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HomeMy WebLinkAboutMINUTES - 10221996 - D7 t TO: BOARD OF SUPERVISORS FROM: William Walker, M.D. Health Services Director DATE: October 4, 1996 SUBJECT: Accept the Final Report of the Third Party Safety Audit of the Unocal San Francisco Refinery.In Rodeo RECOMMENDATION: Accept the final report of the third party safety audit of the San Francisco Refinery in Rodeo. The final report will be presented by the Health Services Department and EQE International, the third party auditor. BACKGROUND: On July 11, 1995, in response to a series of incidents which had occurred at the Unocal Refinery in 1994 and 1995, the Board of Supervisors directed the staff to undertake a Safety Audit of the Unocal Refinery located in Rodeo. The Board approved the Audit Scope of Work and the contract between the County and Unocal for conducting the audit on February 1, 1996 and for the Health Services Director to send out a Request for Proposals (RFP) for contractors interested in conducting the Safety Audit. The Board appointed the Audit Monitors Group, which included four community representatives from Rodeo, Tormey or Crockett; an Oil Chemical and Atomic Workers International Union representative and Supervisors Smith and Rogers or their representatives on June 18, 1996. The Board approved EQE International to serve as consultant to the third party safety audit on July 23, 1996. EQE International performed the audit at the Unocal Refinery between September 9 and September 30, 1996 and presented the final report to the Audit Monitors Group on October 3, 1996. CONTINUED ON ATTACHMENT: YES NO XX SIGNATURE RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER .,lG TATTTRF(-,)- ACTION OF BOARD ON October 22 , 1996 APPROVED AS RECOMMENDED X OTHER VOTE OF SUPERVISORS x UNANIMOUS(ABSENT-----_) I HEREBY CERTIFY THAT THIS IS A TRUE AND AYES: NOES: CORRECT COPY OF AN ACTION TAKEN AND ABSENT: ABSTAIN: ENTERED ON THE MINUTES OF THE BOARD OF SUPERVISORS ON THE DATE SHOWN. Contact person:Randy Sawyer 646-2286 ATTESTED_October 22 , 1996 cc: Health Services Director PHIL BATCHELOR,CLERK OF THE BOARD OF Hazardous Materials(via HSD) SUPERVISORS AND COUNTY ADMINISTRATOR Community Development County Counsel BY 1A DEPUTY D7 WM INTERNATIONAL UNOCAL SAN FRANCISCO REFINERY } = THIRD PARTY AUDIT' September 30, 1996 ' Prepared For: Contra Costa County Health Services-Department Environmental Healtli Division Hazardous Materials Section x Martinez, California EQE Project No.:,300040.01 EQE INTERNATIONAL Third Party Audit of Unocal's San Francisco Refinery TABLE OF CONTENTS Section Description Paye ' 1. Summary1 - 1 ' 2. Scope 2 - 1 3. Observations 3 - 1 4. Exception Report 4 - 1 5. Method 5 - 1 6. Contractor Experience 6 - 1 September 30, 1996 EQE International Summary Third Party Audit of Unocal's San Francisco Refinery SUMMARY Background ' The Contra Costa County Health Services Department (CCCHSD), in cooperation with Unocal and the Bay Area Air Quality Management District (BAAQMD), developed a scope of work for an independent Third Party Audit of Unocal's San Francisco Refinery. The audit scope of work was approved by the Contra Costa County Board of Supervisors. This report documents the results of this audit. ' EQE International EQE was selected as the auditor for the Third Part Audit. EQE (EQE) Y provided four process safety consultants to conduct the audit. The audit was co-managed by the CCCHSD Project Manager and the Unocal Project Manager. An Audit Monitors Group, appointed by the Contra Costa County Board of Supervisors, monitored the entire audit process. This included participation in the selection of the audit contractor, review and comment on the audit method and protocol, on-site observation of ' audit activities, review of audit progress, and review of audit results. The Audit Monitors Group included: two County Supervisors, or their representatives; four public representatives, from Rodeo, Crockett, or Tormey; and one Unocal Oil, Chemical and ' Atomic Workers (OCAW) International Union representative. Audit Scope The Third Party Audit included the following elements: 1) Review of Good Neighbor Audit 2) Incident Investigation 3) Operating Procedures 4) Training 5) Contractors 6) Mechanical Integrity 7) Management of Change 8) Unocal's Loss Control Management 9) Catacarb Release Action Items ' The scope of audit elements 2 through 7 correspond to elements specified in the applicable process safety management (PSM) regulation, Process Safety Management of Acutely Hazardous Materials (California Code of Regulations, Section 5189 (8 CCR 5189)). Elements 2 - 7 were audited for compliance with 8 CCR 5189. The scope of audit element 1 required