OSHA Inspection: MONTANA REFINING COMPANY, INC.

Issued

Nov 24, 2009

Abate by

Apr 21, 2010

Penalty

Current $1,750

General-duty citation text

29 CFR 1910.119(d)(3)(i)(B): Process safety information pertaining to the
equipment in the
process did not include piping and instrument diagrams (P&ID's):
On or about July 15, 2009 and at times prior thereto:
(a)Drawing Title: P&ID LEGEND, Drawing No. Legend, Sheet No.: 1 of 1, (MRCI
RC 127) did not have designation or notation for the alphabetical text
"A.G.O."
which can be found on Drawing No. 01-D-002, Sheet No. 2 of 10, (MRCI RC
129).
"A.G.O." is found in the upper right hand corner as a title for a
continuation arrow
symbol.
(b)Drawing Title: P&ID LEGEND, Drawing No. Legend, Sheet No.: 1 of 1, (MRCI
RC 127) did not have designation or notation for the alphabetical text
"L.S.R." which
can be found on Drawing No. 01-D-003, Sheet No. 3 of 10, (MRCI RC 130).
"L.S.R." is found in the descriptor of the D-0104 Accumulator at the top
of the page.
(c)Drawing Title: P&ID LEGEND, Drawing No. Legend, Sheet No.: 1 of 1, (MRCI
RC 127) did not have designation or notation for the alphabetical text
"WW" which
can be found on Drawing No. 01-D-003, Sheet No. 3 of 10, (MRCI RC 130).
The
symbol, "WW" is found in the descriptor of the piping from the bottom of
D-0104
Accumulator.
(d)Drawing Title: P&ID LEGEND, Drawing No. Legend, Sheet No.: 1 of 1, (MRCI
RC 127) did not have designations or notations for the alphabetical text
used in
conjunction with instrument symbols. For example, the following notations
are used
often in conjunction with instrument symbols:  "FV", "SV", PI, PE, TE, TI,
LT, FI,
FT, etc. which can be found throughout all the submitted P&ID drawings.
(e)Drawing Title: P&ID LEGEND, Drawing No. Legend, Sheet No.: 1 of 1, (MRCI
RC 127) did not have symbolic representation or designation to match the
barometric
damper symbol in the combustion gas throat of the crude heater H-0101
found on
Drawing No.: 01-D-004, Sheet No. 4 of 10, (MRCI RC 131).
(f)Drawing Title: P&ID LEGEND, Drawing No. Legend, Sheet No. 1 of 1, (MRCI
RC
127) did not have symbolic representation or designation for "abandoned"
piping or
"line out-of-service" piping which appears on Drawing No.: 01-D-004, Sheet
No. 4
of 10, (MRCI RC 131).
(g)Drawing Title: Crude Unit Crude Heater, Drawing No.: 01-D-004, Sheet
No. 4 of
10, (MRCI RC 131) was not updated following piping modifications. The 2007
MOC
for this piping modification (MRCIDJ 1066) indicated that the P&IDs had
been
updated but with the qualifying statement "there was no change to the
drawings, it
stayed the same".
(h)A dial pressure gauge mounted on the upper piping connection of the
LI/LT to Crude
Tower T-0102 was not symbolically represented on Drawing Title: Crude Unit
CrudeTower, Drawing No.: 01-D-005, Sheet No. 5 of 10, (MRCI RC 121).
(i)Prefac Tower T-0103 pressure gauge PI-01208 which was symbolically
represented
on Drawing Title: Crude Unit Prefractionator Tower, Drawing No. 01-D-003,
