Beruflich Dokumente
Kultur Dokumente
0 ABSTRACT
A risk assessment was conducted in Nestl Manufacturing Malaysia Chembong Ice Cream
factory. The purposes of this assessment are to identify hazards that may potential cause harm to
fitters and others in the place of assessment; to assist the management to evaluate the chances of
that harm to the fitters and the possible severity that could come from the hazards; and to provide
measures to ensure that the risks are adequately controlled at all times. The hazards identification
and risk assessment was carried out in Ammonia Refrigeration Plant. The methods used for
hazards identification include workplace inspection, referring to non-major hazard CIMAH report
and from interview and survey from fitters involved in this process. There are totally 10 hazards
identified during the hazard identification which include ammonia gas release, physical space
constrain, fall from height, crush by falling hazard, slip and fall, explosion, electrical shocked,
expose to chemical, expose to noise, and ergonomic hazard. The most critical safety hazard is
ammonia gas release with risk rating of 8. Meanwhile, the most critical health hazard is chemical
exposure hazard which is the Ammonia work station with risk rating of 8. The control measures
that recommended for the ammonia gas release hazards are implementation of safety features at
equipment, gas sensor detectors, periodic maintenance, warning signage, review of work
instructions, permit to work system, LOTO, provide appropriate PPE and training. Control
measures for most critical health hazard are training on the correct way to handle ammonia
maintenance and oil drainage, review of work instruction, baseline for health surveillance,
lockout / tagout system, stand-by person, training and provide appropriate PPE.
2.0 INTRODUCTION
Formally known as Nestl Cold Storage Sdn Bhd, the company name was changed to
Nestl Manufacturing (Malaysia) Sdn Bhd in year 2003. Nestl Chembong Ice Cream factory
manufactures ice cream, ice confection and frozen confection products. The factory (NMM-CE
Ice Cream factory) was built in year 1996 and first commercial production started in March 1997.
This factory is certified for OHSAS18001:2007 and MS1722: Part 1 for Occupational Safety and
Health Management System and ISO14001:2004 for Environmental Management System. This
factory is located at Jalan Perusahaan 4, Kawasan Perindustrian Chembong over a total land area
of approximately 35,500 sq meters with a build up area of 5,146 sq meters. The head office in
Leadership Team from various departments namely, Factory Controller, Production Manager,
First Line Managers, Industrial Performance Manager, Senior Application Group Executive,
Plant Engineer and executives, Senior Quality Assurance Executive, Resource Unit Executive,
Warehouse Executive, Supply Chain Executive, SHE Executive and Senior Human Resource
Executive who indirectly report to Factory manager. This presented in Figure 1. The work force
in this factory consists of approximately 26 management staffs which included the executives,
senior executives and managers and 158 non-management staffs such as operators, technicians as
well as contract partners. According to Occupational Safety and Health (Safety and Health
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Officer) Order 1997 (3) (j) (1), the employer shall employ a safety and health officer if any other
manufacturing activity other than the manufacturing activity specified in subparagraphs (f) to (i),
employing more than five hundred employees. Due to total number of employees in this factory
less than 500, therefore a SHE Executive is hired to ensure the compliance to legal and internal
safety, health and environment requirements. The SHE executive is directly report to Factory
manager and indirectly report to Group Safety & Health Manager who is based in Head Office.
Besides, the safety and health committee is established to ensure the safety and health program in
this factory effective. The Safety and Health Committee organization chart as presented in Figure
2.