follow-up of a previous audit performed in August 1995. The scope of audit element 9 required follow-up of Unocal action items that were identified as a result of the Catacarb release in August 1994. The status of action items related to elements 1 and 9 was reviewed and verified. The scope of audit element 8 assessed the "Safety Culture" at the Unocal Refinery, through an examination of Unocal's loss control management policies, procedures, 1 and actions. September 30, 1996 1 EQE International Third Party Audit of Unocal's San Francisco Refinery ' SUMMARY Conclusion In the opinion of the auditors, for the scope of this audit, the Unocal San Francisco Refinery is essentially in compliance with the requirements, and the intent, of the applicable PSM regulation. Findings or deficiencies, indicating instances where Unocal is not in complete compliance with the PSM regulation, are included in the Exception Report section of this ' report. A total of seven findings were identified during this audit; six are regulatory issues. In the opinion of the auditors, Unocal's practices and procedures were in compliance on four of the regulatory items, but documentation verifying compliance was either unavailable or incomplete. In those instances, the Exception Report includes the following notation: "This is a documentation issue." i 1 1 i 1 September 30, 1996 2 EQE International Scope Third Party Audit of Unocal's San Francisco Refinery ! SCOPE Review of Good Neighbor Audit ' The Good Neighbor Audit, conducted in August 1995, was reviewed by an EQE auditor who did not participate in the Good Neighbor Audit. The scope of this audit element included a ! review of regulations and all findings and recommendations from the Good Neighbor Audit. Status of all recommendations was reviewed, including items that were closed in the January ! 1996 follow-up review. Unocal developed a HS&ER Remedial Action Tracking Report, Good Neighbor Agreement Audit (dated September 18, 1996), that documents the actions and current status of all items included in the Good Neighbor Audit (dated August 25, 1995). ! Records were reviewed to determine the status of each finding and recommendation from the Good Neighbor Audit, followed by discussions with Unocal's Health, Safety and Emergency Response (HS&ER) Superintendent and HS&ER Specialist. ! Incident Investigations Incident investigation is one element of a process safety management (PSM) program. Unocal's Incident Investigation Program was reviewed using the Cal/OSHA "Guideline for Process Safety Management Audit." ! The purpose of incident investigation is to systematically identify the fundamental causes of process-related incidents and develop and implement corrective actions to prevent their ! reoccurrence. Non-privileged incident reports from January 1993 through June 1996 that resulted in, or had ! the potential to result in, hazardous material spills or releases were reviewed and categorized by their root cause, in an attempt to identify incident trends. ! The audit included a review of incident communications and safety meeting agenda items. The system for following up on incident recommendations was also reviewed. ! Operating Procedures Operating procedures is one element of a PSM program. Unocal's Operating Procedures Program was reviewed using the Cal/OSHA "Guideline for Process Safety Management Audit." ! The purpose of operating procedures is to provide operating personnel with specific instructions for carrying out all operating tasks in a safe, consistent manner. Well-written ! operating procedures will make operating personnel aware of specific hazards that they must control in the execution of their duties. ! September 30, 1996 1 EQE International ! Third Party Audit of Unocal's San Francisco Refinery SCOPE Operating procedures were reviewed in several refinery units. In accordance with the audit scope, units were selected that are considered high hazard (as determined by Unocal when prioritizing the order of process hazards analysis studies for all refinery units). The procedures were reviewed in the following units: Unicracking Unit (U-240), Sulfur Plants (U-234, U-236, and U-238), Coker Unit (U-200), and the Duo-Sol Unit (U-220). Training I Training is one element of a PSM program. Unocal's Operator Training Program was ' reviewed using the Cal/OSHA "Guideline for Process Safety Management Audit." The purpose of the training element is to ensure that employees have received formal ' instruction in the skills necessary to safely operate and maintain the process. Verification of competency in these skills is included in the training element. Training course materials were reviewed by the auditors. In addition, records documenting