Sheet
No. 3 of 10, (MRCI RC 130) was not found in the schematic position
represented on
the drawings.
(j)Crude/Raw Naphtha heat exchanger E-0107 an open gate valve with a
caution tag
where the crude exits the tubes of the heat exchanger is symbolically
represented on
Drawing Title: Crude Unit Crude Charge To Desalter, Drawing No. 01-D-001,
Sheet
No. 1 of 10, (MRCI RC 128). The valve was found open but the caution tag
was not
present.
(k)Crude/DSL Side Reflux heat exchanger E-0101 instrument device TE-01112
on the
raw diesel fluid piping entering the shell of the exchanger. This
instrument device was
symbolically represented on Drawing Title: Crude Unit Exchanger Train,
Drawing
No. 01-D-002, Sheet No. 2 of 10, (MRCI RC 129). An instrument device was
found
in the schematic position represented on the drawings but it was
designated as TI-
1736.  Control device TE-01112 was not present.
(l)Crude/DSL Side Reflux heat exchanger E-0101 instrument device TE-01113
on the
raw diesel fluid piping leaving the shell of the exchanger is symbolically
represented
on Drawing Title: Crude Unit Exchanger Train, Drawing No. 01-D-002, Sheet
No. 2
of 10, (MRCI RC 129).  An instrument device found in the schematic position
represented on the drawings was designated as TI-1737. Control device
TE-01113 was
not present.
(m)Two, 2", gate valves were schematically represented as car-sealed open
(CSO) at the
piping inlet of sour water surge tower fuel gas into the crude heater gas
train. This is
symbolically represented on Drawing Title: Crude Unit Crude Heater,
Drawing No.
01-D-004, Sheet No. 4 of 10, (MRCI RC 131). The same sour water surge
tower fuel
gas piping section is also labeled as "line out of service" resulting in a
dichotomous
situation. The line was taken out of service and the valves should be
car-sealed closed
(CSC).
(n)Crude Heater H-0101 in the Crude Unit combustion gas damper in the exit
throat of
the crude heater was symbolically represented on Drawing Title: Crude Unit
Crude
Heater, Drawing No. 01-D-004, Sheet No. 4 of 10, (MRCI RC 131). This
drawing
is
missing the symbol for motor operation of the combustion gas damper and
the symbol
for in-line instrument feeding a signal to the motor driven combustion gas
damper.
(o)Crude Heater H-0101 in the Crude Unit combustion gas damper in the exit
throat of
the crude heater was symbolically represented on Drawing Title: Crude Unit
Crude
Heater, Drawing No. 01-D-004, Sheet No. 4 of 10, (MRCI RC 131). A stack gas
measuring device in the heater stack did not have any symbolic
representation on the
P&ID.(p)Crude Heater H-0101 in the Crude Unit abandoned, 2" diameter, flow
measuring
station with pressure taps and tubing that was not symbolically
represented on Crude
Unit Crude Heater, Drawing No. 01-D-004, Sheet No. 4 of 10, (MRCI RC 131).
The
abandoned flow measuring station was found upstream of the fuel gas
control valve
FV-01426. The orifice was not on the drawing and cross-hatched to
demonstrate
abandonment.

