Document k67Vq0kXD9vdwZevv51JY1ERE

Region 6 - Enforcement & Compliance Assurance Division INSPECTION REPORT Inspection Date(s): Media Program: Regulatory Program(s) December 11 - 14, 2023 Air Clean Air Act (CAA) 112(r)(1) - General Duty Clause and 112(r)(7) 40 Code of Federal Regulations (C.F.R.) Part 68 Chemical Accident Risk Management Program (RMP) Company Name: Facility Name: Facility Physical Location: (city, state, zip code) Mailing address: (city, state, zip code) County/Parish: Facility Phone Number Facility Contact: United Natural Foods, Inc. (UNFI) UNFI Lancaster 2100 Danieldale Road Lancaster, TX 75134 2100 Danieldale Road Lancaster, TX 75134 Dallas (910) 546-9790 John Perry Facility Maintenance Manager John.Perry@unfi.com FRS Number: Identification/Permit Number: Media Identifier Number: NAICS: SIC: 110000713133 ICIS 360159360 RMP 1000 0024 7057 424410 General Line Grocery Merchant Wholesaler 5141 Groceries, General Line Personnel participating in inspection: Aimee Boss EPA Region 6 Enforcement and Compliance Assurance Division (ECAD) Diana Lundelius EPA Region 6 ECAD Brian Chamberlin UNFI Carlos Sneed UNFI John Perry UNFI Paige Laborde Baker Botts Physical Scientist Senior Enforcement Officer EHS Partner Trainer Facility Maintenance Manager Outside Counsel EPA Lead Inspector Signature/Date AIMEE BOSS Digitally signed by AIMEE BOSS Date: 2024.02.13 11:56:25 -06'00' 2/13/2024 Aimee Boss Date Supervisor Signature/Date SAMUEL TATES Samuel Tates Digitally signed by SAMUEL TATES Date: 2024.02.13 12:22:12 -06'00' Date 6ENFORM-019-R8.2 (02/12/2020) 1 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 Section I - INTRODUCTION PURPOSE OF THE INSPECTION United States Environmental Protection Agency (EPA) Region 6 inspectors Diana Lundelius and Aimee Boss ("EPA or we") arrived at the UNFI Lancaster facility (UNFI or the Facility) at 9:00 AM on December 11, 2023, for an announced inspection. We met with Brian Chamberlin, EHS Partner UNFI, Carlos Sneed, Trainer UNFI, John Perry, Facility Maintenance Manager UNFI, and Paige Laborde, Outside Counsel, Baker Botts at the opening conference. We presented our credentials to Brian Chamberlin and informed him that this was an EPA inspection to evaluate compliance with the requirements of the Chemical Accident Prevention Provisions of 40 C.F.R. Part 68 and the CAA 112(r)(1) and (7). The inspection was prompted by the Facility's June 12, 2023, anhydrous ammonia release. The initial Texas Commission on Environmental Quality (TCEQ) Air Emission Event Report, dated June 13, 2023, estimated 3,000 lbs of anhydrous ammonia released from a solenoid valve. As a result of the incident, the facility was evacuated, and 12 employees voluntarily went to a nearby hospital for exposure evaluation and were released the same day. Employee representatives were invited to participate in the inspection. The facility does not have union representation. FACILITY DESCRIPTION UNFI is located in an industrial park in northern Lancaster, near Interstate 20 and Interstate 35 in the far southern portion of Dallas County. The facility operates 24 hours a day, seven days a week with approximately 460 employees. The facility is a large refrigeration warehouse with multiple sections, which utilizes an anhydrous ammonia refrigeration system to keep products at temperatures just above or well below freezing to preserve food products and meet food safety standards. The facility was constructed in 2010 and underwent a large expansion beginning in 2021, completed in 2022. As part of the expansion, the ammonia system capacity increased to approximately 15,000 pounds, which is above the 10,000-pound threshold quantity for RMP regulated toxic substances. Anhydrous ammonia is the only RMP regulated substance present at UNFI Lancaster. An owner or operator of a stationary source that has more than a threshold quantity of a regulated substance in a process, as determined under 68.115, shall comply with the requirements of the Part 68 - Chemical Accident Prevention Provision. UNFI submitted its initial RMP registration in August 2021 and identified the ammonia refrigeration system as a Program Level 3 facility. UNFI contracts Innovative Refrigeration Systems, Inc. ("Innovative Refrigeration") to oversee the refrigeration process at the facility. Innovative Refrigeration designs, fabricates, and installs customized, turn-key industrial refrigeration systems. Innovative Refrigeration prepares the Risk Management Plan program documents and the facility procedures for UNFI to review and implement. The procedures and other responsive records were produced on the facility's behalf and were not originally developed by UNFI. No UNFI employees perform maintenance. Innovative Refrigeration contractors oversee and implement all monitoring, operation, maintenance, and repairs for the refrigeration system. 2 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 Section II - OBSERVATIONS EPA's review began on September 29, 2023, in response to an initial request for information on September 18, 2023, regarding the June 12, 2023, release incident. EPA conducted additional review and observations during the inspection with UNFI personnel noted on the sign in sheets (see Appendix 1). The EPA team also accompanied UNFI personnel on a brief walking tour of the facility during the inspection to view the areas that house the refrigeration system key equipment and components. 