OSHA Inspection: WOOD RIVER REFINING COMPANY

Issued

Feb 5, 1992

Abate by

Apr 6, 1992

Penalty

Initial $3,500 · Current $6,000

Issued

Feb 5, 1992

Abate by

Mar 29, 1993

Penalty

Initial $5,000 · Current $6,000

General-duty citation text

Section 5(a)(1) of the Occupational Safety and Health Act of 1970:  The
employer did not furnish employment and a place of employment which were
free from recognized hazards that were causing or likely to cause death
or serious physical harm to employees in that employees were exposed to:
....the hazard of fires and explosions at the Cracked Gas Plant of
the Shell Wood River Manufacturing Complex as a result of system upset
and/or equipment failure.
a)  The Gas Plant/Distilling 2 control room was not located outside
of the critical radius of hydrocarbon release from the V-3968 vessel
in the Gas Oil Plant.
b)  Shell did not control contractor work, such as the use of
sparkproducing
equipment in hazardous locations through the effective
implementation and enforcement of a "hot work" permitting system.
1.  April 15, 1991: contractors were noted using a cutting torch
at the north west corner of the Benzene Extraction Unit with
only a departmental safety permit.
2.  June 28, 1991:  cpontractors are observed chipping concrete
in the Gas Plant with only a departmental safety permit.
c)  Shell Oil Company did not provide an effective system to ensure
that critical process equipment was maintained to control the risk of
releases and other accidents.  Urgent and high priority (to be completed
in a timely manner as follows:
1.  Urgent request for replacement of spent caustic, T-X027,
is still in progess although request was submitted 5/12/90.
2.  High priority request for renewal of two spools of 14" flare
header from 9th Street to North Property Flare due to
corosion was requested on 4/23/90 and has not been completed
3.  High priority request for pipe renewal on 6" fuel gas line from
flange north of support S-1217 to next flange was requested on
11/19/90 and has not been completed.
4.  High priority request for PR top reflux. dist. pipe renewal from
the flange east of the 1st center support east of PsE-3126, S-241
to flange west of 4th center support headed east was requested
11/28/90 and has not been completed.
d)  Shell did not provide periodic refresher training to the Gas Plant
operators in the following areas:
1.  Safe job procedures.
2.  Job hazards.
3.  What-if situations/scenarios.
e)  Shall did not develop operating procedures for occasions when the
unit was operated outside of critical limits, which were established by
process.
f)  Shell did not ensure that mechanical design information for process
and instrumentation was kept current.
1)  The engineering flow diagram for V3301 and V3310 in the
Rectified Absorber Unit, number E-24242-5 was not changed to show that
V-3310 has been replaced by V-3315 during the 1989 shutdown.
2)  The utility flow diagram for the ammonia injection system in the
Rectified Absorber Unit, number E-24273-1 was not changed to show that
the ammonia charge from the Alkyl Plant has been replaced by a charge
from two ammonia cylinders located in the Gas Plant.  The change was
made approximately two years ago.
g)  Operating procedure governing the lightning of the North property
flare did not contain a step-by-step outline of how to relight the flare
when it is extinguished during upsets or normal operations.
h)  Shell did not conduct hazard and operability studies or their
equivalent on all operation units to ensure that to process design,
installation, and operations were safe.
i)  Shell had not implemented a procedure to ensure that all
employees affected by the change(s) made to processes, procedures, etc.,
i.e. changes were made to the ammonia water injection system
approximately
two years ago.  Ammonia is no longer charged from the pressure
vessel, CH-190, but from two large ammonia cylinders.
j)  Shell did not ensure that pressure relieving equipment was
installed and maintained in a manner which assured proper operation.
1.  The bonnet vent block valve on the bellows pressure relief
valve, R4305-1, for the Depropanizer column, V-3302, was not
car sealed opened to assure proper operation.
2.  The pressre gauge monitoring the space between the pressure
relief valve and the rupture disk for the Rectified Absorber
Unit (RAU) Absorber/Deathanizer, V-3300, indicated