Issued

Nov 24, 2009

Abate by

May 3, 2010

Penalty

Initial $3,500 · Current $3,500

General-duty citation text

29 CFR 1910.119(d)(3)(i)(D): The process safety information concerning
relief system design
and design basis:
(a)The process safety information did not contain information pertaining
to relief system
design was incomplete for relief valves, including but not limited to,
RV-0103, RV-
0108, RV-0110, RV-0116, RV-1513 and RV-1533. The process safety information
(PSI) for these valves did not include information regarding pressure loss
at the
pressure relief valve inlet of the selected relief valves.  This
information is necessary
per recognized and generally accepted good engineering practices (RAGAGEP).
Abatement note:  Applicable RAGAGEP includes but may not be limited to
Sections
2.2.1 and 2.2.2 of the 1994 API RP-520 Sizing, Selection, and Installation
of Pressure-
Relieving Devices in Refineries and 2004 ASME Section VIII, Pressure
Vessel Code,
Division 1.vision

Issued

Nov 24, 2009

Abate by

May 3, 2010

Penalty

Initial $2,450 · Current $2,450

General-duty citation text

29 CFR 1910.119(e)(5):  The employer did not establish a system to
promptly address the
team's findings and recommendations; assure that the recommendations are
resolved in a
timely manner and that the resolution is documented:
(a)On or about June 17, 2009 and at times prior thereto, the employer
failed to resolve a
recommendation developed during the PHA completed in July 2006,
recommendation
#55 to include in the appropriate procedures for the Crude Heater H-0101
requirements to switch off gas from the Sour Water Stripper overhead from
the Crude
Heater to the relief header when the heater pilots are not in service.
Verbal
statements and the P&ID drawing are inconsistent as to whether or not the
piping,
which is still in place, has been car sealed closed.
(b)On or about June 17, 2009 and at time prior thereto, the employer
failed to include
recommendations numbered 54, 56, and 57, developed during the PHA
completed in
July 2006 in the "what if" checklist and also failed to include them in
the list of
recommendations from this report.ndations

Issued

Nov 24, 2009

Abate by

May 3, 2010

Penalty

Initial $3,500 · Current $1,610 Reduced

General-duty citation text

29 CFR 1910.119(f)(4):  The employer did not develop and implement safe
work practices to
provide for the control of hazards during operations such as
lockout/tagout; confined space
entry; and opening process equipment or piping:
(a)On or about August 5, 2009, and at times prior thereto, the employer
did not
implement safe work practices for maintenance employees in that for most
assigned
maintenance work it was left up to the employee to decide which safety
procedures
applied for any given work order.  Neither the maintenance supervisor who
assigned
the work orders or the operator who issued safe work permits evaluated the
assigned
work to determine what personal protective equipment (PPE) was needed or
what
safety procedures were necessary to protect the employee(s).  As a result
of oversight
by the employer, employees have been exposed to the hazards such as but
not limited
to the hazards of confined space entry (See MRCI case number 080), working
with
energized electrical systems (see MRCI case number 082).r

Issued

Nov 24, 2009

Abate by

May 3, 2010

Penalty

Initial $1,050 · Current $1,050

General-duty citation text

29 CFR 1910.119(g)(2):  The employer, in consultation with the employees
involved in
operating the process, did not determine the appropriate frequency of
refresher training:
(a)On or about June 2, 2009, and at times prior thereto, the employer did
not consult
with the Crude Unit operators on the appropriate frequency for refresher
training. The
company did not allow for employee input into the refresher training
schedule.

Issued

Nov 24, 2009

Abate by

May 3, 2010

Penalty

Initial $3,500 · Current $3,500

General-duty citation text

29 CFR 1910.119(j)(2): The employer did not establish and implement
written procedures to
maintain the on-going integrity of process equipment:
(a)On or about July 15, 2009, and at times prior thereto, a program
element missing
from the employer's MI Program is API 579-1 Fitness for Service (FFS). FFS
is used
to demonstrate the structural integrity of an in-service component that
may contain a
flaw or damage. The guidelines provided in this Standard can be used to
make run-
repair-replace decisions to help determine if pressurized equipment
containing flaws
that have been identified by inspection can continue to operate safely for
some period
of time. MRCI's MI Program outline does not reference API 579-1. Lack of an
adequate FFS program increases the risk of release of hydrocarbons and
related fire
and explosion hazards.
(b)On or about July 15, 2009, and at times prior thereto, a program
element missing
from the employer's MI Program is Section 6.2.8. of the API RP 576,
Inspection of
Pressure-Relieving Devices which states that if the "as-received pre-test"
is not
performed on a pressure relief valve then the following inspection
interval must be
shortened. The inspection interval was not shortened for RV-0103 when the
as-
received pre-test was skipped.
(c)On or about July 15, 2009, and at times prior thereto, a program
element missing
from the employer's MI Program is Section 5.5.6.b of the 2006 API 570
Piping
Inspection Code which recommends that Testing Measurement Locations (TMLs)
for
piping include locations just downstream of orifices". On July 29, 2009,
the OSHA
Team could not field verify the location of a TML in Piping Circuit
HC-01086-H-B6-
1 downstream of a flow monitoring station with orifice. Failure to place
TMLs in the
recommended locations can lead to inaccurate findings as to the thickness
of the
piping and may result in release of hydrocarbons and related fire and
explosion
hazards.
(d)One program element missing from the employer's MI Program is the API
Standards
applicable to the maintenance of controls and instruments. The employer's
Mechanical
Integrity Program (MRCIMJ 509) only lists ANSI, ISA and NACE as the codes
and
standards that MRIC employs to maintain MI. An adequate MI Program would
have
directed MRCI employees to also employ applicable API Standards such as:
API RP 551 Process Measurement Instrumentation
API RP 552 Transmission Systems
API RP 553 Refinery Control Valves
API 554, Parts1-3, Process Control System Design
API 555 Process Analyzers
API 556 Fired Heaters and Steam Generators
Lack of an adequate maintenance program for controls and instruments
increases the
risk that such instruments may fail, which may result in the release of
hydrocarbons
and related fire and explosion hazards.n