40 C.F.R. Part 68 - CHEMICAL ACCIDENT PREVENTION PROVISION Subpart A - General 40 C.F.R. 68.10 Applicability - UNFI is a stationary source that has more than a threshold quantity of a regulated substance in their process. The initial RMP submittal was on August 16, 2021, by Innovative Refrigeration on UNFI's behalf, and the most recent submittal was made March 4, 2022. UNFI is an RMP Program Level 3 facility that is also subject to the Occupational Safety and Health Administration's (OSHA) Process Safety Management (PSM) Standard (29 CFR 1910.119). 40 C.F.R. 68.12 General requirements - UNFI resubmitted their most recent RMP registration update on March 4, 2022, to update the person responsible for Part 68 implementation. The regulated substance included in the registration in the toxics table is ammonia, which is listed over the threshold quantity for the RMP Program Level 3 process. 40 C.F.R. 68.15 Management - UNFI has developed a management system to oversee the implementation of the risk management program elements. UNFI provided an organizational chart that outlined the positions for implementation of the individual elements of the RMP, as required by this subpart. Subpart B - Hazard Assessment 40 C.F.R. 68.20 Applicability - UNFI operates an RMP Program Level 3 process which is subject to this subpart, and thus is required to conduct a hazard assessment, prepare a worstcase release scenario analysis, and complete the five-year accident history. We reviewed the documentation provided to make this analysis and identified no areas of concern with this section. 40 C.F.R. 68.22 Off site consequence analysis (OCA) parameters - UNFI employed the parameters specified by EPA in this rule by using the RMP*CompTM software. We reviewed the off site consequence analysis and supporting documentation and found that the OCA was completed within 2 months of the public release of the 2020 census data. 40 C.F.R. 68.25 Worse-case release scenario analysis - UNFI identified and analyzed at least 3 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 one worst-case scenario in its Program 3 process using the RMP* CompTM software, thus meeting the requirements of the regulation. 40 C.F.R. 68.28 Alternative release scenario analysis - UNFI identified and analyzed at least one alternative release scenario in its Program 3 process using the RMP* CompTM software, thus meeting the requirements of the regulation. 40 C.F.R. 68.30 Defining off site impacts-population - UNFI did not use the most current Census Bureau population data, as specified in the regulation, to calculate the population numbers reported in their RMP. The off site consequence analysis was completed on August 16, 2021. The 2020 census data was publicly released on September 16, 20211. The RMP*CompTM software did not yet include the 2020 census data, however, it should have been considered when creating or updating the off site consequence analysis affected population for the RMP registration [See AOC 1]. EPA notes that the distances to endpoints would not change as a result of using 2020 census data, nor would the maps indicate the affected areas to endpoint. 40 C.F.R. 68.33 Defining off site impacts-environment - UNFI used US Geological Survey maps data to determine the environmental receptors and the distances to endpoints, as required by this subpart. 40 C.F.R. 68.36 Review and update - UNFI understands that documentation associated with the worst-case scenarios should be updated and reviewed at least every five years. The facility anticipates conducting a review in 2026. 40 C.F.R. 68.39 Documentation - UNFI operates an RMP Program Level 3 process which is subject to this subpart, and thus is required to prepare a worst-case release scenario analysis and complete the five-year accident history. We reviewed the documentation provided to make this analysis and identified no areas of concern with the information included in the OCA data, except as previously noted. The facility used the EPA Model RMP*CompTM, thus meeting the requirements of the regulation. 40 C.F.R. 68.42 Five-year accident history - UNFI did not report any accidental release(s) in their RMP that resulted in deaths, injuries, or property damage. The June 12, 2023, release does not meet the RMP reportable criteria. We reviewed the documentation previously provided to EPA which summarized the release incident to make this determination and identified no areas of concern with this section. Subpart D - Program 3 Prevention Program 1 2020 Census Timeline of Important Milestones, https://www.census.gov/programs-surveys/decennialcensus/decade/2020/planningmanagement/release/timeline.html#:~:text=April%2026%3A%20The%20Census%20Bureau,variety%20of%20oper ational%20quality%20metrics. 4 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 40 C.F.R. 68.65 Process safety information (PSI) - We reviewed various sections of the process safety information for the RMP covered process at UNFI. UNFI's documentation, provided to EPA electronically on December 13, 2023, meets the requirements of this subpart. 