Common Audit Findings 2 – Operating Procedure, Safe Work Practice, and Training Issues

By /

Introduction Process safety audits frequently uncover confusion regarding PSM program requirements and implementation. This is Part 2 in a five-part series highlighting common audit findings. This section includes selected audit findings related to Operating Procedures (OPs), Safe Work Practices (SWPs), and Training.

Selected Audit Findings (see reference for complete list)

Operating Procedures

All operating phases are not explicitly addressed in OPs: The OSHA regulation and good industry practice clearly require/expect that each covered process will have OPs which address 7 operating phases.  Some issues we often see in meeting this requirement include:

  • When discussing “initial startup” procedures, we are often referred to “normal startup” procedures. The “initial startup” procedures are intended for the initial startup of the covered process, and are likely to include additional pre-commissioning activities and steps or for startup following a de-inventory of the entire process (e.g., as part of a big turnaround).  The “normal startup” procedures referred to are typically addressing “startup following a turnaround, or after an emergency shutdown.” For example, batch processes may routinely be started-up daily and semi-continuous or continuous processes may start up routinely following normal shutdowns or scheduled maintenance. Of course, the initial startup may have occurred many years ago, and as a result, such procedures may no longer exist or may be archived/available in some fashion.
  • When we ask about or look for “normal operations” OPs, sometimes (1) there is a lack of clarity about what they should be, (2) the information is simply not available, or (3) the information is dispersed across multiple OPs. Normal OPs typically cover activities such as (1) daily field/board operator duties, including operator rounds/readings; (2) sampling; (3) troubleshooting; and (4) routine activities (e.g., switching filters or pumps).  However, these are often not clearly labeled as “normal operations” procedures, and this could result in unnecessary attention during a regulatory inspection.
  • Some units have some OPs which represent “temporary operations” (e.g., routine bypassing of a piece of equipment that requires cleaning or maintenance) but these OPs do not always exist. The most common source of temporary OPs for most units is associated with temporary management of change (MOC) packages and there is no reference to this in the operating manuals or in the “procedure on writing and revising procedures” (if one exists).
  • When reviewing the emergency shutdown procedures, it is not uncommon to find that (1) the conditions under which emergency shutdown is required are not explicitly stated or are lacking and/or (2) the assignment of shutdown responsibility to qualified operators is not documented (e.g., by explicitly defining who does what for each OP step or section and clearly stating that only qualified operators can execute the emergency shutdown).
  • We often note that the differences between “emergency shutdown” and “emergency operations” procedures are not clearly defined/understood and (2) there are no references to the “corrective actions” included in the operating/safe limits tables as being part of the emergency operations procedures (see the OSHA guidance related to this in Part 1 of this series). Typically, emergency shutdown procedures are those pertaining to immediate shutdown of a piece of equipment, process section, or entire process based on loss of containment or deviations outside of a safe upper/lower limit, while emergency operations procedures are those associated with loss of a utility, loss of the control system, shutdown of an upstream/downstream unit, or operation outside of an operating limit.
  • There are often no specific procedures for “startup after an emergency shutdown.” For most units, the state of the process after an emergency shutdown will be different from the state after a normal shutdown.  The subsequent startup would need to start with placing the system in the proper configuration for startup so that the normal startup procedures could be used, after appropriate checking of the process and equipment.

Guidance: Provide OPs for all required operating phases, with adequate detail to address the issues discussed above. In most cases, two best practices exist: (1) clearly-named individual OPs are provided for each operating phase and (2) all operating phases are clearly identified in each OP. If an operating phase is not relevant for the process, this should also be documented to avoid possible confusion or be seen as an oversight (e.g., initial startup).

 

Safety systems and their functions are not provided in OPs: Discussion of safety systems must be included in OPs to help operators (1) understand what safety systems exist in their process and (2) know how these systems function as well as actions they must take to activate a system when appropriate.  However, even when there is adequate information about the safety systems and their design in the PSI, adequate information may not be summarized or referenced in the OPs, as required. There is often not enough information in the OPs to inform operators on how they should interact with each safety system (e.g., how do they activate fire protection if it does not automatically activate, how do they respond to one or multiple toxic or combustible gas detectors alarming), and appropriate thought should be given to providing the right level of detail.  Also, the safety systems may not be a formal refresher training subject.

