Document mmoJYvNzawXKaw72pQwYE1z5g

ABDOO102670 GUIDANCE FOR IMPLEMENTING PROGRAMS >:. FOR OSHA 29 CFR 1910.119 PROCESS SAFETY MANAGEMENT OF HIGHLY HAZARDOUS CHEMICALS PART TWO PROCESS HAZARD.ANALYSIS X'J- by PrimaTech June 10, 1994 . .. ovc.,0 . , Primatech Inc. ` 445 Hutchinson Avenue, Suite 200 Columbus, Ohio 43235 1' (614) 841-9800 ABDOO102671 GUIDANCE FOR IMPLEMENTING PROGRAMS FOR OSHA PSM PROCESS HAZARD ANALYSIS This document contains information that may assist a company in establishing, or reviewing and updating, the process hazard analysis (PHA) element of their process safety management (PSM) program. The information in this document is based upon the U.S. Occupational Safety and Health Administration's regulation, 29 CFR 1910.119, Process Safety Management of Highly Hazardous Chemicals. However, this information may be of use to anyone developing or updating a PSM program for any purpose. In 1993 the U.S. Department of Labor Occupational Safety and Health Administration (OSHA) commissioned Primatech Inc. to develop a "training material reference manual" related to 1910.119. The purpose of the manual is to provide OSHA's Office of Training and Education with a resource for training federal and state OSHA field officers on enforcing the PSM regulation. The training material reference manual features an annotated form of the Program-QualityVerification (PQV) inspection checklist originally presented in Appendix A of OSHA Instruction CPL 2-2.45A. Example programs are provided to illustrate the positive and negative indicators of the checklist questions. OSHA has agreed to allow Primatech to make this information available to interested parties. This should in no way be construed as acceptance by OSHA of the suitability of the information or examples provided herein. The format of this document follows the PQV inspection checklist presented in Appendix A of OSHA Instruction CPL 2-2.45A, often referred to as the "compliance directive". For each question in the PQV inspection checklist, clarification is provided on the checklist item along with positive program indicators and negative program indicators for each question. The positive and negative program indicators are intended to provide ideas for the user to help them in assessing their existing or planned program. The example programs provided in this document illustrate approaches taken by companies seeking to address the requirements of 1910.119. These examples have not been reviewed and/or endorsed by OSHA and should not be construed as model programs. The example programs provided herein were developed for specific processes, and are not generic in nature. Since the OSHA PSM regulation is performance-based, readers are strongly encouraged to develop programs tailored to their own covered processes. 1 ABDOO102672 This document is offered for the user's general guidance only. This document does not attempt to provide any interpretation of the OSHA regulations. Primatech makes no claims regarding the acceptability to OSHA of the information contained herein to OSHA. Consequently, Primatech can accept no liability for any use which the user may make of the information contained herein. Note that the information contained in this manual does not necessarily represent the opinion of Primatech. ABD00102673 OVERVIEW This guidance document is arranged in a tabular format. The following is a description of each of the column headings used in the table: PQV Question The PQV question is derived from the checklist in Appendix A of the OSHA Compliance Directive (CPL 2-2.45A), which is based on the specific regulatory requirements for the element. Note that the verification portion of the checklist includes questions for records review, on-site conditions, and interviews. In order to avoid unnecessary duplication of information, this guidance document references the checklist questions from the records review section only. Specific questions or concerns from the on-site conditions and interviews sections that are not addressed in the records review section are accounted for in the positive and/or negative program indicators column. Explanation The explanation clarifies or provides additional insight into the PQV question. In some cases, the explanation provides an interpretation of the PSM requirement. In no cases should the information contained in this column be viewed as a substitute for the actual regulatory requirement. Positive Program Indicators The information included in the positive program indicators column is intended to provide guidance and examples on what to look for in a well developed program. This column also includes guidance on what to look for when evaluating PSM programs. This column is not intended to contain all conceivable attributes of a good program for all industry types. Rather, it is intended to provide suggestions and ideas on what a good program might include. 3 ABDOO102674 Negative Program Indicators The information in the negative program indicators column is intended to provide guidance on possible signs of a poor or incomplete program. This information could be of assistance for identifying potential problem areas when conducting PSM program evaluations. A PSM program that contains one or more of these attributes does not necessarily constitute a poor program. Rather, this information is intended to serve as a guide on what to look for in a less developed program. It is important for the user of this manual to understand that over 25,000 employers may be covered under the PSM standard. Covered facilities range from large complex chemical, petrochemical, or petroleum facilities, to relatively simple ammonia refrigeration or chlorination systems. This guidance document cannot cover all of the possible ranges regarding the content of PSM program elements in the various industry groups. Additionally, since the PSM standard is a performance based regulation, this guidance document can not addresp the specific approaches different companies or facilities may choose to implement in complying with the requirements. In addition to the table, this guidance document contains several helpful appendices, including: Appendix A - List of Acronyms Contains description of key acronyms used in the guidance document. Appendix B - Glossary of Terms Contains definitions of key terms used in the guidance document. Appendix C - Technical References Contains a list of helpful technical references to support the information presented in the table. 