40 C.F.R. 68.67 Process hazard analysis (PHA) - UNFI provided EPA with their PHA schedule detailing corrective action completion dates and due dates. The initial PHA was completed in 2020. Due to the 2022 expansion, the PHA was completed again in 2023 to include new equipment from the October 2022 expansion. All revalidation dates were met per regulation requirements. UNFI's provided PHA schedule has a revalidation due date in 2025. With a follow up PHA completed in 2023, the next revalidation would be due in 2028. The PHA studies were conducted using the What If/Checklist method. The 2020 and 2023 PHAs did not include evaluation of the failure of engineering and administrative controls. PHA findings and recommendations are documented electronically in the ePSM software platform, an online service and maintenance application containing information for process safety information, compliance audits, incident investigation, management of change, employee training, emergency planning, contractor safety and additional RMP and PSM program elements. The ePSM platform is maintained by the refrigeration contractor, Innovative Refrigeration. One finding from the 2020 PHA has a due date of July 31, 2023, UNFI did provide documentation of the action taken. However, this 2020 PHA finding was not included as a repeat finding in the 2023 PHA which occurred before the due date. Two findings from the 2023 PHA were documented as incomplete, one with a due date of December 13, 2023, making it past due by the end of EPA's inspection. Additionally, UNFI did not provide documentation to confirm that there was communication to affected employees of the PHA findings or corrective actions completed. [See AOC 2]. 40 C.F.R. 68.69 Operating procedures - This section requires operating procedures to be certified annually. We reviewed several operating procedures for the covered process. Operating procedures are available to employees and contract operators via the facility's electronic ePSM software platform. We reviewed and discussed various operating procedures, including the operation of the ammonia dispersion tank, the ammonia loading procedure, confined space entry, and the lockout/tag out safety policy and procedure with UNFI personnel and Innovative Refrigeration. The procedures are all generic and do not reflect actual sitespecific operations, and do not adequately address the consequences of deviation, emergency operations, or temporary operations. UNFI personnel indicate that the operating procedures as a whole are under revision to add required site specific conditions unique to the Lancaster facility. UNFI certified that the operating procedures were current, accurate, and reviewed as often as necessary for 2022. However, there was no annual certification for operating procedures for 2021 and the 2023 annual certification was incomplete at the time of the inspection. [See AOC 3]. 40 C.F.R. 68.71 Training - Initial training is required prior to an employee performing operations in a covered process, and refresher training is required at least every three years, or more frequently if needed to ensure safe operations. All employees receive general training during new employee orientation which includes safety hazards and emergency response, and 5 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 department specific training through on-the-job and computer-based training. We requested training records for review and were provided the files for several employees at different experience levels. We reviewed several refresher training cycles based on the employee start dates. Of the employee files we reviewed, each had taken the initial training required for their specific job title and responsibilities. For one PHA team member, initial training occurred in 2015 and no refresher training was documented until 2022. [See AOC 4]. 40 C.F.R. 68.73 Mechanical integrity (MI) - EPA reviewed mechanical integrity program documents, procedures, and records for the RMP covered process equipment. The UNFI MI program is overseen and implemented by the contractor, Innovative Refrigeration, and includes preventative maintenance elements, which consist of a combination of daily, weekly, monthly, semiannual, and annual inspections, depending on the type of process equipment and its function. UNFI employees complete only visual inspections. No UNFI employees perform maintenance. All maintenance and repairs for the RMP covered process are completed by Innovative Refrigeration contractors. EPA reviewed UNFI's relief valve replacement schedule which states that the relief valve installation dates were in 2017 and in 2022, with upcoming replacement dates in 2022 and 2027, respectively. This schedule conforms to the International Institute of Ammonia Refrigeration (IIAR) recommended practice. On December 19th, 2023, EPA conferred with Innovative Refrigeration employees to discuss outstanding MI questions for the inspection. The relief valve replacements for 2022 were past due at the time of inspection. Innovative Refrigeration confirmed the relief valves originally installed had lost their accreditation from the manufacturer, and the relief system had to be redesigned to accommodate a new model valve which had not been ordered at the time of EPA's inspection. UNFI provided records of the June 2021, June 2022, and June 2023 annual relief system inspections. UNFI also provided semiannual inspection and maintenance reports for June and December of 2022, and June of 2023. UNFI was unable to provide documentation of the annual inspection and maintenance report for 2023 and the semiannual report for December of 2023 at the time of EPA's inspection. [See AOC 5]. 