required training were examined. ' Contractors Contractor safety is one element of a PSM program. Unocal's Contractor Safety Program was reviewed using the Cal/OSHA "Guideline for Process Safety Management Audit." Additionally, the "Oversight of Contractors" questions, included in the audit scope, were investigated with this element. The purpose of this element is to ensure that contract employees are informed of the hazards associated with their work and that they are trained to a level adequate to safely perform their job, including any applicable safe work practices or procedures. Contractor safety training material and training records were reviewed by the auditors. Mechanical Integrity Mechanical integrity is one element of a PSM program. Unocal's policies, procedures, and practices regarding preventive/predictive maintenance and quality assurance were reviewed Iusing the Cal/OSHA "Guideline for Process Safety Management Audit." The purpose of the mechanical integrity element is to ensure that process equipment is in a condition suitable for its intended service for the specified duration of service. Mechanical integrity is accomplished through written maintenance and inspection procedures, employee training and qualification, and quality assurance procedures. 1 September 30, 1996 2 EQE International i Third Party Audit of Unocal's San Francisco Refinery SCOPE The audit scope included a review of the quality assurance program for positive materials ' (equipment) identification and confirmation of satisfied design standards, and review of the preventative and predictive maintenance program, including the frequency of inspections and standards for determination of acceptable testing/inspection results. The audit included a review of the maintenance and inspection records related to the existing odor abatement compressors. Management of Change Management of Change (MOC) is one element of a PSM program. Unocal's MOC procedures and practices were reviewed using the Cal/OSHA "Guideline for Process Safety Management Audit." The purpose of managing change is to ensure the change is reviewed with the same degree of care and skill as original plant design, and to prevent introduction of new, uncontrolled hazards into the workplace. Completed MOC documentation for changes that have been installed or completed in the Unicracking Unit (U-240), Sulfur Plants (U-234, U-236, and U-238), Coker Unit (U-200), and the Duo-Sol Unit (U-220) was reviewed. Unocal's Loss Control Management System The primary objective of this audit element was to assess the "Safety Culture" within Unocal's San Francisco Refinery. Although the term "Safety Culture" is difficult to precisely define, it may be thought of as a measure of safety consciousness in the workplace. Several subjective issues were explored during the assessment of this element, such as: • Is safety foremost in everybody's mind during each phase of operation? • Do plant operators feel comfortable stopping production if they perceive a significant safety issue? • Does Management support the operating personnel when steps are taken to ensure safety? • Is Management's commitment to safety clearly communicated? • Does safety take priority over all other aspects of refinery operations? iCertain elements of Unocal's Loss Control Management system contain requirements that, if adhered to, would help create a positive safety culture at the San Francisco Refinery. In accordance with the scope of this audit, the following elements, and sub-elements, of Unocal's Loss Control Management program were reviewed and discussed with refinery personnel: September 30, 1996 3 EQE International Third Party Audit of Unocal's San Francisco Refinery SCOPE Element 1 - Leadership and Administration 1.1 General Policy 1.2 Loss Control Coordinator 1.3 Senior and Middle Management Participation 1.4 Established Loss Control Standards 1.5 Participation in Loss Control Activities 1.6 Management Meetings 1.7 Loss Control Reference Manual 1.8 Individual Responsibility for Loss Control 1.9 Establishment of Loss Control Plans/Objectives 1.10 Loss Control Committees and/or Representatives 1.11 Refusal to Work Due to Loss Control Hazards 1.12 Reference Library 1.13 Document Control 1.14 Regulation and Codes Element 15 - Personal Communications 15.1 Training in Personal Communication Techniques 15.2 Job Orientation/Induction ' 15.3 Task Instruction 15.4 Planned Personal Contacts Element 16 - Group Communications 16.1 Group Loss Control Meetings 16.2 Record Keeping 16.3 Management Involvement Element 17 - General Promotion 17.1 Loss Control Bulletin Boards 17.2 Critical Topic Promotion 17.3 Individual Awards and Recognition 17.4 Loss Control Information Publications ' 