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IBi a. o 0 "O 0 0 . ss c *2i Q." = "0D E O Q. $5 a'JS a. 5* sA E0 9 co I i ^ 51^ 2 cf , 1 = -2* `T2) <nw. ^tc0ois*7 '5 o- 550!Bl s| 2 g 51s o. -o C -i 0 g _ a - a il c 5 g i g 1 E3 o0 S -O g O) 9 0 *o 0 I I I i I \ m 1 i I i ABDOO102689 APPENDIX A List of Acronyms 19 ABDOO102690 LIST OF ACRONYMS AlChE * American Institute of Chemical Engineers ANSI * American National Standards Institute API * American Petroleum Institute ASHRAE * American Society of Heating, Refrigeration and Air-Conditioning Engineers ASME * American Society of Mechanical Engineers ASTM American Society for Testing and Material AWS * American Welding Society BFD Block Flow Diagram CCPS * Center for Chemical Process Safety ( CGA * Compressed Gas Association CMA * Chemical Manufacturers Association DIERS Design Institute for Emergency Relief Systems EPA Environmental Protection Agency FEMA Federal Emergency Management Agency FMEA Failure Mode and Effects Analysis FTA Fault Tree Analysis HA20P Hazard and Operability Study HHC Highly Hazardous Chemical IDLH Immediately Dangerous to Life and Health MAR * International Institute of Ammonia Refrigeration 20 ABDOO102691 ISA LC LD MSDS NFPA * OSHA P&ID PEL PFD PHA PSM PQV SOCMA SOP STEL Instrument Society of America Lethal Concentration Lethal Dose Material Safety Data Sheet National Fire Protection Association Occupational Safety and Health Administration Piping and Instrument Diagram Permissible Exposure Limit Process Flow Diagram Process Hazard Analysis Process Safety Management Program-Quality-Verification Synthetic Organic Chemical Manufacturers Association Standard Operating Procedure Short Term Exposure Limit * Mailing address and telephone numbers included ABDOO102692 Referenced Agency Addresses and Phone Numbers AlChE American Institute of Chemical Engineers 345 East 47th Street New York, New York 10017 Phone: 212-705-7338 ANSI American National Standards Institute 11 West 42nd Street New York, New York 10036 Phone: 212-642-4900 ASHRAE American Society of Heating, Refrigerating and Air-Conditioning Engineers 1791 Tullie Circle, N.E. Atlanta, Georgia 30329 Phone: 404-636-8400 ASME American Society of Mechanical Engineers 22 Law Drive P. O. Box 2300 Fairfield, New Jersey 07C'7-2300 Phone: 800-843-2763 AWS American Welding Society 550 N.W. LeJeune Roac' Miami, Florida 33126 Phone: 800-443-9353 CCPS Center for Chemical Process Safer.* of the AlChE 345 East 47th Street New York, New York 10017 Phone: 212-705-7319 22 ABDOO102693 Referenced Agency Addresses and Phone Numbers (Continued) CGA Compressed Gas Association 1725 Jefferson Davis Highway, Suite 1004 Arlington, Virginia 22202 Phone: 703-412-0900 CMA Chemical Manufacturers Association 2501 M Street, N.W. Washington, D.C. 20037 Phone: 202-887-1100 MAR International Institute of Ammonia Refrigeration 1101 Connecticut Avenue, N.W., Suite 700 Washington, D.C. 20036 Phone: 202-857-1110 ISA Instrument Society of America 67 Alexander Drive P.O. Box 12277 Research Triangle Park, North Carolina 27709 Phone: 919-549-8411 NFPA National Fire Protection Association 1 Batterymarch Park Quincy, Massachusetts 02169 Phone: 800-344-3555 23 ABDOO102694 \ GLOSSARY OF TERMS BLOCK FLOW DIAGRAM or BFD1 A diagram used to show the major process equipment and interconnecting process flow lines as well as flow rates, stream composition, temperatures, and pressures. The BFD is intended as a simplified diagram. CHECKLIST2 Detailed list of desired system attributes or steps for a system or operator to perform. Usually written from experience and used to assess the acceptability or status of the system or operation compared to established norms. CONSEQUENCE2 The direct, undesirable result of an accident sequence usually involving a fire, explosion, or release of toxic material. Consequence descriptions may be qualitative or quantitative estimates of the effects of an accident in terms of factors such as health impacts, economic loss, and environmental damage. DECISION TREES4 Decision trees are a special case of event tree models used to guide the user through multiple questions and provide a course of action based on the outcome of all of the questions. They provide no logical method of choosing the initiating event. ELECTRICAL ONE-LINE DIAGRAM1 A diagram including legend of the electrical power distribution system that could contribute to a highly hazardous chemical release showing such items as power consumers, the chain of supply back through starters, distribution centers, substations to the main feeder, emergency power supply, and connections to various components. For complex systems, the one-line diagram may be a group of drawings. FACILITY3 The buildings, containers and equipment that could reasonably participate in a catastrophic release as a result of being physically interconnected or of their proximity and in which dangerous substances are used, stored, manufactured, handled, or moved. 