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2.2. Process Overview
In NMM-CE Ice-cream factory, there are few operations which include warehouse
operation, ice-cream production, ammonia refrigerant plant, cold room for ice-cream storage, and
distribution. There are different safety and health hazards in each of these areas. For this
Ammonia Plant is the heart of the operation in Ice-cream factory to support ice-cream
processes and supply low temperature for finished goods storage in - 25C. Ammonia (NH3) is
commonly used to lower temperatures below freezing point and in the manufacture of synthetic
ice. The ammonia refrigeration process is operating by changing the state of the cooling medium
in order to remove heat from a cold environment or body and release it into a warmer
maintained by either compression or absorption. Compression systems are in widest use such as
exchange unit (condenser), heat being given off in the process, and led as a liquid through an
expansion valve or a throttle system into an evaporation chamber (evaporator), in which the
refrigerant absorbs heat while returning to the gaseous state, after which it is drawn again into the
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3.0 OBJECTIVE
To identify the critical hazards that may potential cause harm to operators in the place of
assessment;
To evaluate the possible severity that could come from the hazards; and
To highlight hazards and control measures to the management to ensure that the risks are
4.0 METHOD
The definition of hazard is a source or a situation with the potential for harm in terms of
human injury or ill health, damage to property, damage to the environment or a combination of
these (2). Hazards have the potential to cause people injury or ill health. Therefore, it is important
to identify hazards at the place of work before the risks associated with these hazards can be
assessed and if there are no controls exist or existing control are insufficient, effective controls
should be implemented based on the control hierarchy. In order to reduce the risks of incidents,
an organization need to apply the process of hazard identification and risk assessment to
Prior to hazard identification, ammonia plant area layout was obtained to identify the area
that going to do the assessment. Hazard identification should aim to determine proactively all
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sources, situation or behaviors or combination of these arising from this workplace with potential
The following methods are used to identify safety and health hazards at NMM CE Ice-
cream factory:
the potential hazards that could be found at the place of work which including
ergonomics.
Ammonia is a hazardous substance that exists in this factory, which falls under
Major Accident Hazards) Regulations 1996. Although the quantity does not
finished product from supplier that is received at -28C and at pressure 14 Bar. In
the event of emergency situation, a large quantity of NH3 gas or liquid will be
discharged and give rise to a dense widespread fog. Hence, the Non CIMAH
report has been referred and studied to obtain information on the composition of
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III. Interviewed with staffs
The fitter or technician were interviewed and simple survey has been carried out
about the safety and health hazards from the task, working procedures and usage
Appendix C.
sequences in order to determine magnitude and to priorities identified hazards. In other words,
risk is the combination of the likelihood of an occurrence of a hazardous event or exposures and
the severity of injury or ill health that can be caused by the event or exposures. In this report,
semi-quantitative risk assessment method has been used and the risk matrix as per presented in
Table 3 below is used to assess the risk posed by the safety and health hazards in this workplace.
This rating is based on the likelihood of an event occurring. Each category is represented by
a rating value ranged from 1 to 4. The value of likelihood is determined based on the past
accident records of similar case that happened in this factory as well as similar cases that
happened in other factories in Malaysia. The opinion from the fitter also will take into
consideration to determine the rating of likelihood. Table 1 indicates likelihood using the
following values:
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LIKELIHOOD CRITERIA RATING
Most likely The most likely result of the hazard being realized 4
frequently
occasionally
The severity can be divided into 4 categories. Severity is based upon increasing level of
rating value ranged from 1 to 4. It is based upon the increasing level of severity to an individuals
injuries. This rating is based on the severity of the past incidents and opinion of the experienced
Major injury Major injury that resulting to lost time / short term ill 3
8
health effect (high fever, alkaline burn, sore eyes, MSD)
nausea)
Negligible injury Injury will only resulting near miss / first aid / no ill 1
health effect
To use the risk matrix as presented in Table 3, first is to determine the severity of hazard
that best describes the outcome of the risk by referring to column. Then follow the likelihood row
to find the description that best suits the likelihood that the severity occurred. Then risk level is
SEVERITY (S)
Permanent
Negligible Minor Major
LIKELIHOOD (L) Disability /
injury (1) Injury (2) Injury (3)
Fatality (4)
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Highly Unlikely (1) 1 2 3 4
Unlikely (2) 2 4 6 8
Likely (3) 3 6 9 12
The risk ranking can be used to prioritize necessary actions to effectively manage workplace
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Table 4: Priority Table
By using the three methods of hazard identification stated in section 4.1, following are the
Ammonia gas is lighter than air; however release of ammonia at the pipelines or
valves will rapidly absorb moisture from air and form a visible dense white cloud.