17.5 Group Awards and Recognition 17.6 Housekeeping Promotion System 17.7 Records of Program Promotion Activities The audit examined Unocal's policies, procedures, and actions to determine if the intent of the Loss Control Management system is met. In those cases where Unocal does not comply with detailed requirements contained in the above sub-elements, the auditors used their judgement to determine the relevancy of the requirement to Unocal's overall "Safety Culture." September 30, 1996 4 EQE International Third Party Audit of Unocal's San Francisco Refinery SCOPE Catacarb Release Action Plan The Catacarb Release Corrective Action Plan (plan included in audit scope of work dated December 2, 1994) was reviewed to determine the status of the action plan. Unocal developed a HS&ER Remedial Action Tracking Report, Catacarb Public Action Plans (dated September 16, 1996), that documents the actions and current status of all items included in the December 2, 1994, Corrective Action Plan. 1 A meetingwas held with Unocal's Environmental Affairs Superintendent and Administrative P Assistant, Unocal's Audit Project Manager, and CCCHSD's Audit Project Manager to discuss status and review documents related to each Action Plan item. Additionally, two representatives from the Bay Area Air Quality Monitoring District attended the meeting and participated in discussions related to several items. Personnel Interviews The number of personnel (both Unocal and contract employees) interviews conducted during the course of the Third Party Audit is summarized at the end of this section. The following table provides descriptions and example positions of the listed categories: Category Description Examples Operator/Mechanic Unocal employees, includes - Head Operator field and control room - Control Board Operator operators, and maintenance - Field Operator mechanics, pipefitters, - I&E Technician electricians, technicians, etc. - Mechanic ' - Pipefitter - Electrician - Laborer Contractor Contract employees, includes - Supervisor supervisors and employees - Safety Supervisor - I&E Technician - Mechanic - Pipefitter - Laborer Staff/Supervision Unocal operations, - Operating Department Process maintenance, and technical Supervisor supervision and staff, includes - Operating Department Engineer supervisors, engineers, and - Process Engineer support staff - Project Engineer - Loss Control Supervisor - Maintenance Supervisor - HS&ER Specialist -Trainer - Administrative Assistant September 30, 1996 5 EQE International Third Party Audit of Unocal's San Francisco Refinery SCOPE Category Description Examples Management Unocal management, includes - Refinery General Manager major department managers - Operating Division General Superintendent - Operating Division Superintendent - Maintenance Division Superintendent ! - Chief Engineer - Process Engineering Supervisor - Engineering Design & Construction Supervisor - Environmental Affairs Superintendent - Health, Safety, & Emergency Response Superintendent ! September 30, 1996 6 EQE International a C 0 a � O � CT M M GD "� G+ 0 1 a� O Q W y O M O O 1 � w z w � o tAw n 44- � o r w o �, n oa � � O � 10 Z2 o H O � T f► p w N d rn y...A 4 'GCS V CCS CCS wS -41 1 Observations September 30, 1996 1 EOE-International 1 Third Party Audit of Unocal's San Francisco Refinery OBSERVATIONS Incident Investigations 1. Unocal has established incident investigation procedures that address minor incidents and incidents that result in, or could have resulted in, serious consequences. Minor 1 incidents, or those that had only minor consequences, are usually investigated by the appropriate supervisor. Incidents with more serious consequences are investigated by a team. For team investigations, at least one of the team members has received training ' in incident investigation techniques. For incidents involving contractors, contractor personnel participate in the investigation. Incident reports are retained for at least five years. 2. Incidents are reported on a form that includes a description of the incident, the initial cause, the basic cause, follow-up recommendations, and actions taken. Witness accounts are appended to the report form. For incidents involving emergency response, a report is prepared that reviews the emergency response efforts, including positive and negative aspects of the response. Initiation of incidents investigations are started promptly, usually within 24 hours of the incident (the PSM regulation requires investigation initiation within 48 hours). 