40 C.F.R. 68.75 Management of change (MOC) - EPA discussed UNFI's written procedure for MOC and associated documentation with UNFI personnel. The MOCs were documented and tracking using the ePSM program. We reviewed the facility's two MOCs to evaluate the implementation of the procedures. UNFI failed to document the required pre-start up safety review (PSSR) training for the expansion of the facility that was part of one MOC, or include personnel who would conduct visual inspections. The required MOC/PSSR training should have taken place before operation of the expansion began in October 2022. The PSSR training record provided by Innovative Refrigeration included only the UNFI maintenance manager. A finding of the 2023 compliance audit recommended that PSSR training be conducted for other affected employees to address this deficiency [See AOC 6]. Additionally, the MOC program document and procedures do not explain the use of the online ePSM database tracking system. Also, because the operating procedures were changed as a result of the expansion, those updates 6 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 should have been included as part of the MOC [See AOC 7]. The other MOC EPA reviewed is still open to complete the relief system redesign and installation of the new model relief valves. 40 C.F.R. 68.77 Pre-startup safety review (PSSR) - UNFI provided documentation regarding PSSR which accompanied the MOC's reviewed. The PSSR procedures do not explain the use of the online ePSM database tracking program. There is no date specified in the procedures or other documents furnished for EPA's review that indicate the date when ammonia was introduced to the covered process when the expansion was completed, prior to beginning operation. Because the completion date for the expansion, the date that ammonia was introduced, and the actual commencement date of operation for the expansion are not specified in documents furnished for EPA's review, UNFI cannot confirm that construction completion dates for equipment, operating procedures, and the training program were updated before or after the system expansion began operation [See AOC 8]. 40 C.F.R. 68.79 Compliance audits - EPA requested the most recent compliance audit for review. UNFI provided the compliance audit report completed and certified in November 2022. The next compliance audit will be due in 2025. UNFI tracks the actions of the findings and recommendation from the compliance audit in the ePSM electronic database system. Several of the findings had a due date of July 2023. One finding relates back to the PHA performed, and the lack of evaluating potential failure of engineering and administrative controls. Additionally, UNFI did not complete several action items in a timely manner and missed the scheduled dates in the tracking database. Twenty (20) actions were not completed by the projected due dates, and two (2) actions were still incomplete and past their projected due dates at the time of EPA's inspection [See AOC 9]. 40 C.F.R. 68.81 Incident investigation - We reviewed the incident investigation procedure, OSHA reportable accident (300) logs, and work orders to identify all incidents which resulted in, or could have reasonably resulted in, a catastrophic release of a regulated substance. The incident investigation procedure for UNFI specifies that investigations will occur for all releases and near miss releases, as well as for other types of incidents. When reviewing work orders provided by UNFI, we identified several work orders from 2023 that identify ammonia leaks. There was no documentation of incident investigations for these leak events. The procedure also referenced a PSM committee that is supposed to meet on a regular basis to review the progress and findings of incident investigations. UNFI was unable to provide consistent documentation of PSM committee meetings or the status of incident investigations. UNFI indicated that the PSM committee did not begin meeting regularly until June 2023. However, the June 2023 meeting notes furnished did not mention the leak events identified in the 2023 work orders. UNFI failed to implement the written investigation procedures by not convening the PSM committee at the frequency stated, and not including review of ammonia leaks with open work orders [See AOC 10]. UNFI provided records of work orders and investigations related to the solenoid valve involved in the June 12, 2023, release incident. A work order from November 2019 identified that the AU-10 Unit solenoid module was leaking, and this information was communicated to Innovative 7 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 Refrigeration to order a new solenoid module. No documentation was provided to EPA that confirms when the repair was completed. At the time the work order was initiated, the ammonia system was not yet registered as an RMP covered process. A separate third-party contractor conducted an Ammonia Valve Station Failure Report for the June 2023 incident, dated June 28, 2023. This report identified that the solenoid valve leak was the result of deficient inspections and assessments for continued service, and that lack of sufficient maintenance was also a likely contributing factor to the solenoid