The physical hazard is posed by the space constrain at elevated platform where the
This is due to the exposure in the building where maintenance and repairing work
This is due to fitters unloading of ammonia gas cylinder from the lorry by using
forklift to charging area. Unsecured gas cylinder can slip away from the forklift
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5.1.1.5. Slip and Fall Hazard
This is due to accumulation of condensate water and oil residual on the floor area
Equipment failure and pressure vessels rupture will lead to an explosion and could
wipe off the whole building. The contributing causes could be due to external
corrosion, pressure relief valve failure, manufacturing defect, external fire, or human
error.
which potentially contact with energized source can cause electrical shock to the
fitters.
Ammonia is toxic. Exposure to ammonia above 50 ppm can result irritating to the
nose, mouth, throat and causing coughing. At a higher concentration of 300 to 500
ppm, it become a medical risk and can immediately dangerous to life and death.
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Noise is generated in Ammonia Plant by the compressor motor. The noise level is
more than 95 dBA. Impairment hearing loss and psychological stress are the health
Lifting heavy loads can caused fitters to have low back pain which lead to muscle
injuries. Exposure
From the risk assessment, the prioritization of the hazards is presented in Table 3 below as well
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Table 5: Risk Rating of Safety and Health Hazards
Based on the results of risk assessment, accidental ammonia gas release, exposed to
chemical hazard and exposed to noise hazard in the Ammonia Refrigeration Plant are the highest
risk rating for safety and health hazard among the other identified hazards. The risk rating is 8
respectively. The other hazards also need to be addressed as soon as possible such as ergonomic
hazard while lifting heavy load and fall from height hazard while working on elevated platform.
The recommended corrective and preventive actions will be discussed on section 6.1.2.
Safety Hazard
Accidental ammonia gas release is the critical safety hazard found in this workplace.
According to the ammonia fitter, ammonia leaks can be a problem in any refrigeration system.
Mechanical seals and pressure relieve valve can be failed and allow ammonia escape into the
atmosphere. Ammonia is a colorless gas, lighter than air and with pungent smell, when mixed
with air in the ratio of 16% to 25% of gas by volume will form an explosive mixture. Explosive
combustion can occur in flammable mixtures in the work space, it is possible to cause structural
damage in the work space due to the pressure wave. The details on the characteristics of
Ammonia in the form of material safety data sheet (MSDS) are presented in the Appendix
There were few incidents that relate to gas leak in ammonia refrigeration plant occurred
across factories in Malaysia. The common root causes are human error and failure of safe relief
valve functioning. In worst scenario, a catastrophic rupture event that release 800 ppm
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concentration of ammonia gas will form a vapor cloud at maximum 23.94 m in diameter and
Health Hazard
Exposed to chemical hazard is the most critical health hazards found in this workplace.
This hazard is the highest risk rating which is 8 and is categorized as high risk. According to the
chemical health risk assessment (CHRA) report, ammonia gas is the most hazardous chemical
used in this factory. Ammonia is an inhalation irritant and caustic effect. This can create a
problem for most of us because human cannot tolerate exposure to large amounts of this
refrigerant very well. The hazards of ammonia are mainly connection with the irritating
properties, corrosive properties at high concentration. Over-exposure can become a medical risk
and can immediately dangerous to life and death at a higher concentration of 300 to 500 ppm.
Ammonia can enter into human body through inhalation / ingestion, skin contact, or splashes into
eyes.
a) Inhalation / ingestion
can displace life supporting oxygen and cause irritation. The symptoms are
b) Skin Contact
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Splashes of ammonia liquid into eyes or higher concentration of gas are particular
dangerous. The rapid penetration of ammonia into the ocular may result in
5.3. Impact of the Most Critical Safety and Health Risks to the Organization
The identified hazards will not only affecting to the workers but it will also bring impact
to the organization. According to Occupational Safety and Health Act (OSHA1994), it is the duty
of employer to ensure that the workplace is safe and free from health risks in order to prevent
accidents and illness in the workplace. The impact of the most critical safety and health risks to
the organization can be in term of monetary such as direct cost and indirect cost involved by
referring to Accident Cost Iceberg Model as presented in Appendix E and also the non-monetary
such as the reputation of the organization and also the trust from the customers or consumers.