25 FAILURE MODE AND EFFECTS ANALYSIS or FMEA1 A specifically designed method to identify the conceivable ways that a highly hazardous chemical equipment or its components can fail and the effect of the failure on the system with respect to a release. The failure and effects are determined in a study of updated piping and instrument diagrams that describe the facility taking into consideration process chemistry, standard operating procedures, maintenance procedures, operator job descriptions, process flow diagrams, inventory tabulations, electrical one-line diagrams and other documents. The resulting qualitative analysis is translated into a quantitative FMEA when probabilities of the failure of components are assigned. The results of the FMEA are reported for a unit or system of a facility on an FMEA table. The results are entered on a FMEA table for each equipment item or component studied are as follows: the identification number of the item, the name of the item, the other equipment potentially affected with the equipment identification number and the effect of the failure on that equipment, a classification of the criticality ranking of the failure based on quantity or rate of the potential release, the probability of the failure and the suggested action in terms of equipment or procedure to prevent the failure or to mitigate the results of the failure. FAULT TREE ANALYSIS or FTA1 The analysis of the logic diagram constructed from a study of the updated piping and instrument diagrams that describe the facility taking into consideration process chemistry, standard operating procedures, maintenance procedures, operator job descriptions, process flow diagrams, inventory tabulations, electrical one-line diagrams and other documents. The logic diagram is called a fault tree and represents a qualitative analysis of the hazards. Results of the FTA are reported for a unit or system on a table. Entered on the table are the descriptions of the various combinations of equipment or procedural failures that can lead to a release. The combinations are determined by solving the fault tree logic diagram for the minimal cut sets, that is, the smallest combination of equipment or procedural failures, which if all occur, will result in the "top event", that is the highly hazardous chemical release. The table is also entered with a criticality ranking based on the quantity or rate of the potential release, a probability for the respective failures and the suggested action in terms of equipment or procedure to prevent the failure or to mitigate the results of the failure. The analysis of the logic diagram includes the identification of "minimal cut sets." When probabilities are assigned to each element of the event sequence, a qualitative fault tree is obtained which gives the probability or frequency of occurrence of the release. HAZARD2 An inherent physical or chemical characteristic that has the potential for causing harm to people, property, or the environment. 26 ABDOO102696 HAZARD ANALYSIS1 A systematic identification of the potential conditions that may result in an EHS accident. HAZARD AND OPERABILITY STUDY or HAZOP1 A systematic study of updating piping and instrument diagrams that describe the highly hazardous chemical facility taking into consideration process chemistry, standard operating procedures, maintenance procedures, operator job descriptions, process flow diagrams, chemical inventory tabulations, electrical oneline diagrams and other documents. The study is performed by a multidisciplinary team to identify hazard or operability problems that would result in a highly hazardous chemical accident. Deviations from the design value of key parameters (flow, temperature, composition, time, quantity, etc.) of each segment of the highly hazardous chemical facility and its procedures are studied using guide words (such as, more of, less of, none of, part of, more than and other) to control the examination and evaluation. The study team shall consist of trained personnel knowledgeable in the technology and operations, such as process chemistry, the design of the system, the procedures of its operation and maintenance, and the related codes, standards and practices. In addition, the study team shall have technical expertise to answer most questions of the review without resorting to further expertise. The study team shall include a study leader specifically qualified for his or her leadership role by training or previous experience in HAZOP studies and a team secretary who shall record the results of the study. Persons who occupy these team study positions shall be technically trained and be available for the duration of the study. Results of the HAZOP study shall be reported by tabulation for a unit by key equipment, such as vessels or pipelines, and process parameter. The results are entered on the table as follows: guide word, causes of the deviation, consequences of the deviation in terms of a potential release, the criticality based on the quantity or rate of potential release and the suggested action in terms of equipment or procedure to mitigate the deviation. HIGHLY HAZARDOUS CHEMICAL or HHC3 A substance possessing toxic, reactive, flammable, or explosive properties. HUMAN ERROR2 Actions by or failures to act on the part of designers, operators, managers, or other individuals that may contribute to or result in accidents. MATERIAL SAFETY DATA SHEET or MSDS1 27 ABDOO102697 A document which describes, at a minimum, the chemical and physical properties and the physical and health hazards of a substance. 