failure. Innovative Refrigeration provided UNFI a written ammonia loss estimate for the leak, which is not dated. Another third-party contractor submitted a report titled Investigation/Review of Ammonia Release June 12, 2023 on January 19, 2024, for EPA's review. This report concluded that the root cause of the June 12, 2023, incident was fatigue failure due to a failure to identify corrosion and inability to provide mechanical integrity during the repair on the AU-10 solenoid valve back in December 2019. Additionally, the January 19, 2024, report indicates that UNFI made the request for the other contractor to review the ammonia release on June 12, 2023, the same day that the release occurred; therefore, the incident investigation was initiated within 48 hours of the incident as required by the regulation. 40 C.F.R. 68.83 Employee participation - UNFI provided the employee participation policy and plan for review. The policy is not dated, and it appears some elements have not been implemented previously as written in the plan, such as PSM quarterly meetings, which did not occur consistently until June 2023, and the PSM committee being responsible for conducting certain reviews or completing tasks such as incident investigations [See AOC 11]. 40 C.F.R. 68.85 Hot work permit - UNFI discussed the process for conducting hot work on site and we reviewed the hot work procedure. All hot work permits are kept on file until the work is completed, after which the signed off permits are discarded in accordance with UNFI's separate document retention policy. UNFI provided a blank Hot Work Permit sample for review. No areas of concern were identified. 40 C.F.R. 68.87 Contractors - UNFI contracts Innovative Refrigeration to operate and maintain the ammonia refrigeration system covered process. Innovative Refrigeration monitors the system remotely 24 hours a day, seven days a week, in coordination with UNFI's internal visual inspections. Innovative Refrigeration also completes the preventative maintenance, testing, and semiannual maintenance inspections. UNFI provided its written contractor safety procedure. The written procedure does not document how contractor access is controlled at the facility or at the covered process. The 2022 Compliance Audit included a recommendation to develop an access policy, which was listed as completed in March 2023, but a copy of the policy is not referenced in the contractor program document, and was not provided as a separate document for EPA's review. [See AOC 12]. Subpart E - Emergency Response 40 C.F.R. 68.90 Applicability -UNFI is not a responding stationary source, and therefore is only required to meet limited requirements under Program Level 3 to coordinate with local 8 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 response organizations and to conduct annual response notification exercises after making its initial notification. This must be completed after submitting an initial RMP registration, and at least annually prior to December 19, 2024, then annually thereafter. 40 C.F.R. 68.93 Emergency response coordination activities - We reviewed UNFI's Emergency Action Plan. Initial emergency response coordination with the fire department under 68.93(a) and (b) should have been completed within one year, by mid-2022, after submission of the initial RMP registration. The EHS coordinator indicated that this notification was made in 2023, over a year past the required date. [See AOC 13]. 40 C.F.R. 68.96 Emergency response exercises - As part of coordination with local emergency response officials required by 68.93, UNFI is required to conduct annual response notification exercises with the local fire department after its initial response coordination. There was no documentation furnished of a response notification exercise conducted in 2022 calendar year, after the facility should have made its initial coordination with the fire department. An internal response drill in 2021 and emergency responder meeting notes in August 2022 did not meet the criteria of an annual response notification exercise/drill as outlined in 68.96(a) and 68.93(c). EPA notes that the notification made to the Lancaster fire department to respond to the June 2023 release incident counts as an annual notification exercise for 2023. [See AOC 14]. Subpart G - Risk Management Plan 40 C.F.R. 68.160 Registration - UNFI's RMP registration did not include an accurate emergency contact phone number. When dialed from the facility during the inspection, the call went straight to a voicemail box that had not been set up. UNFI personnel confirmed that the phone number listed was not correct. [See AOC 15]. 40 C.F.R. 68.190 Updates - UNFI's initial RMP submittal was on August 16, 2021, and the most recent submittal was made March 4, 2022, to update the person responsible for RMP implementation, the emergency contact, and other points of contact. 