Both most critical safety and health risks will cause injury to those exposed to these
particular hazards. The most severe consequence for most critical safety hazard could be the plant
was blown out and results permanent disability or fatality. The most critical health hazard could
be victim suffered asphyxiation that could result fatality. The organization has to spend for direct
costs such as compensation or medical fees which are exceeded the insurance coverage of the
victim.
Besides, there are also indirect costs involved. If accident happened, this will cause the
operation stop for investigation by Safety and Health Committee and/or Occupational Safety and
Health Officer if requested by the authority. This will result in delay of product supply to
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customer and not meeting customers requirements. This will end up of losing the customer. In
case where the ammonia refrigeration system was collapse and unable to continue the normal
operation, the organization needs to put a greater investment, expertise, parts supplies and
replacements in order to resume the normal operation. This will take lots of time and cause the
Other than that, if the victim suffers health injuries from the irritant chemical, the
organization needs to arrange a series of medical treatment, rehabilitation and back to work
program in order for victim to go back to work as normal fitter or to a lighter work task. Based on
the Accident Cost Iceberg Model, the visible part of Iceberg is representing the insured cost
meanwhile the hidden part is the uninsured cost which is 8 to 36 times greater than the insured
cost.
The organization will report the annual performance report to the shareholder and safety
and health performance is always one of the key focuses of the shareholders. If accident
happened frequently in the organization, customer and consumers will have the perception that
the organization is not taking care of their employees especially the organization is certified with
Standard OHSAS18001 and ISO14001 and will not invest further or buy the products of the
company.
6.0 RECOMMENDATION
6.1. Proposed Control Measures for Each Critical Safe and Health Hazards
should try to eliminate the hazard. It is the best way of protecting workers. Second is by
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substitution where doing the same work in a less hazardous way. Third is engineering control
such as isolation, automation, barriers, absorption, dilution etc. Next is an administrative control
such as safe work system, training, job rotation, etc and lastly is Personal Protective Equipments
where other controls measures are not feasible and where additional protection is needed.
From the assessment, the most critical safety hazard is ammonia gas release hazard which
is high risk. In order to control this hazard, elimination and substitution is not feasible. The
following control measures are recommended and being implementing to reduce the risk:
a) Engineering Control
Safety features i.e. pressure relief valve, temperature and pressure gauges
fittings.
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Gas sensor detectors to audible and visual Alarms were installed to
Non-destructive test i.e. hydrolic test was conducted and tested at 500 to
900 psi
drainage system, manual / automatic shut off valve and pressure relief
valve
b) Administrative Control
ammonia compressors
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Emergency response plan (ERP) and full site evacuation procedure are
process
Emergency drill e.g. fire evacuation and ammonia drill should be practiced
more often with cooperation from the HAZMAT team in Fire & Rescue
Department
and engineering personnel to ensure they have the proper knowledge and
Ammonia safety audit was carried out in yearly basis and all audit gaps
Appropriate PPE are provided in the work area i.e. full face piece with
chemical protective suit, safety shoes, ear muffs / ear plugs, rubber gloves,
Emergency eyewash and shower system are installed at each floor in the
plant
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Besides of the above control measures, Log out Tag out (LOTO) system shall be
implemented where the energy sources (e.g. electricity, ammonia gas, etc.) is isolated and locked
by the fitter who will carry some maintenance work. The isolation point for LOTO should be
clearly mark on the machine / equipment to let the fitter know where should he isolated and lock
so that nobody except the fitter holding the key is allowed to open the lock and turn on the
From the assessment, the most critical health hazard is exposed to irritant chemical
hazard which is high risk. In order to control this hazard, elimination and substitution is not
feasible. The following control measures are recommended and being implementing to reduce the
risk:
a) Engineering control
Isolate of the Ammonia Refrigeration Plant with other working areas i.e.
maintenance work
calibration test and function test must be carry out to prevent any faulty
reading or defect
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The gas sensor detection level should be typically set at range 25-100 ppm
b) Administrative control
etc.