28 ABDOO102698 MODIFICATION1 Any change in existing equipment or procedures that would require a change in process safety information and/or operating procedures. Modification does not include routine maintenance or replacement in kind. OPERATOR2 An individual responsible for monitoring, controlling, and performing other tasks as necessary to accomplish the productive activities of a system. Often used in a generic sense to include people who perform various tasks (e.g.; reading, calibration, maintenance). PIPING AND INSTRUMENT DIAGRAM or P&ID1 One or more detailed drawings including legends and citations of referenced documents showing: every item of highly hazardous chemical equipment and its identification number (including installed spare equipment); every pipe size, flow direction, identification number and identification of ANSI piping specification and break between piping specifications; symbols and identification of every instrument including instrument function to show trips and interlocks represented in accordance with Instrument Society of America standards or a standard adequate for the conduct of a safety review or hazard analysis with an appropriate symbol legend shown, every valve, the failsafe position of control valves or non-hand operated valves in the case of instrument air or power failure; steam traps; representation of insulation or heat tracing of piping, highly hazardous chemical equipment and instruments; sizes of all important equipment nozzles with location shown schematically to reflect function and elevation, such as, drains, vents, flushing connections and steam connections; references to inter-facing with other diagrams describing process, service, treatment, disposal, or utility systems; data on type, size, and set pressures of every relief valve and relieving device; instruments to monitor early detection of abnormal conditions or a highly hazardous chemical release; where critical, the relative elevations between equipment and of key piping; notes or symbols on such items as slope of critical piping to avoid pockets, or, where critical symmetrical piping; notes on each item of highly hazardous chemical equipment, such as. material of construction, design temperature, design pressure, design thermal duty of heat exchangers, design capacity and dynamic head of rotating equipment, etc. PRELIMINARY HAZARD ANALYSIS2 A technique that is derived from the U.S. Military Standard System Safety Program Requirements. Focuses in a general way on the hazardous materials and major process areas of a plant, and is often used as a precursor to further hazard analyses. 29 ABDOO102699 PROCESS CHEMISTRY1 The chemical reactions which are relevant to possible scenarios of highly hazardous chemical releases, including information on raw materials, intermediates, products, and waste products. PROCESS FLOW DIAGRAM or PFD1 A diagram including a legend of a facility which depicts the use, generation, storage or handling of a highly hazardous chemical showing items of equipment (groups of duplicate equipment may be represented by one symbol if desired), flow of material from item to item, simplified basic control loops or major control schemes, points of discharge to the environment, and showing or crossreferencing documents which give details of material balance, flows, raw materials, products, intermediates, treatment chemicals, operating conditions of temperature, pressure and steam characteristics, operating cycles and batch sizes where applicable. A process flow diagram includes, or references, a block flow diagram that depicts the receipt, handling and storage steps at the site of shipping containers of the highly hazardous chemical. PROCESS SAFETY MANAGEMENT2 The application of management systems to the identification, understanding, and control of process hazards to prevent process-related incidents and injuries. REPLACEMENT IN KIND1 The replacement of existing highly hazardous chemical equipment with identical or equivalent highly hazardous chemical equipment, and installation according to criteria for design and operation. RISK2 Combination of the expected frequency (events/year) and the consequence (effects/event) of a single accident or a group of accidents. STANDARD OPERATING PROCEDURE1 The document setting forth the operating procedures covering all details of the operation involving highly hazardous materials that are currently in effect at the facility. TRUTH TABLES4 i i i 30 A listing of all combinations of the states of basic events, the resulting occurrence or non-occurrence of a top event, and the corresponding probabilities for the combinations. 31 ABDOO102701 WHAT-IF CHECKLIST1 A method of hazard analysis based on a systematic study of updated piping and instrument diagrams that describe the highly hazardous chemical facility taking into consideration process chemistry, standard operating procedures, maintenance procedures, operator job descriptions, process flow diagrams, inventory tabulations, electrical one-line diagrams and other documents. The study is performed by a multidisciplinary team to identify hazards or operability problems that could result in a highly hazardous chemical accident. The study is composed of a comprehensive list of questions prepared in advance from study of documents by team members either in conference or independently usually corresponding to their individual background. The study team shall consist of trained personnel knowledgeable in the technology and operations, such as process chemistry, the design of the equipment, the procedures of operation and maintenance and the related criteria for design and operation. In addition they shall have technical expertise to answer most of the questions of the review without recourse to further expertise. The team shall include a person assigned to lead the study and a person to record the results who are technically trained and will be available for the duration of the study. Results of the study shall be reported for a unit on a table. The results are entered on the table as follows: the "what if question and its corresponding consequence/hazard, the criticality based on the quantity or rate of the potential release and the recommended acticr. in terms of equipment or procedure to mitigate the consequence/hazard. 