approximately
1.4 psig during the period 10/23/91 to 11/19/91.
The system was not inspected to determine whether the
pressure relieving devices had failed or leaked or whether
the gauge was inaccurate.
3.  The rupture disc below pressure relief valve R-4333, on
vessel V-3300 was not properly labelled with a tag that
would show it was of the proper disk material, correct burst
pressure, and installed in the correct direction.
k)  Shell did not ensure against the unintentional release and
ignition of hazardous materials, such as propane and butane, due to
defective and/or inappropriate in-house constructed piping and
components in that there was no quality assurance program to Shell
employees.
1)  The Gas Plant/Distilling 2 control was not placed under a
possitive pressure and the electrical equipment inside was not approved
for a hazardous location.
AMONG OTHERS, A FEASIBLE AND USEFUL METHOD TO CORRECT the hazard is, but
not limited to:
The implementation and enforcement of an effective chemical process
saftey program to prevent hazardous releases of flammable and toxic
materials, which includes:
1.  The development and implementation of a procedure addressing
compliance of maintenance procedures and ensuring that all high and
urgent priority items are completed within the quidelines.
2.  The establishment and implementation of a process safety
management
system to ensure that all pressure vessels are inspected and
repaired on a timely basis.  Data should be analyzed by certified LEVEL
II or higher inspectors and amomalous readings resolved prior to
continued operation of the pressure vessels.  Periodic evaluation of the
system shall be condcted to ensure its continued effectiveness.
3.  The performance of hazard an operability studies and/or their
equivalent to recognized possible failure scenarios which could result
in a catastrophic release.
4.  The development and implementation of an effective manmgement
of change procedure ensuring that changes and their consequences are
disseminated to all affected personnel.
5.  The establishment and implementation of an inspection program to
assure that all pressure relief valves and equipment is suitably sized,
installed an maintained.
6.  The establishment and implementation of a quality assurance
program such as that in effect for contractors.  In addition, stored
piping shall be color coded or otherwise effectively identified.
7.  The establishment and implementation of step-by-step procedures
procedures and operator can follow when relighting the flare.
8.  The development and implementation of a process safety training
program with the incorporation of what if drills.  The training
program should also include the definition of skills and knowledge,
the design operating and maintenance procedures, an initial
qualifications assessment,  the methods used to measure performance
and effectiveness, and on-going performance and refresher training
(as referenced in the Guidelines for Technical Management of
Chemical Process Safety development by the Center for Chemical
Process Safety of the Chemical Engineers American Institute).
9.  The development and implementation of written job descriptions
and job safety programs/safe work practices.
10.  The development and implementation of refresher training
programs as recommended by API 750.
11.  Compliance with NFPA 496.  The installation of an air filter
system that would remove harmful levels of flammable gases.  The
installation of monitors for flammable gases and oxygen to ensure
breathing air quality.  The provision of a positive pressure air
system.  The provision of ducting for the air intake away from the
control room.
12.  Compliance with accepted industry guidelines for plant layout
and spacing, including, but not limited to:  the Dow Chemical
Company, "Fire and Explosion Index Hazard Classification Guilde,"
or the Loss Prevention Data Sheet by Factory Mutual, "Spacing of
Facilities in Outdoor Chemical Plant" FM Data Sheet 7-441; or, if
adequate spacing cannot be achieved, alernative methods of
protection must be implemented.  The control room building, a
critical work area, shall be afforded protection through
explosionresistant
construction or adequate barricading.  The process units
shall be provided with alternative means such as delupe systems,
fire sprinklers, spill containment and/or inventory control.

