) Prevention Program: Maintenance 42

Page 43: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Maintenance Requirements

• Critical to safe operations• Preventive maintenance• Inspections and tests required• Running equipment to failure not acceptable

• Maintenance program• Prevent incidents/accidents/releases• Save facility money

CAA 112(r) Prevention Program: Maintenance 43

Page 44: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Maintenance RequirementsOverview

• Prepare and implement maintenance procedures• Train maintenance employees in process hazards, how to avoid or correct

unsafe conditions, and maintenance procedures• Inspect and test equipment

CAA 112(r) Prevention Program: Maintenance 44

Page 45: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Maintenance Program Includes

• Written program• Criteria or rationale used to establish frequency of tests and inspections• Test and inspection schedule established for all equipment• Adherence to calibration testing and inspection schedules• Established process for use, removal, or replacement of equipment out of

specifications• Written test procedures for all tests performed

CAA 112(r) Prevention Program: Maintenance 45

Page 46: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Written Maintenance Procedures

• Maintain ongoing integrity of process equipment• Resources for written procedures include

• Vendors• Equipment manufacturers• Trade association• Industry standards/guidance• Developed in-house• Maintenance history

CAA 112(r) Prevention Program: Maintenance 46

Page 47: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Inspection and Testing

• Use recognized and generally accepted good engineering practices• Develop maintenance schedule

• Manufacturer’s recommendations (preventive maintenance)• Prior operating experience (predictive maintenance)

• Document maintenance activities• Written procedures• Reviews and revisions of procedures

CAA 112(r) Prevention Program: Maintenance 47

Page 48: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Common Deficiencies

• No written maintenance procedures• Equipment not inspected or tested

• Especially underground piping

• Testing/inspection interval not consistent with industry standards• Failure to follow good engineering practices

• Examples: proactive relief valve replacement, hose replacement, painting

CAA 112(r) Prevention Program: Maintenance 48

Page 49: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Compliance AuditInspect your own CAA 112(r) program and fix problems

CAA 112(r) Prevention Program: Compliance Audit 49

Page 50: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Compliance Audits

• Think of this as an opportunity• Play inspector for the day

• Use EPA’s inspector’s checklist found at the bottom of the following website*https://www.epa.gov/rmp/guidance-facilities-risk-management-programs-rmp

• Safety audits ≠ compliance audits

CAA 112(r) Prevention Program: Compliance Audit 50

*Website active as of November 2016

Page 51: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Requirements

• Certify that the facility has evaluated compliance at least every three years • Review all prevention program requirements

• Identify problem areas, recommend corrective actions, and complete corrective actions

CAA 112(r) Prevention Program: Compliance Audit 51

Page 52: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Requirements (cont.)

• Must be performed by at least one person knowledgeable in the process (68.58(b))

• If performed by outside consultant, someone from facility must also participate• In documents, specify the name and title of person from the facility participating in

the audit

• Owner or operator shall develop a report of audit findings (68.58(c))

CAA 112(r) Prevention Program: Compliance Audit 52

Page 53: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Documentation

• Responses to each of the audit’s findings should be developed promptly, and any corrective actions should be explicitly listed

• Addressing deficiencies• Assign responsibility for each recommendation to individual• Assign start date and completion date• Document action taken, label “closed” with completion date

CAA 112(r) Prevention Program: Compliance Audit 53

Page 54: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Requirements (cont.)

• Retain the two (2) most recent compliance audit reports (68.58(e))• Once a compliance audit report is more than 5 years old, it does not need to be

retained

CAA 112(r) Prevention Program: Compliance Audit 54

Page 55: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Common Deficiencies

• Failure to conduct compliance audit every 3 years• No certification by company official• Failure to detect major prevention program errors• Issues identified were not addressed/documented• Same finding appears on subsequent audits• Only partially audited, or assumes that sections audited previously do not

need to be evaluated

CAA 112(r) Prevention Program: Compliance Audit 55

Page 56: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Incident InvestigationAn incident or near miss occurred. Now what?

CAA 112(r) Prevention Program: Incident Investigation 56

Page 57: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Definitions

• Incident: event that resulted in, or could reasonably have resulted in, a catastrophic release

• Catastrophic release: one that presents imminent and substantial endangerment to public health and the environment

CAA 112(r) Prevention Program: Incident Investigation 57

Page 58: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Purpose

CAA 112(r) Prevention Program: Incident Investigation 58

Page 59: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Potential Incidents to Investigate

• CERCLA/EPCRA reportable releases• Risk Management Program reportable accidents• Accidents reported on the OSHA 300 log• Actual/potential events that require equipment changes

CAA 112(r) Prevention Program: Incident Investigation 59

Page 60: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Potential “Near Miss” Investigations

• Many facilities do not value the knowledge that can be gained from “near miss” investigation

• Consider investigation if• “…and the safety systems were tripped”• “…it was fortunate that nobody was in the area”• “…this same maintenance issue / safety valve relieving keeps happening”

CAA 112(r) Prevention Program: Incident Investigation 60

Page 61: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Near Miss Investigations as an Opportunity

Learn from the past to prevent harm in the future

Don’t wait for someone to get injured or a release to occur

before deciding to make changes

CAA 112(r) Prevention Program: Incident Investigation 61

Page 62: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Requirements

• Initiate investigation within 48 hours of incident• Includes weekends and holidays• Investigation for Friday incident must begin no later than Sunday

• Establish knowledgeable investigation team

CAA 112(r) Prevention Program: Incident Investigation 62

Incident Report

Page 63: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Written Report Requirements

• Summarize• Date of incident• Date investigation began• Description of incident• Factors contributing to incident• Address investigation team’s findings/recommendations

CAA 112(r) Prevention Program: Incident Investigation 63

Page 64: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Incident Investigation Resolution

• Owner/operator required to “promptly address and resolve” findings• Regulation does NOT require adoption of all recommendations• All resolutions and corrective actions must be documented• Review findings with all affected personnel• Retain investigation summaries for 5 years

CAA 112(r) Prevention Program: Incident Investigation 64

Page 65: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Common Deficiencies

• “Near misses” are not investigated • Do not investigate various release events• Unresolved or undocumented findings/recommendations• Reports never finalized due to liability• Findings not discussed with affected employees/contractors or documented

that communication occurred• Investigations only find that equipment failure and/or human error was at

fault• Did the investigation get to the true root causes?

CAA 112(r) Prevention Program: Incident Investigation 65

Page 66: Prevention Program for Level 2 Processes - US EPA · Piping, electrical, ... • Prevent incidents/accidents/releases ... • Inspect and test equipment CAA 112(r) Prevention Program:

Tip for Inspections

• When no incidents have been investigated, inspectors review• Information sources (OSHA 300 logs, Risk Management Program reportable,

Emergency Planning and Community Right-to-Know Act (EPCRA) or Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) reportable releases, etc.) to see if incidents should have been investigated

• Procedures to see how near misses are discussed• Procedures to see if all required elements are addressed

CAA 112(r) Prevention Program: Incident Investigation 66