1. New Jersey Toxic Catastrophe Prevention Act, N.J.A.C. 7:31, New Jersey Department of Environmental Protection and Energy, June 18, 1993. 2. Guidelines for Hazard Evaluation Procedures. 2nd. ed., Center for Chemical Process Safety of the American Institute of Chemica Engineers, 1992. 3. Process Safety Management of Highly Hazardous Chemicals, 29 CFR Part 1910.119, Occupational Safety and Health Administration, February 24, 1992. 4. Reliability Engineering and Risk Assessment. Ernest J. Henley and Hiromitsu Kumamoto, Princeton-Hall, Inc., 1981. 32 ABDOO102702 APPENDIX C Technical References 33 ABDOO102703 GENERAL REFERENCES Ammonia Plant Safety fand related facilities^ vol. 23, American Institute of Chemical Engineers, 1981. Ammonia Plant Safety fand related facilities). vol. 24, American Institute of Chemical Engineers, 1984. Ammonia Plant Safety fand related facilities), vol. 27, American Institute of Chemical Engineers, 1987. Ammonia Plant Safety fand related facilities), vol. 28, American Institute of Chemical Engineers, 1988. Ammonia Plant Safety fand related facilities!. vol. 31, American Institute of Chemical Engineers, 1988. "Guidelines for Safe Automation of Chemical Processes," American Institute of Chemical Engineers, 220p. "Guidelines for Investigating Chemical Process Incidents," American Institute of Chemical Engineers, 347p. "Guidelines for Auditing Process Safety Management Systems," American Institute of Chemical Engineers, 136p. "Management of Process Hazards," American Petroleum Institute, Recommended Practice 750. "Process Safety Management (Control of Acute Hazards)," CMA. Chemical Manufacturers Association (CMA's Manager Guide), First Edition, September 1991. "The Revised Field Operations Manual (FOM)," OSHA Instruction CPL 2.54B, June 15, 1989. "State Plan Policies and Procedures Manual," OSHA Instructions STP 2.22A, Ch-2, January 29, 1990. "Integrated Management Information Systems (IMIS) Forms Manual, Chapter V " OSHA Instruction ADM 1-1.12B, December 29, 1989. 34 ABDOO102704 "Systems Safety Evaluation of Operations with Catastrophic Potential," OSHA Instruction CPL 2-2.45, September 6, 1988. "Process Safety Management Guidelines for Compliance," OSHA 3133; U.S. DOL, 1992. "Process Safety Management," OSHA 3132; U.S. DOL, 1992. "Safety and Health Program Management Guidelines," U.S. DOL, 1989. "Review of Emergency Systems," June 1988; U.S. EPA, Office of Solid Waste and Emergency Response, Washington DC 20480. "Chemical Exposure Index," Dow Chemical Co., May 1988. "Accident Investigation * * * A New Approach," National Safety Council, 1983. Process Safety Management Resources from the American Institute of Chemical Engineers for Use by Industrial Hygienists. James A. Gideon and Thomas W. Carmody, American Industrial Hygiene Association Journal (53), June 1992. "Improving Construction Safety Performance," Report A-3, The Business Roundtable. "Recommended Guidelines for Contractor Safety and Health," Texas Chemical Council. "Loss Prevention in the Process Industries," Volumes I and II, Frank P. Lees, Butterworth, 1983. Guidelines for Engineering Design for Process Safety," 500p. ABDOO102705 1 APPENDIX D I Example Programs I I I The following examples illustrate approaches taken by companies seeking to address the l Process Hazard Analysis requirements of 29 CFR 1910.119. These exa-oles have not been reviewed and/or endorsed by OSHA and should not be construed as model I programs. Primatech makes no claims regarding the acceptability to OSHA of the | information contained herein. j The example programs provided herein were developed for specific processes, and are not generic in nature. Since the OSHA PSM regulation is performance-based, readers I are strongly encouraged to develop programs tailored to their own covered processes. CONTENTS D-1 HAZOP analysis - sulfur recovery unit D-2 What-if analysis - ammonia refrigeration system D-3 HAZOP analysis - ammonia refrigeration system D-4 Risk ranking system - process hazard analysis 36 ABDOO102706 D-1 Process Hazard Analysis A Hazard and Operability (HAZOP) study was performed for a sulfur recovery unit, which is generally found in a petroleum refinery. The following is a portion of the worksheets, specifically the sulfur converter and condensers. The worksheets identify the causes and consequences of potential deviations in the system. Safeguards are then recognized, which may prevent the scenario from occurring or mitigate the consequences, should the i scenario actually occur. Where a potential need for improvement was noted, a recommendation was made. 37 ABDOO102707 / c g. --o V*> eg o -- gg gg gggg a. a. sl a. v a> <y> ' oa.uc uc at vi u n VI 111 VI VI O O O 4>c c ti V X * U U W 4. I- u u O. r o. a a. o. a. o c c -- *- COQ -- Xt*uo "D Cl a~> --u ue O O l~ l_ -- ^n x >- a. U L VI L. C A> O -- O <- C ~ ~ i_ !