Issued

Feb 5, 1992

Abate by

Jul 29, 1994

Penalty

Initial $5,000 · Current $6,000

General-duty citation text

Section 5(a)(1) of the Occupational Safety and Health Act of 1970:  The
employer did not furnish employment and a place of employment which were
free from recognized hazards that were causing or likely to cause death
or serious physical harm to employees in that employees were exposed to:
....the hazard of inhalation of toxic substances at the Cracked Gas
Plant of the Shell Wood River Manufacturing Complex under normal
operating conditions or as a result of system upset and/or equipment
failure.
a)  Shell did not provide continuous area monitoring in potentially
hazardous area containing high concentrations of hydrogen sulfide.
b)  Shell did not provide periodic refresher training to the Gas
Plant operators in the following areas:
1.  Safe job procedures.
2.  Job hazards.
3.  What-if situations/scenarios.
c)  Shell did not ensure that mechanical design information for
process and instrumentation was kept current.
1.  The engineering flow diagram for V-3301 and V-3310 in the
Rectified Absorber Unit, number E-24242-5 was not changed
to show that V-3310 had been replaced by V-3315 during the
1989 shutdown.
2.  The utility flow diagram for the ammonia injection system
in the Rectified Absorber Unit, number E-24273-1 was not
changed to show that the ammonia charge from the Alkyl
Plant had been replaced by a charge from two ammonia charge
from two ammonia cylinder located in the Gas Plant.  The
charge was made approximately two years ago.
d)  Shell had not implemented a procedure to ensure that all
employees affected by the change(s) made of processes, procedures, etc.,
i.e. changes were made to the ammonia water injection system
approximately
two years ago.  Ammonia is no longer charged from the pressure
vessel.  CH-190, but from two large ammonia cylinders.
e)  Shell did not provide training on the care, calibrations,
or use of air sampling equipment (MSA combustible gas meter, Drager
H2S ecolyzer)  to Gas Plant operators required to perform critical
air sampling for toxic and/or flammable vapor/gases and oxygen.
f)  Shell did not establish Gas Plant adequate operating
procedures for the charging of ammonia to the debutanizer from the
two ammonia cylinders located in the Rectified Absorbing Unit.  The
existing procedures did not contain the following information;
1.  An explanation of how to charge the ammonia.
2.  An explanation of what valves to open and which valves to
check to assure that they were closed.
3.  An explanation of how to close down the system.
4.  An explanation of how to blank and/or close off lines, i.e.,
the ammonia/water drum was not blocked or plugged.
g)  Shell failed to locate the depressurizing valved for the
Rectified Absorber Unit (RAU) and the Cracked Absorber Unit (CAU)
in the Gas Plant in an area so as to eliminate operator exposure
during upset and release conditions.
AMONG OTHERS, A FEASIBLE AND USE METHOD TO CORRECT the hazard is, but
not limited to:
1.  The development and implementation of an effective management
of change procedure ensuring that changes and their consequences are
disseminated to all affected personnel.
2.  The development and implementation of a process safety training
program with the incorporation of what-if drills.  The training program
should also include the definition of skills and knowledge, the design
operating and maintenance procedures, an initial qualifications
assessment,
the methods used to measure performance and effectiveness,  the
methods used to measure performance and effectiveness, and an on-going
performance and refresher training (as referenced in the Guidelines for
Technical Management of Chemical Process Safety developed by the Center
for Chemical Process Safety of the Chemical Engineers American
Institute).
3.  The development and implementation of written job descriptions and
job safety programs/safety work practices.
4.  The development and implementation of refresher training programs
are recommended by API 750.
5.  Compliance with NFPA 496.  The installation of an air filter system
that would remove harmful levesl of flammable gases.  The installation
of monitors for flammable gases and oxygen to ensure oxygen to ensure
breathing air quality.  The provision of a positive pressure air system.
The provision of ducting for the air intake away from the control room.
6.  The development and implementation of a system or procedure to
regularly update piping and instrument diagrams.  p & IDs in
operating area must be current for the processes for which they
relate.
7.  The development and implementation of training programs on the
care, use, and calibration of the MSA combustible gas meter and
Draeger H2S ecolyzers.
8.  The relocation of the depressurizing valves into the Gas Plant
control room so that operators may depressurize the columns without
having to enter a potentially hazardous area in the event of an
emergency.
9.  The installation of additional supplied air respirators in the
control room.
10.  The development and implementaion of effective operating
procedures
for the charging of ammonia to the debutanizer taking into
account, the aforementioned deficiencies of the existing procedure.
11.  Installation of a fixed, continuous monitoring system for
hydrogen sulfide.