Appropriate PPE are provided in the work area i.e. full face piece with
chemical protective suit, safety shoes, ear muffs / ear plugs, rubber gloves,
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Emergency eyewash and shower system are installed at each floor in the
plant
established. It is similar with the noise surveillance program. The purpose Baseline health
surveillance is to establish a base against which changes in health care status can be evaluated,
not to prevent people from performing work. Periodic health surveillance should be conducted on
all fitters in the area exposure to ammonia gas. The content of the assessment should be similar to
that outlined for the baseline. Periodic follow-up should be done to determine the condition of the
fitters and if found any problems, appropriate action such as review the work procedures or
workstation.
All the control measures are requiring to be reviewed in order to determine the effectiveness
in managing the risk. The output of the reviewing process will be considered as an improvement
program.
The work instructions for maintenance should be reviewed. The steps of machine shut down
and start up shall be clearly stated in the procedure to ensure the applied LOTO and machine
Inspections can be done during the beginning of the shifts by the fitters or periodical
inspection by Safety and Health Committee for any defects and abnormalities and reports to the
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internal audit, it is necessary to check the effectiveness and condition of all the safety features
e.g. pressure relief valve, gas sensor detectors, manual shut off valve, etc.
The competency of the fitters is important in order to carry out the job safely. Competency
can be developed or built through education and training. Before conducting the training, the first
step is to establish a Training Needs Analysis (TNA). The purpose of the TNA is to identifies the
difference between actual and the optimum condition. Then, review current work instruction and
conduct competency based training to the fitters. The effectiveness of the education and training
The effectiveness of warning signs installed as a part of the administrative control must be
made as per the standard, clear, bright, concise, visible, readable and located near the hazard.
Monitoring of health status of every staffs in work area can assist to identify any
possibility of any occupational disease or illnesses. If the results showing any signs of
occupational diseases or illnesses from activities in this area, this means the control measures are
likely to be not effective. Periodic walk-through inspection is also important to identify the
potential hazard and to maintain close contact with the operators. The walk-through inspections
record should be kept with the date of the inspection and discussed the finding with the
management during the weekly, monthly meeting and Safety and health committee meeting
which is every quarterly. Follow-up should be initiated to correct the problem identified.
Behavior observation and feedback, BOF, should be implemented to monitor and review
the effectiveness of the recommended control measures. A critical behaviors checklist will be
established based on the area and they are required to perform behavior observation and feedback
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to his colleagues on a scheduled time. During the observation and feedback, observer will catch
observee do things correctly and give positive reinforcement. If the observer found at-risk
behavior, observer will discuss with the observee to get the activator and come out with the
The main purpose of the control measures and review programs is to ensure the operators
and fitters are safe and health in the workplace. It is stated in the OSHA 1994 that the employer
should provide a safe and healthy working environment to the employees. Besides, the hazards
control measures and effectiveness review programs will benefits a lot the organization and the
operators in term of safety and health and will help to ensure the smooth continuity of the
The hazard control measures as explained earlier such as engineering control and
administrative controls will help to reduce the exposure of the fitters to the hazards. Hence the
risk of the accident will be reduced. Reduction in accident will benefit the organization not only
in term of monetary as well as non-monetary. Time being waste for the investigation, spend time
to hire the new fitter and train them, invest to get parts supplies for replacement, compensation
payment are all categorized as monetary lost. In term of non-monetary, reputation of the
company will be affected by the accident and it will take time to rebuild the reputation and trust
The review of current work instructions and procedures and competency based training will
help to increase the awareness of the fitters on the safe working steps. Periodical walk-through
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inspection will help to identify the unsafe conditions in the workplace and ensure them work in a
safe manner. With the implementation of behavior observation and feedback, the fitters will be
always aware and conscious on the safe behaviors. If the observer found any at-risk behaviors
from the observee, feedback will be given to the observee and activators to be identified and
Lastly, the benefit of the control measures and review programs explain above will provide
a safer and healthier workplace, positive attitude towards work and greater job satisfaction to the
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