/i a> x T5 *-- *8 S e s s io n 1 . SRU ABDOO102708 I 1 I I 1 I I ABDOO102709 -- 00 *8? Z O. *8 >0 <-* w ce - C C 3 >. Vu b0 t>i Co "I w n s C-- -- o* 3 a o u o m 5 3 -- - "7 1/1 - -- b c i u Q -- 5*82 15 b0 0 b M C w w O tl Ob. tn O00O g|g-3* b0--^C00C --** b> --EOb Sb "D -- C 0)0 b -- b b -- 00003--_0 tm It gr *8 & OC-- 03000 b) -- fi. C u in m C W o 0 o e 0 >s "0 1 %K 5 Ob > 0 <* K - > 0 S- iI * g2 CwC 0y0g O 0O0 O. b o. T3 2* g --co b w b O b> 0 3 --- L. 00 c00 0 c s ? oC O a. w b) Vb O o -> C l 12 5 g = a >--4- --0 o0u --b 0 _C 00 0 0 0 -> 0)0 O W r*g g Z 0-- 0 0 V) 0o g 00 TJ b co ^M < c 0-* O O. -- Cb --3 0b "I b3 0 --"3 ---- b V) 2O cO *0 itZ 122 Wb 0 --O 0> g b--U Dl C 'c --O CO --0 * -- 0 CW c0 - ou w0 og a. N n n u3 e ll _j i-- tz g S S2 v-- c o --rg *3- k -- 0> 3 S. C f (t>A 3CO --3 >owft) ec --tc> ft) ft) ft) DEVIATION CAUSES CONSEQUENCES SAFEGUARDS P o te n tia l equipment damage; , N itro g e n s ta tio n in area P o te n tia l release end hoses a v a ila b le to o f a c id gas to in e rt the reaction atmosphere; P otential explosive atmosphere 3. Loss of a u x ilia ry burner flame 1 P o te n tia l runaway Five tem perature re a c tio n ; in d ic a to rs on S u lfu r P o te n tia l c a ta ly s t Converter (Bed 1) damage O1 perator tra in in g P o te n tia l equipment damage; N itro g e n s ta tio n in area P o te n tia l release and hoses a v a ila b le to o f a c id gas to in e rt the reaction atmosphere; P otential explosive atmosphere 4. C atalyst fo u lin g 5. Lower in le t tem perature O p e ra b ility issue O p e ra b ility issue 3O 3o 2! ft) I at OaD>i (A Oo<o X ft) of f i aUc1 A S <o X III FI : See above recommendation for installing permanent n itro g e n connections on S u lfu r Converter to elim inste the need fo r use o f temporary hoses : No recommendations : See above recommendat ion for in sta llin g permanent n itro g e n connections on S u lfu r Converter to elim inate the need fo r use o f temporary hoses z a. - K1 ABD00102710 k i k I k k > k k k k k k k Session: 1 09-21-93 R e v is io n : 0 - - Dwg#: PAID 93-001 Node: 2 Line from S u lfu r Converter (Bed 1) to S u lfu r Condenser Param eter: Flow In te n tio n : To tra n s fe r a c id gas flo w from S u lfu r C onverter to S u lfu r Condenser. DEVIATION CAUSES CONSEQUENCES SAFEGUARDS No Flow 1. L in e becomes blocked i P o te n tia l release Alarms on high pressure o f a c id gas to In re a ctio n furnace fla re ; O perability issue High-high pressure alarm a c tiv a te s shutdown o f P o te n tia l to blow SRU. seal leg; P o te n tia l release Operator tra in in g o f a c id gas and s u lfu r to Area H2S m onitors ! atmosphere; P otential P lant wide emergency explosive response and evacuation atmosphere procedures F ire m onitors are present throughout the u n it A ppropriate response equipm ent, PPE end response teams are present o n -s ite on a 24 hour basis 2 . Emergency valve in a d v e rte n tly a c tiv a te s P otential release o f a c id gas to fla r e ; O p e ra b il1ty issue 3. Loss of flow lO p e ra b ility issue from upstream 4. Line rupture P otential release o f a c id gas to atmosphere; P otential explosive atmosphere Line in sp e ctio n program w ith frequency of inspection determined by c a lc u la te d and observed corrosion rates Area H2S m o n lto rs P lant wide emergency response and evacuation procedures F ire m onitors are present throughout the u n it <sn o1 .X. UU> -a- o0 X UUl oc r CA 1B N *- i *8 i a. RECOMMENDATIONS 1st , I ABD00102711 ABD00102712 Mode: Page: M& Vti) h--Xo au O - -- CO 1CV3D 3M_ non ~C --a *c* --B c Co --0o1> UQD .--E0B.00Ca1. lCuii Xu9 <SQ.C3c OVk.I kai.O3 oi VD k>. c l_ -- 01 0.- E O k. O --C0 o> B*c* TC? --c01 -- c *o b a U tl_____L 8.&SS c 01 V -- w o C k. ** B -- -- -- U -- (A c Q8. 3w Oo C ~ oi --- u -- --COO _J X -- o o (A CB --01 U >. C o-- - -- C01*031 -- O 5 S. 2 O k. 01 -- oo> k B CB >C 3 2 *5.3 z *5. C O oi c O (A c a g *J ^ 0o. --O *Q* Q&. x8 *O> co >(CJ--O3~ COk.I OS> Et II C 8 01 V >8* -8U --bCO kQoci. OOua coi cfc --fc< Sck. cS (A o --*C* ~3O n k. UOa_..I d8~o8 ow B B --~B(aOk-.. .W--06-CC. CoaO(A OC--CcCka.D--n(OuOA O.- L*. <01f\J C O. c X *> o_ _ --o - N u. C0^8 0k.0C oi a o - Vo>*i ioEO_ Cctl a. -- --s cc OI -- Company: Jones R e fin e ry F a c ility : S u lfu r R ecovery U n it uc >a- o0 1< a. aaUtl v> * 3o co --*>. eove fM psi U >. >. COL a. u 8 Ui ot ec Vt DEVIATION ; CAUSES CONSEQUENCES SAFEGUARDS Higher 1. Tubes fo u lin g O utlet in Sul fu r Temperature Condenser P otential in a b ility to condense a ll the elemental s u lfu r; O p e ra b ility issue Temperature In d ic a to r indicates condenser o u tle t temperature Operator tra in in g 2. Loss of b o ile r P o te n tia l Lou le v e l s o ft alarm to feed water equipment damage; board P o te n tia l release o f a c id gas to Emergency v a lv e a c tiv a te s fla r e ; O p e ra b ility on tou-low level issue In d ic a tio n ABD00102713 3. High in le t tenpoi ature P otential in a b ility to condense a ll the elemental s u lfu r; O p e ra b il1ty issue Temperature in d ic a to r indicates condenser o u tle t temperature Tenperature in d ic a to r indicates condenser in le t tenperature Operator tra in in g Lower O utlet Temperature No s ig n ific a n t hazards or lo p e ra b illty issues l I t V V I I P * P P P f ABD00102714 -- 41 t) g ii ( 41 > --aC. aOo z. a--3 eM$t >. >. ca --a C 4) a s* I a 4i t-g. vt tn ooS aIa C3 4ea1i (a>j a 4t lg 4) (9 (A TJ 41 ?| ca m -- 41 l. a g5 -c *? 41 O C *D 4> C 5a. Ca aL. O (A 4) 4a> UaaJ. ea --*w-> a a a >v c IA aa o-- -- ca His* L ^ (A L &&a Sa q.g -- i_ Mc> ga --O (VaM -- L. a CL O o-- s.= 01 a a * 'g --c U (A e a4. oa (A ^ L. aa ? II 2 Ufa 8 ac U g < 25 g-8 (aA a3 af a ca --4* f5 "is --u *D a a -- oi a -- a a C3 aa> a - gr gz2-g.z ca --astAa^cauaMocao--iAo aO3&oCSaoaaE Oa xQ.a6 a a a u a. o c a. a a o O) o g* >- a oe C3 t% va e tt "D 3 v? aa -- at -- & a Q. u. a ABD00102715 i j -- 41 0 *8 t* II ** CO --CB 41 c j? & o> w D 4* U O u Q..C g -- 41 *> tn u 8L5 *8 *2 .S S u8 ? I E*3 o O O U . ** 2X U K U S IA (A 0 4> W UO -*S gz u E 41 1 U O + -- K JB S Jf --OO0 si 41 cam 4* U C "O u 12L 5> C-- 0 fl "0O .Ug sit o0i --*> Ua ao S 3-8 0D a.'S fw D> 0 *s 3 -- U Of X 0 V> Q 0 ** C "g is g0 0u 00 i* <A M 18 01 0 u0 > 0 V) 3-- 0 cf * 8.28 a u o. M0 k. a~ c * IA u~ o V th. ~ 1*8 g 0a. o 0 gr m C0 --w 00 41 > --C UO 2S 5u r"v --Du3 -- (A OO- ID/) u >> >> nc0 --- C e> u VbJVV VV^V ~ 2r st2*s.z *s. w 3 C ~ g E0C--Q./330C0 UoWo C0 O-- 0o 00'000*"^OK"> a. 0 +* o a a. 0 0 01 Irt ^ I I I ABD00102716 K>^ -- gV.. .to).