40 C.F.R. 68.195 Required corrections - The next RMP re-submission will be due by March 4, 2027. However, an additional update to correct the emergency contact phone number should have been made within one month after the March 4, 2022, update, as required by 40 C.F.R. 68.160 and this section, if the facility had verified that the emergency contact phone number listed was invalid. [See AOC 16]. Section III - AREAS OF CONCERN (AOC) EPA Region 6 inspectors Aimee Boss and Diana Lundelius conducted a closing conference at UNFI at 2:30 pm on December 14, 2023 for the inspection. During the closing conference, Aimee Boss and Diana Lundelius reviewed the 14 Areas of Concern noted during the inspection. AOC 1 - 40 C.F.R. 68.30 Defining off site impacts-population 9 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 (c) Data source acceptable. The owner or operator may use the most recent Census data, or other updated information, to estimate the population potentially affected. The off site consequence analysis used 2010 census data. The 2020 census data was publicly released on September 16, 2021, soon after the analysis was completed in early August 2021. While the Marplot mapping program was not updated with the 2020 census data at the time of the initial OCA completion, the maps of affected areas within distance to the endpoint would not have been affected, and the 2020 census population data should have been considered and used instead as soon as it was available. AOC 2 - 40 C.F.R. 68.67(c)(3) & (4) and (e) PHA (c) The process hazard analysis shall address: (3) Engineering and administrative controls applicable to the hazards and their interrelationships such as appropriate application of detection methodologies to provide early warning of releases. (Acceptable detection methods might include process monitoring and control instrumentation with alarms, and detection hardware such as hydrocarbon sensors.); (4) Consequences of failure of engineering and administrative controls. (e) The owner or operator shall 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; document what actions are to be taken; complete actions as soon as possible; develop a written schedule of when these actions are to be completed; communicate the actions to operating, maintenance and other employees whose work assignments are in the process and who may be affected by the recommendations or actions. UNFI failed to evaluate the consequences of failure of engineering and administrative controls for the 2020 PHA and did not complete this evaluation for the 2023 PHA. One finding from the 2020 PHA has a due date of July 31, 2023, UNFI did provide documentation of the action taken. However, this 2020 PHA finding was not included as a repeat finding in the 2023 PHA which occurred before the due date. UNFI failed to address one finding from the 2023 PHA, with a due date of December 13, 2023. Additionally, UNFI failed to provide documentation to confirm that there was communication to affected employees of the 2020 and 2023 PHA findings or corrective actions completed. AOC 3 - 40 C.F.R. 68.69(a) & (c) Operating procedures (a) The owner or operator shall develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process consistent with the process safety information and shall address at least the following elements. (1) Steps for each operating phase: (i) Initial startup; (ii) Normal operations; (iii) Temporary operations; (iv) Emergency shutdown including the conditions under which emergency shutdown is required, and the assignment of shutdown responsibility to qualified operators to ensure that emergency shutdown is executed in a safe and timely manner. (v) Emergency operations; (vi) Normal shutdown; and, (vii) Startup following a turnaround, or after an emergency shutdown. 10 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 (c) The operating procedures shall be reviewed as often as necessary to assure that they reflect current operating practice, including changes that result from changes in process chemicals, technology, and equipment, and changes to stationary sources. The owner or operator shall certify annually that these operating procedures are current and accurate. UNFI failed to assure that operating procedures provide clear instructions and reflect actual site-specific operations. UNFI failed to certify operating procedures for 2021 and 2023. AOC 4 - 40 C.F.R. 68.71(b) Training (b) Refresher training. Refresher training shall be provided at least every three years, and more often if necessary, to each employee involved in operating a process to assure that the employee understands and adheres to the current operating procedures of the process. The owner or operator, in consultation with the employees involved in operating the process, shall determine the appropriate frequency of refresher training. One PHA team member had initial awareness training in 2015 and completed refresher training in July 2023. UNFI failed to provide records for additional refresher training. The employee was missing training records for the period during which they were appointed to be a PHA team member. AOC 5 - 40 C.F.R. 68.73(d)(3) & (e) MI (d) Inspection and testing. (3) The frequency of inspections and tests of process equipment shall be consistent with applicable manufacturers' recommendations and good engineering practices, and more frequently if determined to be necessary by prior operating experience. (e) Equipment deficiencies. The owner or operator shall correct deficiencies in equipment that are outside acceptable limits (defined by the process safety information in 68.65) before further use or in a safe and timely manner when necessary means are taken to assure safe operation. The IIAR standard requires replacement of relief valves every five years. UNFI's Relief Valve Replacement