Common Audit Findings 5 – Other PSM Elements

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Introduction: Process safety audits frequently uncover confusion regarding PSM program requirements and implementation. This is Part 5 in a five-part series highlighting common audit findings. This section includes selected audit findings related to Management of Change (MOC), Pre-startup Safety Review (PSSR), Contractors, Incident Investigation (II), Emergency Planning and Response, Compliance Audits (CA), and Employee Participation (EP).  

Selected Audit Findings (see reference for complete list)

Management of Change

Temporary Changes: There are seldom limits established for the number of “extensions” allowed to temporary MOCs or criteria established to allow an extension. Good industry practice typically limits (1) the timing for temporary changes (typically to no more than 6 months) and (2) the number of extensions allowed before the change must be reverted or made permanent (typically only two or three extensions are allowed).  In addition, closure of the temporary MOC is often not documented or there is a poor “paper trail” (i.e., how the change was returned to the original design or was changed to permanent [via an expanded or new MOC]).  The MOC system should (1) provide a maximum time limit for temporary MOCs (including extensions) and (2) ensure good documentation of all temporary MOCs, including reviews for extensions and the final resolution.

Informing/Training: MOC requires that affected employees be informed of and trained on the change, and PSSR requires confirmation that training of operations personnel has occurred prior to startup. Often (1) people are “missed” when the communication is provided and/or (2) there is a lack of clear guidance and consistent application on when and how “training” is to be provided. Many MOCs are typically “simple” changes where “informing” personnel should be sufficient. These issues can be addressed by (1) ensuring designated employees are informed and sign-offs (or similar documentation) are complete and accurate and (2) establishing specific criteria for when formal training on an MOC is required and for which group(s).

Management of Organization Change (MOOC): Although MOOC is not a specific regulatory requirement in the OSHA PSM regulation, OSHA has issued a memorandum  indicating that appropriate organizational changes should be considered as part of the MOC system. However, often MOOC is not implemented or is not implemented consistently for all personnel changes.  Therefore, facilities should consider implementing an adequate MOOC program as part of their MOC system.

 

Pre-startup Safety Review

PSSR Team: Sometimes PSSRs are performed by one or two persons. Although there is no specific regulatory requirement for a team to be involved, good industry practice PSSRs typically use a multi-disciplinary PSSR team (e.g., typically including operations, engineering, maintenance, and safety personnel as a minimum) to ensure a thorough review.

PSSR Approval: Sometimes there is no documentation that clearly shows how and when the PSSR was performed and how any PSSR-identified deficiencies were corrected prior to startup. All potential action items from the PSSR checklist should be captured for follow-up, which is important from both a process safety and regulatory perspective.  Documentation should also be provided if no follow-up is to be performed. Facilities should make sure their MOC/PSSR system and its workflow ensures all deficiencies are tracked and corrected and there is documented management approval that the change is “safe to start up.

 

Contractors

Performance Evaluation: Employers are required to periodically evaluate the performance of contract employers in fulfilling their obligations.  Typically, this should include (1) meetings with each major contract employer (e.g., typically annually) and smaller contractors (e.g., based on work activities) to review their performance and identify any needed upgrades, (2) periodic, detailed audits of contract employee safety programs, qualifications, and training records, and (3) documented periodic field audits.

 

Incident Investigation

Incident Investigation Timing: The regulations require that investigation be initiated promptly and no later than 48 hours following the incident, but sometimes the date/time the investigation began (1) is not documented in the incident investigation reports or (2) indicates it started “late.” Note that the latter often occurs when the documentation is based on the date/time that the first formal incident investigation team meeting occurred, but the investigation usually begins when the pertinent facts and information are initially gathered and preliminary reporting occurs, which usually occurs during the same shift or day of the incident.  So, these issues can be addressed by ensuring that the incident report documentation captures the date and time when the data collection for the preliminary incident report was initiated.

 

Emergency Planning and Response

Compliance with EPR-related Regulations: Although OSHA’s EPR element is very brief, it incorporates the following regulations via reference: (1) 1910.38(a) [Emergency Action Plan], (2) 1910.165 [Employee Alarm Systems, which is referenced in 1910.38], and (3) 1910.120(a), (p), and (q) [Hazardous Waste Operations and Emergency Response]. Common issues with meeting the requirements of these referenced regulations include (1) names or titles of persons who can be contacted for more information are not provided, (2) issues with the facility alarm system being audible/detectable in all locations have not been addressed, (3) places of refuge (e.g., shelter-in-place locations) are not formally designated or do not meet a set of adequate, consistent requirements, (4) critiques of emergency responses or drills are not consistently issued or recommendations are not adequately addressed, (5) training of the emergency response team (or fire brigade) is inadequate or inconsistent, and (6) required training levels through the facility are not well-defined or consistently applied (i.e., first responder awareness, first responder operations, hazardous materials technician, hazardous materials specialist, and on scene incident commander).  Facility emergency personnel should (1) be knowledgeable of all these EPR-related regulations and (2) ensure their emergency action plan and emergency response plan (if they are a responding facility) and the associated program adequately complies with them.

 

Compliance Audits

Audit Certifications: It is fairly common to find that (1) there is no formal “certification” of a previous audit(s), (2) the certification(s) has been lost or misplaced, or (3) certifications are provided by third parties (e.g., independent auditors) rather than by the employer.  These issues can be avoided by (1) establishing the form/format for compliance audit certifications to be made by the employer (e.g., typically the plant manager or designee) and (2) ensuring the certifications are consistently retained along with the required two most recent compliance audit reports.

 

Employee Participation

Employee Consultation: The employee participation element requires that the employer “consult with employees and their representatives on the conduct and development of process hazards analyses and on the development of the other elements of process safety management” in the regulations.  Good employee participation on PHA teams is often observed but there is often a lack of consultation on the development/implementation of other PSM elements (e.g., lack of documentation that the site safety and health or PSM committee [if one exists] is involved in the “development” or revision of the PSM procedures and also includes a cross section of employees from various plant groups).  One way to address this is to (1) ensure that safety and health (or PSM) committee meetings include employees from various plant groups or areas and are documented and (2) include a “standing agenda item” to review any new/revised PSM element procedures.  Other methods of consulting with employees can also be documented, such as participation in annual PSM-emphasis safety meeting for all employees.

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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.

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