[This blog series derives from a technical paper written by Eli Macha, President of Macha PSM]
In addition to incident investigation, this section will also briefly address emergency notifications. If someone has just been hired to oversee a PSM program, it is important to immediately inform them of two timelines. If an incident or near-miss occurs, the incident investigation must be initiated within 48 hours upon discovery.[1] Second—and more urgently—is the requirement to make emergency notifications immediately upon discovery. While it is not codified (to the author’s knowledge), the notification to the National Response Center at (800) 424-8802 should be made within 15 minutes. The EPA utilizes a chart which begins penalizing facilities for delayed notification after 15 minutes (this comes from anecdotal experience with an EPA inspection that was prompted by an accidental release). The penalty amounts increased at 30 minutes, 45 minutes, and capped out at 1 hour. In short: make the notification as soon as humanly possible. It behooves PSM Coordinators to save the number in their phones. In addition to the Federal requirement, many states and local jurisdictions have their own reporting requirements that PSM Coordinators should be sure to research ahead of time.
Making it onto the “to don’t” list is failing to investigate near-misses. Properly utilized, near-miss incident investigations make for a great leading indicator. A PHA can only foresee so many potential scenarios. When a near-miss occurs and a potential crisis has been averted, this is an excellent opportunity to shore up the facility’s defenses. Imagine, for example, a forklift driver striking an evaporator with their mast. The unit is bent a little, but the fans still work properly, and no pipes or valves were broken, meaning no ammonia was released. Rather than wiping the nervous sweat from the brow and moving on, savvy PSM coordinators will launch a full incident investigation. Why did it happen? Revisit the relevant PHA scenarios. More than likely, safeguards were attributed to the scenario, which needs to be modified. Perhaps additional engineering or administrative controls are necessary to avoid a similar accident in the future.
Finally, how can the incident investigation element be optimized for the ammonia refrigeration industry. Two areas come to the fore: system specificity and release calculations. First, incident investigations are a good motivator for using valve tags. Rather than labeling the incident investigation as “evaporator valve leak,” use the exact valve number so it can be referenced later. Detailed and accurate release calculations can also be quite helpful when putting a report together. Unfortunately, this task is easier said than done when it comes to ammonia refrigeration systems.
Unlike chemicals which remain liquids at ambient pressure and temperatures, ammonia evaporates. Furthermore, it is typically difficult to know how much ammonia was released from the system. If the release occurred from a segment which was previously isolated, then a detailed calculation can ensue to look at how much ammonia was in that one section. Otherwise, the calculation will need to take into account the hole size and shape. The duration of the release is also important for determining the estimated quantity. The task of the release calculator typically requires many guesses—many of which have drastically different outcomes. Imagine, for example, a gasket leaks and it is discovered that ammonia was pouring through one tiny segment of the gasket. Should one estimate that the hole is 1/32” inches in length or 1/64” inches in length? This difference may seem small, but may very well be the difference between over or under 100 lbs of ammonia (the reportable quantity). Selecting a qualified and experienced ammonia refrigeration expert to assist in release calculations will help to generate the most accurate release calculation.
[1] Title 29 CFR §1910.119(m)(2) & Title 40 CFR §68.81(b)
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