Schedule required the relief valves, installed in 2017, to be replaced in 2022. UNFI failed to complete the relief valve replacements in 2022, which are past due. The installed relief valves lost their accreditation from the manufacturer, and UNFI's refrigeration contractor redesigned the relief system to accommodate a new certified solenoid valve, but the replacements had not been ordered at the time of the inspection. UNFI also failed to provide documentation of the semiannual report for December 2023 at the time of EPA's inspection. AOC 6 - 40 C.F.R. 68.75(c) MOC (c) Employees involved in operating a process and maintenance and contract employees whose job tasks will be affected by a change in the process shall be informed of, and trained in, the change prior to start-up of the process or affected part of the process. UNFI failed to document PSSR/MOC training for the refrigeration system expansion that was associated with the MOC, which should have taken place before operation began in October 11 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 2022. Although Innovative Refrigeration conducted a PSSR review with the UNFI maintenance manager, other UNFI employees who were assigned to conduct visual inspections were not included in the training. Additionally, Innovative Refrigeration did not provide records of the PSSR/MOC training provided to its own contractor employees who were assigned to operate and maintain the system. AOC 7 - 40 C.F.R. 68.75(e) MOC (e) If a change covered by this paragraph results in a change in the operating procedures or practices required by 68.69, such procedures or practices shall be updated accordingly. UNFI failed to include an update to its operating procedures as part of the MOC for the expansion. UNFI also failed to include a description of the online ePSM database software program used to track MOCs in the MOC program document and procedures. AOC 8 - 40 C.F.R. 68.77(b) Pre-startup safety review (b) The pre-startup safety review shall confirm that prior to the introduction of regulated substances to a process: (1) Construction and equipment is in accordance with design specifications; (2) Safety, operating, maintenance, and emergency procedures are in place and are adequate; (3) For new stationary sources, a process hazard analysis has been performed and recommendations have been resolved or implemented before startup; and modified stationary sources meet the requirements contained in management of change, 68.75. (4) Training of each employee involved in operating a process has been completed. In the PSSR program documents and procedures, UNFI failed to include a reference to the use of the online ePSM database tracking program, the date when ammonia was introduced to the covered process when the expansion was completed, and the specific date the expansion began operation. UNFI also failed to document that PSSR training was completed for affected employees prior to operation of the expansion. A 2023 compliance audit finding recommended conducting this training to address the deficiency. AOC 9 - 40 C.F.R. 68.79(d) Compliance Audit (d) The owner or operator shall promptly determine and document an appropriate response to each of the findings of the compliance audit, and document that deficiencies have been corrected. UNFI failed to document the November 2022 audit finding recommendations to address deficiencies had been corrected by the respective due dates noted in the ePSM tracking system. Two (2) actions were still incomplete and past the due dates at the time of EPA's inspection. Twenty (20) other corrective actions were not completed by the assigned due dates. For one audit finding, UNFI failed to document the PSM committee members' attendance at an MOC & PSSR workshop, and the workshop was supposedly held two months past the scheduled due date. UNFI failed to address the compliance audit finding that evaluation of engineering & administrative control failures was not included as part of the 2020 and 2023 PHAs. This is confirmed by the lack of evaluation and findings for hazards addressed by engineering and 12 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 administrative controls listed in the PHAs. UNFI failed to effectively address potential failures by claiming that "in instances where these controls were assumed as failing, they were documented in the scenario description." AOC 10 - 40 C.F.R. 68.81(a) & (e) Incident Investigation (a) The owner or operator shall investigate each incident which resulted in, or could reasonably have resulted in a catastrophic release. (e) The owner or operator shall establish a system to promptly address and resolve the incident report findings and recommendations. Resolutions and corrective actions shall be documented. UNFI failed to follow their written incident investigation procedure by not performing incident investigations for ammonia leaks identified in six (6) work orders in 2023. The investigation procedure states that UNFI will investigate near miss and other release events. UNFI also failed to document quarterly incident investigation follow up review by the PSM committee, as required by the UNFI incident investigation procedure. AOC 11 - 40 C.F.R. 68.83(b) Employee Participation (b) The owner or operator shall 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 this rule. UNFI failed to