Issued

Nov 24, 2009

Abate by

May 3, 2010

General-duty citation text

29 CFR 1910.119(o)(2):  The compliance audit was not conducted by at least
one person
knowledgeable in the process:
(a)On or about June 2, 2009, and at times prior thereto, the refinery PSM
compliance
audits failed to identify programmatic mechanical integrity deficiencies
in that the
written operating procedures to maintain mechanical integrity of process
equipment
were inadequate.  Inadequate written procedures increase the likelihood
that decisions
regarding equipment inspection and maintenance will fail to meet
recognized and
generally accepted engineering practices and increase the risk of
mechanical failures
which may lead to catastrophic release of hydrocarbons resulting in fire
and
explosion.

Issued

Nov 24, 2009

Abate by

May 3, 2010

Penalty

Current $3,500

General-duty citation text

29 CFR 1910.119(j)(4)(iii): The frequency of inspections and tests of
process equipment to
maintain its mechanical integrity was not consistent with applicable
manufacturers
recommendations and good engineering practices, or more frequently if
determined to be
necessary by prior operating experience:
(a)On or about July 15, 2009, and at times prior thereto, the employer did
not reduce
the inspection interval of RV-0103 in 2003 after it failed to receive an
"as-received
pre-test or pop-test" when it was sent out to VRC Consultants in Evanston,
Wyoming
for rebuild. This is contrary to recognized and generally accepted good
engineering
practice (RAGAGEP).  Employees are exposed to increased risk of fire and
explosion
due to possible failure of the relief valve.

Issued

Nov 24, 2009

Abate by

May 3, 2010

General-duty citation text

29 CFR 1910.119(j)(6)(ii): Appropriate checks and inspections were not
performed to ensure
that equipment was installed properly and consistent with design
specifications and the
manufacturers instructions:
(a)On or about July 15, 2009, and at times prior thereto, the employer
failed to perform
an adequate installation inspection of RV-0116 that protects Crude Tower
T-0102.
The employer did not assure that the equipment was installed properly and
consistent
with design specifications and the manufacturer's recommendations, in that
the
bonnet
of the bellows relief valve was not fitted with a vent-to-atmosphere
fitting as
recommended by Section 5.2 of the 1994 API RP-520 Sizing, Selection, and
Installation of Pressure-Relieving Devices in Refineries, Part II-
Installation.eving