Guidance: Ensure that safety systems are discussed or referenced in OPs. In some cases, one OP may be provided to document multiple safety systems or a set of OPs or for a unit, OPs for safety systems can also be distributed among several OPs, as appropriate.

 

OP review and certification process: When we ask how often the OPs are reviewed, we can receive a variety of answers, including (1) “we review them annually as part of the certification,” (2) “every three years as part of the refresher training schedule,” or (3) “we review them when they are changed due to a management of change.”  The first response is beyond regulatory requirements since OSHA does not expect annual, in-depth reviews of all the procedures [5], although this can be a GIP depending on the overall scope.  The other responses suggest that not all the procedures are being reviewed “as often as necessary” per the regulation.  Involving all the operators in periodic procedure reviews as part of refresher training is helpful but is not regulatory.  Review only by some operators and not including operations supervision or engineers may miss some actual operating practices and is a lost “employee participation” opportunity. Even though the regulatory requirement for annual certification of OPs has been in place since 1992, we still too frequently find that implementation of this has eroded over the years and gaps exist in the certification documentation, sometimes for extended periods.  Also, some new processes have been introduced without including a requirement for annual certification of the OPs. In many cases, certification documentation does not explicitly confirm the current revisions of the OPs are “current and accurate” or identify the process used to determine the status of the procedures.

Guidance: Ensure OPs are reviewed on a practical schedule, to support the 3-year refresher training schedule. Ideally, operators should lead or at least be involved in the review process to help ensure that the OPs reflect actual operating practices. OPs should be certified annually, providing documentation on the review process (along with use of the MOC system) used to keep them current.

 

Safe Work Practices

Non-compliance with regulatory requirements from associated SWP OSHA regulations: Several of the SWPs referred to in the PSM regulations have their own internal audit requirements, as mentioned in the “Requirements/Background” section.  There are 3 issues with these that we frequently find during compliance audits:

  • Sites are not complying with the OSHA 1910.147(c)(6)(i) requirement to “conduct a periodic inspection of the energy control procedure at least annually to ensure that the procedure and the requirements of this standard are being followed.” In some cases, we can find no evidence of any annual reviews.  In many cases, there may not be “field” inspections or there may not be inspection of all the pertinent types of energy control procedures. OSHA considers periodic inspections to be a “hot topic.” Potential reasons include personnel changes and/or management systems that may “erode” over time.
  • A majority of sites do periodic “permit audits” but some do not audit all the completed confined space entry (CSE) permits, as required by OSHA 1910.146(d), within at least one year of the entry. In other cases, they regularly review their CSE procedure and permit form, but not all the completed CSE permits.
  • The hot work permit (HWP) nor the associated site procedure/training discuss all the pertinent fire prevention and protection requirements in OSHA 1910.252(a). Although listing all of these requirements on the HWP form may not be practical or necessary, it is certainly reasonable to go through the requirements and sources of the requirements during training on the site’s HWP procedure.  Periodic training for employees and contractors who use the HWPs and with personnel who authorize the permits should be provided.

Guidance: Ensure that non-PSM OSHA requirements for SWPs are met, in particular the requirements for periodic review of completed permit documentation. In addition, when additional training and audit requirements are built into corporate or site SWPs, ensure that these requirements are met consistently, since they will typically be reviewed by auditors/inspectors.

 

Hot work permits (HWP) do not consistently identify the object on which hot work is to be performed: Many sites do a good on implementing the OSHA 1910.252(a) requirements associated with the hot work element.  However, the additional PSM requirement to identify the “object” of the hot work is sometimes missed.  When we review completed HWPs, there are usually some cases where this identification is not provided or is vague.  Typical descriptions provided are often along the lines of “C Rx 3rd floor” (when the reactor is large and hot work hazards are different depending on which side is being worked on), “Fabricating New Water Line” (lacks any specific location or range), or “Weld Repairs on North Stairs” [not specifying at which level(s)]. In some cases, this may partly result from use of HWPs that do not include a specific “location” box on the form.