> x oa ut> ae a. -- V) c n *> <n c(OB -- >- O-- --mc01*ba0 ~Xba o 3 2L --M 3b- U3u > --3 M(A O (A l - m ab c b .2 "8 2 ABD00102717 D-2 What-if Analysis - Ammonia Refrigeration System A What-if analysis was conducted for an ammonia refrigeration facility. The following is .a portion of the worksheets, specifically the ultra low vessel. The worksheets identify potential hazards and consequences of a system as well as recognize current safeguards in place to reduce the risk or likelihood of an incident. Recommendations were made where there was a potential need for improvements. 36 j V 41 fti c s u Q L. ft. U. -- KOOtu g 2! c c -- - *ao "<oc ae. x> xu iu> o- *O1 1OkHk j- CO (M oo- o e k. au +* +* u w tti- ~C avauux^-xuo^ ................................................ Session 1 f o r SAMPLE Conpany: S m ith 's Company L o c a tio n : P rin c e to n , NJ F a c ilit y : Anvnonia R e frig e ra tio n System Conrnents ABD00102718 + Company: S m ith 's Conpany F a c ilit y : Anrnonla R e frig e ra tio n System System: Page: ABD00102719 hj I a - -- . *a cn ----- > a> a ijfi 38 m a--^ 3 o at l. Ca >. D i- _P~_ T, a -- -- ~ o o r ii o a a6 a a o-- ~a.i_enasi~o> w3 Qo .ae--ooo.o--a xa--o s 5 K) g > V> t) >. QC I/I SI a 01 ee > oQ.- --Ce 43o rsi o sl| - - S S1 >i>. >. (0ft) t/> i c *51 aa .a* aa a-- 8 cc ao -8 II a-- o b. % (. Ol oc "a "a -a g 6 > C6 'iOOi --v 8 r w au 4 wa _ a-- c a w a o.-- t 3 u -- --+c* oiai. ** a Co aat.* >a a-- w t u at. +* ua a> a _ 3J aw _ -- --c *U a --c c5 a a oi a 5 a a (A c n IM "is ---- o aw --a c *c c c 'o 8. a* aa aa a-- XE a ow >a -- o a 5M- 3> Cao -- a-- a-- i- > a NO3 i i i i i i - I0 a i i i i ABDOO102720 i i co "O 0 i m -- 4ml > in -- L. 90U --9-1 in e i 1 &- ---- 0 0 in 3 > A _O* T0J 0> ? ^ ** i o 00 3 -E WO --C C C _oJ OU - -- rvj X-- i > > > E b O ~ 0 0--0 >> --0 --o fSi. iM0n - CD 3 III 2II- i /> (nx/> >n. XO c0 ---- 0k i 1 *9 0 --- L. 9oU --*9-* in c >a 0 O-- -- -- .0 0 in 3>m -oj "0D 0> > _Sl '--" lu >- 0 o o O --0 c 0.^..2 ~7 k ME: O e 0 --9 -- K0 (Q_. 0 M0 -- o0 Sl 0 k -- b. ^ lb W b 0W -- CO><A -- >T UO sw- --0 --c u0 ABDOO102721 System: Page: Company: S m ith 's Company F a c ilit y : Anmonla R e frig e ra tio n System Ii * > Vi J|| m nm ca >. > v> 3- t: nr l. a u oeo *D in <s ca t> * L. *D fc. gl (A ill v> 3* --&> --c * *-- f > <A D) > V) -- 0> 41 t I I I I f I t ABDOO102722 *IW> &&B l >-- o a - o 3 a w u --- "o e >* o Q.-- --_aa u h- > c u e a ooO oQL.. o---- e_t_> wOa ^--gw ^ it >.o'B5`g.8gJ O a -- --> o a o o a a-- M --a . a i5 SS.2-- a s w w oaw w w ot- > a > w a-- o w> --v a- -- X 23 SO 8 "D I ^O t>t --X 4X* --L ^3 -3 -- "oD --c >, uj J? aw to w a al. > a W o -- 8/ a-- a-- a L. O 5 ' a a. r --o ao 8-fi i u a-- a o *a- Xa Xa '5 3 & w oaw ---- *o-a06a 0a waw * -- w ^ w oca a B a^ U rhl -- a 5 o5 v> > u u o ~Cw --ain w--w w o-- x w aO c ~o a 3a w a >* > --* a-- a >> w o -- 5-- a--^ aau a a .* o. a a ow c5 >o --3 --o c .2 f M It --a 3a o o -- 3 2c a-- --a --oQ. --a x aw o> w -- aa * "O > --a 3O w ac a-- a a ao -- -ac--awa n> w --= a a> o.- --o ao to c IV O - <- 3 -- ag> g WWW IWO (>/. > CE *2 o a w>. w > a> oa sis 2 w= wwaatu aa3wwa&a to I -> ABDOO102723 System: Page: o <0 Ol 01 O>l 01 o (R --> au n ii n n ._D ou ro "D " 8 3*8 S L 3 (lw frit* ubecr-a.kb.M -- ~0>UOC3UC3L. -- 0.800.0-- OCB 3 o Q. -- o >4- e u a > sea a. u 3 -- 0 a +c* mo01 --*> > o Era l. Si u >c0> o8OoW8. VI S 01 twt w0-8oc > 3 .O 8CJ CO aJ O* E al. o<M % It a w (A >. > VMM V) 3o >e --> u a -o *u- --3 --3 Ou t> -- Cl O > C -- LC -- 0-s) oX_T3I --3O TT3W) a0ou)> v. w a f V> C L. > o Or O ~ O (A U > -- l_ -- CL w 3 Q_3 > O ** i 3 -- M CD 40 > a. ~ o> -- c u e> o. > o > I *> "5 o w 3a 0 Cl Ol <A m --' a - 3 -- 41 5 a- It D l o mo l. -oo a b Lu O a*c-. c 3 5 a>o>.--c E Wc Co. Co>i -- L. a e 01 * C (A C -C CA 4- O) 01 eO. --.c Ja. Conpany: S m ith 's Coapany F a c ilit y : Anvnonie R e frig e ra tio n System ABDOO102724 System: page: * > V 4-> nu aL.t*c-' o t> * t> ai Lui/iunXagi u n _ 4>0CCCC.0~0 >vtfc.*aoao 'v.c. -- TJ a C -- e -- p ~ 9 --< cn itbvig^ei.oi at . - o -- ru &o L2..2Of o>MC(-Cc-e<^u co-- a***o>>o ---- --oGggo.SeQo.oo--ouo. $ _ te. V t 2 c9- --"O -- ent u3o kt i_ -- O..C c uuO > | 0 30 -- t > CD V > K (A t 0> V o* --o xo CrvOi Co J iE nn ca >* >. I01 V) > (A > Q. M 01 -- i_a -- C 3 c. > o > -- Company: S m ith 's Company F a c ilit y : Anmonla R e frig e ra tio n System ABD00102725 - *84 O R e v is io n : sa 2 ci 5 a c co c -- SOD O O _ 4. c O * -- Cl i HU uv> a-- m Kt co a > cn c- C <- b 3> II __ OOVL. -o ~ 5 D OB -- U Bl L l_ U CO e> o d c o O OO -- u O Q. -- o -- w a 1*5 COocoO ------*>*> o8. O(A O --ec oc O-- Loo. -- S5 *o4 >. B-- --' O PC>l 3 QO. OPI -- k. O> B OO X in I Ol V O a. -- bo.. System: 1 Armwnie R e frig e ra tio n System Session: 1 09-28*93 >. CO 9 r*. <o CO fSI K9 K> (M i- 8 OO u --c rL 3o o> o g Du O ... O 3 >. 10 co "O 5 -o CB T9 -- V) V) aO L. L. Cl Cl 8o 5 Cl D *8 oo o aI i F I u b cn >. 3 Cl b. C O-- >. B C -- O C D u- o c s a o >lc. cawoi auuo a: o u w --o o |oo_ --b- BIT. Q. C a in BB| O Cl v o 4-1 wB ou n 8. vi a _oi o> o CO in > bo (a/>. O O 0_9i 8w -Q 3 ~ O--U 09 -- -- *J &C B -- B-- 3 -> CO CO O C. 0.8 r E Cl > 3 c_ u o o. B 3 -- *----304*b rM -- s o o -- b >- -- - u ---- 3--0 in 3 O V) i iC_l Co >O) Q. a. Cl W g- -- B Cl ^ > cn Bci >. cn --> >Cb-l 3 m co -- CO -- u a in >. >O bCloII:--bl ~ Cl -- 0 C D -- O O' B B l_ O U 01 -- in ti o >c Co Oo. Z Cl O w > oo> o TS uin 3o --'O o i t m Cl Q. I 3 55 icnn 0.0w. Cl c io. -- Cel 41 -- cn > -- c-- -- B Cl M > UPI Cl >> s -I *4 Bo V) -- 8 --^ ABDOO102726 D-3 HAZOP Analysis Ammonia Refrigeration System A Hazard and Operability (HAZOP) study was performed for an ammonia refrigeration facility. The following is a portion of the worksheets, specifically the ultra low compressors. The worksheets identify the causes and consequences of potential deviations in the system. Safeguards are then recognized, which may prevent the scenario from occurring or mitigate the consequences, should the scenario actually occur. Where a potential need for improvement was noted, a recommendation was made. 39 ABDOO102727 t i i r A Session 1 fo r OSHA I ABDOO102728 -- ss o o je os u so. 5 g. o a o > cn swmsa f a C2 O C S-- i- a.