Issued

Nov 24, 2009

Abate by

May 3, 2010

Penalty

Initial $3,500 · Current $3,500

General-duty citation text

29 CFR 1910.119(l)(1):  The employer did not establish and implement
written procedures to
manage changes to process chemicals, technology, equipment, and
procedures; and, changes
to facilities that affect a covered process:
(a)On or about 7/8/2009, and at times prior thereto, the employer did not
implement
management of change procedures for changes in operating procedures.
Changes were
consistently made with verbal agreement only at the time of the change and
then noted
in the operating procedures; without following management of change (MOC)
procedures.
(b)On or about 7/01/09, and at times prior thereto, the employer did not
implement
management of change procedures for Work Order Number 67498 titled "Replace
Desalter relief valve with one having "J" orifice. This relief valve
replaced a relief
valve which had an "H" orifice.
(c)On 7/1/09 Montana Refinery provided a copy of  w.o. # 66070 per request
#95
(MRCIRP 165-166)  entitled "Need a hot tap done on vac htr fuel gas line."
Within
the comments section of this work order is stated the following:
"Downstream of the
fuel gas control valve for the vac htr, we need to do a hot tap so we can
monitor
the
pressure to the burner tips.  There was no documentation of management of
change
being conducted for this change in equipment. The failure to perform this
procedure
without ensuring that the safety and health aspects of this change and the
technical
basis for the change were reviewed by qualified staff presents the
opportunity for a
catastrophic release of highly hazardous chemicals above the threshold
level.
Likewise the failure to perform a management of change can result in an
this
temporary change becoming permanent because of the lack of a process to
establish a
date for its removal and return to normal operation.

Issued

Nov 24, 2009

Abate by

May 3, 2010

General-duty citation text

29 CFR 1910.119(l)(2): The employer's management of change procedures did
not assure
that the following factors were evaluated; (i) the  technical basis for
the proposed change, (ii)
the impact of change on safety and health, (iii) modifications to
operating procedures, (iv)
The employer's management of change procedures did not assure that the
necessary time
period for the change had been determined, and (v) authorization
requirements for the
proposed change.
(a)On or about July 9, 2009, and at times prior thereto, the employer
failed to document
that the technical basis for a change was evaluated;  failed to document
the impact of
the change on safety and health; failed to determine if any operating
procedures were
required as a result of the change; and failed to document that the change
had been
properly authorized.
(b)On or about July 8, 2009, and at times prior thereto, the employer did
not implement
procedures to manage change to operator procedures. Changes to operator
procedures
without going through a formal process to address those changes may result
in
unanticipated results which may increase risk of release of hydrocarbons
resulting in
fire or explosion.
(c)On or about July 7, 2009, and at times prior thereto, the MOC for work
order #
61343 entitled: "Run temporary line to put units sour water to HTU sour
water
stripper-this line is to be removed after completion of 3rd stage NaHS
(This MOC for
temporary line only)"  does not specify a date for removal of this
temporary line nor
does it provide a work order number for this temporary line to be removed.
(d)On or about July 9, 2009, and at times prior thereto, the documentation
for the
management of change w.o. # 98453 and # 101386 entitled "Temporarily pipe
desalter water to sour water stripper to help control H2S going to API.
Remove
piping (w/o # 101386) when new waste water system is operational"
indicates that the
date of the work order to remove the temporary line is the same date as
the date of
the change was approved for installation of the temporary line (1/11/06).
The failure to specify an expiration date for a temporary change can
result in
catastrophic consequences which may lead to release of hydrocarbons and
fire or
explosion hazards.n

Issued

Nov 24, 2009

Abate by

May 3, 2010

General-duty citation text

29 CFR 1910.119(l)(4):  Where a change covered by this paragraph resulted
in a change in
the process safety information required by paragraph (d) of this section,
such information
was not updated accordingly:
(a)On or about June 25, 2009 and at times prior thereto, the process
safety information
for the Crude Unit, specifically the P&ID drawing 01-D-004, rev. 8, dated
6/18/09,
was not revised to reflect changes to the crude heater piping for the
superheated steam
changed under MOC #65570, dated 11/5/07.