Issued

Feb 5, 1992

Abate by

Oct 29, 1992

Penalty

Initial $5,000 · Current $6,000

Issued

Feb 5, 1992

Abate by

Oct 29, 1992

Penalty

Initial $5,000 · Current $6,000

Issued

Feb 5, 1992

Abate by

Aug 29, 1992

Penalty

Initial $3,500 · Current $6,000

Issued

Feb 5, 1992

Abate by

Dec 29, 1992

Penalty

Initial $2,000 · Current $5,000

Issued

Feb 5, 1992

Abate by

Sep 29, 1993

Penalty

Initial $2,500 · Current $6,000

Issued

Feb 5, 1992

Abate by

Sep 29, 1993

Penalty

Initial $2,500 · Current $6,000

Issued

Feb 5, 1992

Abate by

Oct 29, 1992

Penalty

Initial $5,000 · Current $6,000

Issued

Feb 5, 1992

Abate by

Mar 6, 1992

Penalty

Initial $2,500 · Current $6,000

Issued

Feb 5, 1992

Abate by

Feb 7, 1992

Issued

Feb 5, 1992

Abate by

Mar 6, 1992

Penalty

Initial $5,000 · Current $6,000

Issued

Feb 5, 1992

Abate by

Mar 6, 1992

Penalty

Initial $5,000 · Current $6,000

Issued

Feb 5, 1992

Abate by

Apr 6, 1992

Penalty

Initial $5,000 · Current $6,000

Issued

Feb 5, 1992

Abate by

Nov 29, 1992

Penalty

Initial $2,500 · Current $6,000

Issued

Feb 5, 1992

Abate by

Nov 29, 1992

Penalty

Initial $2,500 · Current $6,000

Issued

Feb 5, 1992

Abate by

Mar 6, 1992

Penalty

Initial $5,000 · Current $6,000

Issued

Feb 5, 1992

Abate by

Mar 6, 1992

Issued

Feb 5, 1992

Abate by

Jan 29, 1993

Penalty

Initial $5,000 · Current $6,000

Issued

Feb 5, 1992

Abate by

Oct 29, 1992

Penalty

Initial $5,000 · Current $6,000

Issued

Feb 5, 1992

Abate by

Oct 29, 1992

Penalty

Initial $35,000 · Current $42,000

General-duty citation text

Section 5(a)(1) of the Occupational Safety and Health Act of 1970:  The
employer did not furnish employment and a place of employment which were
free from recognized hazards that were causing or likely to cause death
or serious physical harm to employees in that employees were exposed to:
....the hazard of inhalation of toxic susbstances at the Cracked
Gas Plant of the Shell Wood River Manufacturing Complex under normal
operating conditions or as a result of system upset and/or equipment
failure.
a)  Shall failed to make available an adequate supply of
airsupplied
respirators in the Gas Plant/Distilling 2 control room for
operating personnel required to remain in the control room during
emergencies, such as the sudden release of toxic and/or flammable
vapors/gases.
b)  Shell did not provide for filtration of the Gas Plant/Distilling
2 control room atmosphere for light hydrocarbons, such as propane.
AMONG OTHERS, A FEASIBLE AND USE METHOD TO CORRECT the hazard is, but
not limited to:
1.  The development and implementation of an effective management
of change procedure ensuring that charges and their consequences
are disseminated to all affected personnel.
2.  The development and implementation of a process safety training
program with the incorporation of what-if drills.  The training
program should also include the definition of skills and knowledge,
the design operating and maintenance procedures, an initial
qualifications assessment, the methods used to measure performance
and effectiveness, and an on-going performance and refresher
training (as referenced in the Guidelines for Technical Management
of Chemical Process Safety developed by the Center for Chemical
Process Safety of the Chemical Engineers American Institute).
3.  The development and implementation of written job descriptions and
job safety programs/safe work practices.
4.  The development and implementation of refresher training programs
as recommended by API 750.
5.  Compliance with NFPA 496.  The installation of an air filter system
that would remove harmful levels of flammable gases.  The installation
of monitors for flammable gases and oxygen to ensure breathing air
quality.  The provision of ducting for the air intake away from the
control room.
6.  The development and implementation of a system or procedure to
regularly update piping and instrument diagrams.  P & IDs in operating
area must be current for the processes for which they relate.
7.  The development and implementation of training programs on the care,
use, and calibration of the MSA combustible gas meter and Draeger H2S
ecolyzers.
8.  The relocation of the depressurizing valves into the Gas Plant
control room so that operators may depressurize the columns without
having to enter a potentially hazardous area in the event of an
emergency.
9.  The installation of additional supplied air respirators in the
control room.
10.  The development and implementation of effective operating
procedures
for the charging of ammonia to the debutanizer taking into
account the aforementioned deficiencies of the existing procedure.
11.  Installation of a fixed, continuous monitoring system for hydrogen
sulfide.

Issued

Feb 5, 1992

Abate by

Mar 6, 1992

Issued

Feb 5, 1992

Abate by

Oct 29, 1992