*" "a S? -- u-- E n V S JJ >* & l p^ a m * o> s sW 3 C ID -- (A w> 3S3 a tr w o SO.*' 5 8 L 1/1 E i Isl o-- a K. rw s -- (/>*' 3S3 O' u O s a. ~ g3 SS? s 8: k It E s> K1 f > <0 -- A a _3 &S - Q. ~ O' S O b Di w3 n M v> -- S "O f"- 3 0) 3 > 8: -- 8t S-- ** 3 O tfi 0 > W 5 X W I0t1 o2 -e --& S W 6 l uni a O Ol > Wo w "O Q.-- vi 2a. ocn W X S pi w -- u -- E3 o o. a |= 3 =C *s8 OOu u a .e u n& C > o 'I S3 o a a s 4 IA 8 o 3o ws 3 i o -- * 3 01 S a 01 x x s *< "5 -- l_ as Co se-- 3 n <*-&> -- -- SCO^ 01 CL C O -- Q."s Z <- ai -- 01 41 3 *g 8 S SS aO 0a) s o w-- --w -- 3 -- 01 L. -- 3 0> o a m x 3 S *s S * -- 3a 6 -- W O wX C o-- 01 a--s s 0*a c -- S s oo a o Sr S-- P'S- > i_---- 0) l_ ii u 4) -- Q. S -- ^c 5E s> o3 8 83 O O (A -- U ^ 01 U ---- was u OW 0--30 01 01 O -- 0s> oo.s01 x--e 0si w-- w-- c o CL S O. S S C E> -- B Cl O S C O E3 O 'D O 01 O -- |_ ---- O -- ** -- y z > 0--3 C 8o 2 03 3 01 I S pw-- u -- s *1 ( ^-- -- O Ol 1 s WC *-s2*8 8 S M Ol L "8-s -- f pi -- OS -- a jz --060 -- a -- Ol 3 -3C c I noxciito^p -- o T1 tl Hu3 0) Ol S S C e -- SOS '> -- -- Q_ O U 3 V01i ^-- -- If >ID5 c 01 s ac s-- -- Ol Coo-- won't, s c -- W *3 *0 Q. U S O w s D s 01 -- oa o-i c -- w~ $1 <e xX c * n-- 1= o- -- a o m 03 0 |li *- -- C < a. co -sg ws c5 x s Ss EaCs 10 t- -- ABDOO102729 0 to V ae & J * | O fit 1 c _J (A (IMA e za> c co al > to a3 a: "> & c 'i o It K) *O O' -J -- IM L -- -- u- < Q. >. x c0 --~ COit) ttol Co r= (A k w kT X to g0 0 "D 0 03 V) Dl 0 inCO h0- 03 U00 0U <S> B to- *5 * c ill K*0> XM 3Ul 0 I0- Xto 0o*e a*- | u D> >+0* t>o 0 0 u 00 0 OO 0X0o "S L. _ CA a. 0 a. o to -- o U0o EgO. 0 tzl (_> s . i> - :. 0Ju2 E Q. V> (A Of | (A w -fc. 4> S9^ Iw k c L t 6 O00O33U3 'toO.) Qo./--.C)0.pUet'----e-'------b j*0:-uk35* X rv ~ . 0 0 O) X-- 0 0 -C U 3 Co ~ 0 0 u -a o t- X oi/i 2o --o *-> 0 0 L. 8 t 0 u 0 Ol O > a OX --O' (A a Q. c cn a o X C 3 t>o o-- >fe2 *0D 00 0 -- 0 v> a 'i K.' o S. ABDOO102730 ~ Cl V *8 oi * Ol s i a _c i CA X i0 ee < 3o t oi i UJ e * i lb mm i e U a a. o a V cn L. 13 a i ai </> Ut 0 M *L cO x~Sa sn Hi 4. -- ** t g-s oc a a i- X a 4- ** a a u aaa o a> oo &I Qfe. -- aa o xa uS o-- fe e a | S a Si! 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If UO IoK Id V IA CJ1 .3 7 au --c _T> Cw q. w -- g 3 61 O W u u -o *? o> --> oA TJ vi C 4i a hto >. a (a u aa ua II U -- 6) 3 U "O *- .5-5 51; v ~4i ao -- 6.--O Xo a -- O O --' Ol VI C t- -- o(A CO --3 Cl > 0kO.! tf. - C ~Ci> W6C1 B tl ----M -- ~ C -- e ! 3J 3 4> --ui--- I-CIL.6) 3ao -coIS si--c*>o!ZloQw. 3A L. O u c* CJ t> *> -- ^ (_ * .8 nu e * o - Z i. * & o4c> ^ u u I r v i r i i i i p p r i i i p R R ABD0010273ZT- 0) 4> xg a3. # CO * 1_ CO 4 e3 eg > fVie C3vD uI 3 K> _Ol - -- rov>j r\j > --30i/i rJ COu 2?Z S* g --c o> *> -- x au. ABDOO102735 -- g a -- > ea -- Ca~ uv> --*>> >alJc- . OC 5&.0- --]o Oa >*v- -1>. U c itapi t3wl C O O (A (A 01 W w -- a jz > fc* to - <A (AO3 U W --> L. c ^ 3(A ^HO- 3 L. a o &3 U C * O) fcA to C (A u3 3 --** wia 3 a. (/> orc ec s5 it l ae 3 (A --aOnv3 3 -OJ &L. w-- s. >. Lo. "2O .Oe u (A -- ~ ft) (A o o> eu/ yo>. c> o -- * Cl GU w .n) oL. --> O O (A * 'i o o i.Jr - 1= 3 C OOu L> ~ TaoJ .-- (A C "O g -- _ ? SO (. * uc_ ---- s -8 U3 ~V "33 : o =2 O3 -- T>----U------>C-X~OLC. O -wp U ----> 3 uo - .O>. g= uc --i 5 C C (A 3 C O. <A O wo --(A "g (A 3 O -- (A 3 aO uC -- --c ABDOO102736 -Cu> z a. Ms s. K> *O* o> (QA. O- a3r>i cauan T>> 4> *LV. >L41.. TcJ 3 (i n g 1* a7 O O) > oU --o f &S&_ - 4> .O-M5 a u *i | S a Si 1=111 U 3C U M 1 C* 4>1 a3 a w CO >. t> co a-- f~ U (K M i "c nu i UJ 1 i (A 4 to i 3 0) I 1 i U1 4_ t I 1 u no _3o( OM' U 43. CO 1 . * (A 0O> ^ --3 4(4iA.1 Cy3fl u-- a Sfe L. ~ Q.+* RS oa O^VOC l 4. C & N mcj 41 EBOC s MS CA % GO -O owCB ocU eo 4fc> >--** ISS ua a.-- O- oo eE Session: 1 09-29*93 Revision: 0 Dug#: P i10 6O6A/0 Node: 1 U ltr a Low Compressors (UB-1 end U8-2) P aram eter: Phase In te n tio n : Anrnonia is handled as a gas in the conpressor s u c tio n end d ic h a rg e lin e s ABDOO102738 D-4 Risk Ranking System - Process Hazard Analysis The following is a summary of definitions used in a risk ranking system. Both potential severity and likelihood values are defined. The definitions of severity are broken down into categories for injuries, fires, releases and explosions. 40 ABDOO102739 Potential l Seventy High 1 Moderate 2 Low 3 None 4 SEVERITY AND LIKELIHOOD DEFINITIONS DEFINITIONS OF SEVERITY For Injuries Fatality or extended disabling injury For Fires Conflagration or destruction of system Releases Causes complete shutdown of system and has off-site consequences Lost time injury (LTI) First aid case Fire large enough to disrupt system operations Incipient fire only Causes partial shutdown of system and has on-site consequences Release can be handled by small spill procedure No injuries No fires No release For Explosions Any explosion or detonation Overpressure or underpressure failure of equipment Internal unplanned equipment pressure fluctuation without failure No pressure fluctuations DEFINITIONS OF LIKELIHOOD Likelihood Potential High 1 Moderate 2 Low 3 Extremely Low 4 Description Can potentially occur once or more per year. Can potentially occur once every several (two - three) years, but less than once a year. Can potentially occur once every ten years-, but less than once every several years. Can potentially occur once in the lifetime of the system. 41 ABDOO102740 RANKING: 1 2 I3 T Y 4- LIKELIHOOD 1 23 1 23 246 367 478 4 4 7 8 9 do m m co< 42 RANKING: L I D O O l"rm ^ ABDOO102741 SEVERITY - 12 3 4 1 234 2 4 67 3 678 4 7 89