Guidance: Ensure that hot work permits and work control practices require identification of the specific location and object to be worked on. Periodically review completed hot work permits and require additional training as needed.

 

Control over entrance (and exit) for the covered process units is not adequate: Although most sites have procedures/practices covering control over entrance/exit of maintenance, support personnel, contractors, and other visitors to covered process units.  However we often observe that the discipline of people following entrance procedures is lacking. Sign-in and sign-out logs are typically used with operator contact in the control room prior to entry to hazardous areas to help ensure that the required work can be conducted safely. It is not unusual to review logs or work permits and observe that workers did not sign in or out on during the task.  Often, people sign in, but then fail to sign out, which could lead to unnecessary rescue efforts in an emergency. In some cases, entrance procedures may allow entry to an entire facility (for security), rather than entry into covered processes areas, which auditors should review carefully for effectiveness. Being allowed into a facility does not mean that visiting personnel should be able to enter hazardous process areas without following access control requirements.

Guidance: Develop procedures for entry into covered process areas in addition to typical security measures for entrance into the overall facility. Periodically review sign in and sign out logs and update them to help ensure they are being used correctly.  Provide corrective training for violators as needed.

 

Training

Refresher training does not ensure that employees adhere to the current operating procedures: One of our focus issues the last few years has been the part of the regulatory requirement “to assure that the employee understands and adheres to the current operating procedures of the process” is often not addressed. Refresher training often (1) uses the same written tests (or subsets of the tests) used for initial training, (2) includes individual or group reviews of some procedures, and (3) some “what if” or “tabletop” drills on some training on operating/emergency scenarios. These practices can be useful to verify understanding of training for a group but not for individuals or on the specifics of the current revisions of the OPs.  However, these methods are not sufficient to establish adherence to the OPs, especially for tasks that are done infrequently.

Guidance:  Provide a “demonstration of proficiency” component in the refresher training program in addition to written test verification of understanding to help provide adherence to the current OPs.  For example, it can be useful to (1) identify the “critical” procedures for which refresher training to verify “adherence” will be required (typically startup, shutdown, emergency, and other critical procedures) and (2) require some amount of “field demonstrations” on these critical procedures (e.g., repeating some of the demonstrations used in initial training and/or demonstration of proficiency on some procedures [“what-if” or “tabletop” group simulation, monitored execution or simulation of some procedures]). Review the quality and results of written testing procedures. A true/false question format is likely less effective in establishing understanding of OPs and to emphasize the continuing adherence to OPs.  While not required, periodic recheck of knowledge of the OPs can be useful as a good industry practice to evaluate the long term retention of training and help emphasize the adherence requirements (e.g., recheck 3 to 6 months after training). In addition, a focus on operational discipline programs to promote continued adherence to OPs and other requirements and to evaluate gaps can also be used to evaluate, document, and improve overall adherence efforts.

 

Lack of a process or documentation that employees are consulted on the appropriate frequency of refresher training: A common audit finding is that employees are not adequately consulted on the appropriate frequency of refresher training. Since refresher training cycles can be up to three years with some training repeated at shorter (annual) intervals, or where some training may be provided prior to each execution of a particular OP.  Consulting with employees on the frequency of training on OPs or other topics at the 3-year time limit allows both experienced personnel and new personnel to provide input to the training process.  In some cases, consultation on the frequency may have occurred at one point, but has not been sustained by repeated consultation (e.g., annually or at the 3-year refresher training limit).  Refresher training may also be required “on demand” for infrequently performed tasks when they are scheduled (e.g., a unit shutdown/startup which only occurs on a 3-5 year frequency).

Guidance:  Consult with employees at least during each 3-year refresher training cycle on the frequency of refresher training and provide appropriate documentation of the input received. This can be done in a safety meeting, or can be included as questions on training checklists or tests to receive and document the employee feedback on training frequency. In addition, while not required, consultation with employees on the content and quality of refresher training materials and instruction can also provide feedback to improve the refresher training program.

Download Full Original Manuscript (PDF). Used with permission.

References

 

The published version of this complete article can be found on Chemical Processing’s website where you can also access more tools and resources to help you run safe, efficient facilities.

Scroll to Top