Issued

Nov 24, 2009

Abate by

May 3, 2010

Penalty

Initial $3,500 · Current $3,500

General-duty citation text

29 CFR 1910.119(m)(1):  The employer did not investigate each incident
which resulted in
or could reasonably have resulted in a catastrophic release of highly
hazardous chemicals in
the workplace:
(a)A hydrogen release that occurred on or about 12/23/2008;
(b)On or about 3/22/2009, a pump-head leaked, relief valve did not lift,
pressure was
1400 p.s.i.re

Issued

Nov 24, 2009

Abate by

May 3, 2010

Penalty

Initial $1,050 · Current $1,050

General-duty citation text

29 CFR 1910.119(m)(5):  The employer did not establish a system to
promptly address and
resolve the incident report findings and recommendations:
(a)On or about 7/8/2009 and at times prior thereto, the employer did not
ensure that all
incident findings and recommendations were documented in their tracking
system,
including but not limited to the following:
- Case number 85 for an incident which occurred on or about 3/29/2009
- Case number 82 for an incident which occurred on or about 1/13/2009
- Case number 81 for an incident which occurred on or about 11/13/2008
- Case number 78 for an incident which occurred on or about 5/12/2008
- Case number 76 for an incident which occurred on or about 11/6/2007

Issued

Nov 24, 2009

Abate by

May 3, 2010

Penalty

Initial $1,750 · Current $1,750

General-duty citation text

29 CFR 1910.119(m)(6):  Incident reports were not reviewed with all
affected personnel
whose job tasks are relevant to the incident findings including contract
employees where
applicable:
(a)On or about 7/8/2009 and at times prior thereto, the employer did not
review PSM
incident reports with all affected personnel whose job tasks are relevant
to the incident
findings.  Incident reports are posted on the bulletin board but are not
reviewed with
personnel.

Issued

Nov 24, 2009

Abate by

Apr 21, 2010

Penalty

Initial $1,750 · Current $1,750

General-duty citation text

29 CFR 1910.132(d)(1):  The employer did not assess the workplace to
determine if hazards
were present, or likely to be present, which necessitate the use of
personal protective
equipment (PPE):
(a)On or about July 29, 2009, and at times prior thereto, the employer did
not conduct a
flash hazard assessment for electrical panel boxes in the control room
which
maintenance employees have worked on while they were energized. The breaker
boxes/breaker panels/control room load center were not field marked to warn
qualified personnel of potential arc flash hazards.
Abatement note:  See NFPA 70E and NEC 2002 regarding flash protection.rol

Issued

Nov 24, 2009

Abate by

May 3, 2010

General-duty citation text

29 CFR 1910.303(g)(1)(i)(B):  The width of working space in front of the
electric equipment
was less than the width of the equipment or 762 mm (30 in.), whichever is
greater:
(a)On or about July 29, 2009 and times prior, the employer failed to
provide adequate
clearance in front of the 220 volt electrical disconnect panel the breaker
panel box
(aka Control Room Load Center) marked as "Control Room, NE Corner, 120 Vac
Load Center, Computer/BAiley Cabinet Power" and the 220 volt electrical
disconnect
panel. They were blocked by the uninterruptable power system (UPS). In
event
of an
emergency, employees are restricted in accessing the electrical panel.ical

Issued

Nov 24, 2009

Abate by

May 3, 2010

General-duty citation text

29 CFR 1910.037(b)(2):  Each exit was not clearly visible and marked by a
sign reading
"Exit":
(a)On or about July 29, 2009 and at times prior thereto, the employer did
not "mark"
each exit in the control room with an illuminated exit sign.  Lack of
signage could
lead to confusion during an emergency situation at night if power was
lost; increasing
the risk of employee injury.e

Issued

Nov 24, 2009

Abate by

May 3, 2010

General-duty citation text

29 CFR 1910.178(l)(4)(iii):  An evaluation of each powered industrial
truck operator's
performance was not conducted at least once every three years:
(a)On or about July 22, 2009, and at times prior thereto, forklift
performance
evaluations were past due for at least ten of the current forklift
operators.s