Ammonia Inhalation. To share lessons learned gained from incident investigations through a small group discussion method format.
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1 Purpose To share lessons learned gained from incident investigations through a small group discussion method format. To understand lessons learned through a Systems of Safety viewpoint. This material was produced by the Labor Institute and the United Steelworkers International Union under grant number 46DO-HT11 Susan Harwood Training Grant Program, for the Occupational Safety and Health Administration, U.S. Department of Labor. It does not necessarily reflect the views or policies of the U.S. Department of Labor, nor does mention of trade names, commercial product or organizations imply endorsement by the U. S. Government. Volume 07, Issue The Labor Institute 1
2 Background Information Before beginning this, please review this and the next page which contain information that will introduce the concepts of and Systems of Safety. Creating a safe and healthy workplace requires a never ending search for hazards that sometimes are not obvious to us. These hazards exist in every workplace and can be found by using various methods. are just as the name suggests: learning from incidents to prevent the same or similar incidents from happening again. Systems Are Not Created Equal: Not equal in protection and not equal in prevention. Using our Systems Focus to uncover system flaws or root causes is only one part of controlling hazards. We also need to look at the systems involved to decide on the best way to deal with the problem. The most effective way to control a hazard is close to its source. The least effective is usually at the level of the person being exposed. The system of safety in which the flaw is identified is not necessarily the system in which you would attempt to correct the flaw. 2
3 Ammonia Inhalation Major Safety System Level of Prevention Design & Engineering Highest the first line of defense Maintenance & Inspection Mitigation Devices Warning Devices Middle the second line of defense Training & Procedures Personal Protective Factors Lowest the last line of defense Effectiveness Most Effective Least Effective Goal To eliminate hazards To further minimize and control hazards EXAMPLES OF SAFETY SUB- SYSTEMS** Technical Design and Engineering of Equipment, Processes and Software Management of Change (MOC)** Chemical Selection and Substitution Safe Siting Work Environment HF Organizational (must address a root cause) Staffing HF Skills and Qualifications HF Inspection and Testing Maintenance Quality Control Turnarounds and Overhauls Mechanical Integrity Enclosures, Barriers Dikes and Containment Relief and Check Valves Shutdown and Isolation Devices Fire and Chemical Suppression Devices Machine Guarding Monitors Process Alarms Facility Alarms Community Alarms Emergency Notification Systems Operating Manuals and Procedures Process Safety Information Process, Job and Other Types of Hazard Assessment and Analysis Permit Programs Emergency Preparedness and Response Training Refresher Training Information Resources Communications Investigations and To protect when higher level systems fail Personal Decisionmaking and Actions HF Personal Protective Equipment and Devices HF Stop Work Authority Management of Personnel Change (MOPC) Work Organization and Scheduling HF Work Load Maintenance Procedures Pre-Startup Safety Review Allocation of Resources Buddy System Codes, Standards, and Policies** HF - Indicates that this subsystem is often included in a category called Human Factors. * There may be additional subsystems that are not included in this chart. Also, in the workplace many subsystems are interrelated. It may not always be clear that an issue belongs to one subsystem rather than another. ** The Codes, Standards and Policies and Management of Change sub-systems listed here are related to Design and Engineering. These subsystems may also be relevant to other systems; for example, Mitigation Devices. When these subsystems relate to systems other than Design and Engineering, they should be considered as part of those other system, not Design and Engineering. Revised October
4 Title: Ammonia Inhalation Identifier: Volume 07, Issue 45 Date Issued: June 1, 2007 Statement: The delay in commissioning a new injection system for service, proper location of a condensate drain header and the absence of PPE added up to an injured employee. Systems of Safety are utilized to provide prevention from this type of incident. The protection afforded by replacing old, outdated equipment is accredited to a well-defined Design and Engineering System of Safety approach. Despite previous reports of line pluggage, there was no action taken within the Maintenance and Inspection System of Safety to clean or repair the equipment. With the Training and Procedures System of Safety, Operations should include a well-defined procedure that includes specific instructions to safely clear a plugged quill. It should also include personal protective clothing (Personal Protective Factors System of Safety) that would prevent any exposure to hazardous environments. (Note: PPE should be used as a last resort due to the fact that the hazard is still present.) An administrative policy that states that the job will not begin or that the job will be discontinued at the first failure of any of the mechanisms would provide maximum protection through the Design and Engineering safety sub-system of Organizational Policies. 4