implement the written employee participation program and policy consistently. PSM committee quarterly meetings specified by the program did not begin until June 2023, according to the meeting records provided to EPA. UNFI also failed to document PSM committee reviews it conducted (or was supposed to conduct) in accordance with the written program. AOC 12 - 40 C.F.R. 68.87(b)(4) Contractors (b)(4) The owner or operator shall develop and implement safe work practices consistent with 68.69(d), to control the entrance, presence, and exit of the contract owner or operator and contract employees in covered process areas. UNFI's contractor safety document fails to specify how contractor access is controlled. The 2022 compliance audit included a finding recommending that a contractor access policy should be developed, and the resolution to this finding was noted as completed March 2023; however, UNFI failed to provide documentation that the policy has been developed or implemented. AOC 13 - 40 C.F.R. 68.93(a), (b), & (c) Emergency Response Coordination Activities (a) Coordination shall occur at least annually, and more frequently if necessary, to address changes: At the stationary source; in the stationary source's emergency response and/or emergency action plan; and/or in the community emergency response plan. (b) Coordination shall include providing to the local emergency planning and response organizations: The stationary source's emergency response plan if one exists; emergency action plan; updated emergency contact information; and other information necessary for developing 13 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 and implementing the local emergency response plan. For responding stationary sources, coordination shall also include consulting with local emergency response officials to establish appropriate schedules and plans for field and tabletop exercises required under 68.96(b). The owner or operator shall request an opportunity to meet with the local emergency planning committee (or equivalent) and/or local fire department as appropriate to review and discuss those materials. (c) The owner or operator shall document coordination with local authorities, including: The names of individuals involved and their contact information (phone number, email address, and organizational affiliations); dates of coordination activities; and nature of coordination activities. Initial emergency response coordination with the fire department under 68.93(a) and (b) should have been completed with one year, by mid-2022, after submission of the initial RMP registration in August 2021. UNFI failed to complete coordination and notification to the local fire department until 2023. AOC 14 - 40 C.F.R. 68.96(a) Emergency Response Exercises (a) Notification exercises. At least once each calendar year, the owner or operator of a stationary source with any Program 2 or Program 3 process shall conduct an exercise of the stationary source's emergency response notification mechanisms required under 68.90(b)(3) or 68.95(a)(1)(i), as appropriate, before December 19, 2024, and annually thereafter...The owner/operator shall maintain a written record of each notification exercise conducted over the last five years. UNFI failed to conduct and document an annual response notification exercise in 2022. AOC 15 - 40 C.F.R. 68.160(b)(6) Registration (b) The registration shall include the following data: (6) The name, title, telephone number, 24hour telephone number, and, as of June 21, 2004, the e-mail address (if an e-mail address exists) of the emergency contact. UNFI's RMP registration failed to include an accurate emergency contact phone number. When contacted during the inspection, the call went straight to a voicemail box that had not been set up, and UNFI personnel confirmed that the phone number was not correct. AOC 16 - 68.195(b) Required corrections (b) Emergency contact information-- Beginning June 21, 2004, within one month of any change in the emergency contact information required under 68.160(b)(6), the owner or operator shall submit a correction of that information. UNFI failed to recognize that the emergency contact phone number in the registration was invalid when the March 4, 2022 registration update was submitted, and failed to correct it within one month. 14 United Natural Foods, Inc. - Lancaster Inspection Dates: December 11-14, 2023 Section IV - FOLLOW UP On December 19, 2023, EPA Region 6 inspectors Aimee Boss and Diana Lundelius held a video conference call with UNFI contractor, Innovative Refrigeration, to discuss their role and responsibilities at the facility. Innovative Refrigeration's Service Manager for UNFI's system and PSM Manager participated on the call. EPA subsequently received additional information from Innovative Refrigeration on December 19, 2023: a Work Order for a recurring ammonia leak in the engine room, the PSSR training conducted for the expansion MOC, and an explanation of the relief valve replacement MOC. EPA also received approximately 109 documents from UNFI after exiting the Facility on December 14, 2023, until January 19, 2024. This additional information was reviewed and considered for issuance of the inspection report. Section V - LIST OF APPENDICES Appendix 1 - Opening and closing conference sign-in sheets. 15 Appendix 1 Opening/Closing Conference Sign-in Sheets