5 Ammonia Inhalation Discussion: An operator on the alky unit was required to steam out the ammonia injection quill on a caustic treater. The operator properly valved out the ammonia. When steaming out this line, the operator felt the steam hose until he could no longer feel steam flowing. The operator noticed that the steam flow had ceased indicating the line needed to be drained and depressurized. This process was then repeated until the quill was unplugged. The operator cracked the bleed valve to drain the condensate. No condensate came out; so the operator slightly opened the drain valve some more. A sudden mixture of ammonia, condensate and steam came out with force; resulting in the operator getting sprayed with condensate and inhaling ammonia. The investigation revealed the following facts: Ammonia is normally injected into the tower to prevent corrosion. The flow meter on the quill was not functioning properly. It is normal practice to steam out the quill to unplug. In past practice, it is normal to depressurize and drain the line through the bleeder. Frequency of plugging varies from minutes to as long as five days. It is believed that low pressure could be a contributing factor to the plugging. Fittings on the steam-out header are screwed with a number of them leaking. A new ammonia injection skid was in place but not yet commissioned. 5
6 Analysis The Logic Tree is a pictorial representation of a logical process that maps an incident from its occurrence, the event, to facts of the incident and the incident s root causes. Event Worker inhaled Ammonia Ammonia splashed off top of cylinder cabinet No PPE worn Ammonia present in caustic wash Condensate bleed valve opened Bleed valve located above cabinet (Root Cause) Procedure did not require PPE (Root Cause) No SOS Failure System required steam out SOS Failure Design and Engineering SOS Failure Training and Procedures Quill developed plug (Root Cause) SOS Failure Design and Engineering 6
7 Ammonia Inhalation Recommended Actions 1. Commission the new ammonia skid mounted injection equipment. 2. Replace the steam-out header with a better design to eliminate possible exposure. 3. Review and change procedure to include instruction on safely unplugging of quill and to address PPE. 4. Train effected workers to the new procedure. 7
8 Education Exercise Working in your groups and using the Statement, Discussion, Analysis and Recommended Actions, answer the two questions below. Your facilitator will give each group an opportunity to share answers with the large group. 1. Give examples of ways to apply the Statement at your workplace. 2. Of the examples you generated from Question 1, which will you pursue in your workplace? (Note: When we say something you may pursue, we mean a joint labor-management activity or a union activity rather than an activity carried out by you as an individual.) 8
9 Ammonia Inhalation Trainer s Success Inventory Following a (LL) session, the trainer who led the LL should complete this form. This information will: 1) Help you reflect on the successes and challenges of the session; 2) Help USW with new curriculum development; and 3) Help USW as a whole better understand how the LL Program is supporting their workers. By reviewing LL from different sites or from other areas of their workplaces, workers are able to analyze the information and apply these lessons to their own workplaces in order to make their workplaces healthier and safer. 1. Site name (if there are participants from ore than one site, please list all). 2. Date of LL training 3. LL number used in today s Training 4. Your name 5. Summary of Education Question 1: Please summarize participants examples of ways to apply this LL Statement to their workplace. Please continue on reverse side. 9
10 6. Summary of Education Question 2: Please summarize which actions or recommendations participants discussed pursuing at their workplace(s). Thank you for completing this form. 10
11 Ammonia Inhalation EVALUATION : Ammonia Inhalation Please answer the two questions below: 1. How important is this lessons learned to you and your workplace? (Circle one.) Rate on a scale of 1 to 5, with 5 being the most important What suggestions would you make to improve this? 11
12 End of Training Trainer s Instructions Please complete the information below. Trainer s Name (Please Print) Date of training: No. of Participants: Total Hourly Management Location of Training: USW Local # Send: 1. This page; 2. The Education Exercise (page 8); 3. The Trainer s LL Success Inventory form (pages 9 and 10); 4. The evaluation for each participant (page 11); and 5. The Sign-in sheet (page 13) to: Doug Stephens United Steelworkers International Union 3340 Perimeter Hill Drive Nashville TN Thank you for facilitating the sharing of this Lesson Learned with your coworkers. 12
13 Ammonia Inhalation Sign-in Sheet Name of Class Date of Class Instructors: Please Check One* H M Print Name Signature *H = Hourly Worker M = Management or Salaried Worker 13
14 14
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