3. Findings from incident investigations are communicated in several ways. At management and department meetings, incidents are discussed as part of the safety ' topic on the agenda. Safety is the first item discussed on the agenda. Depending upon the incident, the details are often communicated to appropriate personnel as part of the incident follow-up. This is documented on the incident investigation form. 4. Unocal performs thorough investigations of incidents that result in serious consequences. Selected other incidents, most notably those involving failures of the lockout/tagout system, are also thoroughly investigated. Root cause analysis is performed for these types of incidents. However, for many incidents that could have resulted in serious consequences, a root cause analysis is not documented, and is not always performed. Performing root cause analysis on incidents with the potential for serious consequences, and communicating the results to all appropriate departments, will better address systemic failures, thus helping reduce the Unocal San Francisco Refinery overall incident frequency. 5. In accordance with the audit scope, non-privileged incident reports from January 1993 through June 1996 that resulted in, or had the potential to result in, hazardous material 1 spills or releases were reviewed and categorized by their root cause, in an attempt to identify incident trends. A table, Summary of Incidents, 1993 - 1996, is included at the end of this section. September 30, 1996 2 EQE International Third Party Audit of Unocal's San Francisco Refinery OBSERVATIONS The total number of reported incidents increased approximately 20% from 1994 to 1995. For the years 1993, 1994, and 1996 (six months) the total number of incidents appears relatively constant. The auditors were unable to identify an explanation for the increase in incidents in 1995. The incidents q categorized as either "Inadequate Procedures" or "Procedure not Followed," when combined, are relatively constant from 1993 to 1996. Over the last ' several years, Unocal has reviewed and updated many procedures to ensure compliance with the PSM regulation. This review and update process is consistent i with the observed trend where "Procedures not Followed" now outnumber "Procedures Inadequate." This trend may indicate an opportunity to evaluate the effectiveness of the operator and maintenance training programs, specifically in the area of safe work Ipractices. 6. A total of six reported incidents were related to the odor abatement compressors for the time period analyzed (an additional incident occurred on August 16, 1996). Four of the six reported incidents were attributed to equipment failure. Unocal has plans to replace the existing compressors with a system that is intended to be more reliable and designed for the process conditions. The new odor abatement compressors are scheduled to be operational by January 1, 1997. Operating Procedures 1. Unocal has adopted a facility-wide standard format for operating procedures, converted and updated existing operating procedures, and developed additional operating procedures as required since the introduction of the process safety management standard. 2. In addition to operating procedures, reference information such as safe operating limits, equipment information, and unit drawings are located in the control rooms. 3. Material safety data sheets are available on-line via computers tied into the refinery network. 4. Operating procedures are reviewed annually. The review is performed by operators in conjunction with the process supervisor. 1 5. Written safe work practices (facility-wideprocedures) have been implemented. The procedures are reviewed with personnel annually, and spot-checks (audits) are performed and documented at pre-established frequencies. i 1 September 30, 1996 3 EQE International Third Party Audit of Unocal's San Francisco Refinery OBSERVATIONS 6. Operators that were interviewed were able to quickly access operating procedures and reference information in hard-copy format. The operators understand the format and organization of this information and indicated that the written procedures reflect current practices. All operators who were interviewed understood how to request changes to procedures when necessary. 7. Unocal operators have a long tradition of using written operating procedures when 1 conducting nonroutine tasks. Operators who were interviewed indicated that the procedure reformatting and revision process is improving the quality of the procedures. ' Training Note: Maintenance and contractor safety training were reviewed with the Mechanical Integrity and Contractors elements respectively, and applicable training observations are summarized with these elements. 1. Unocal has a well-developed, well-documented initial training program for new operators. The training program requires both written and field performance tests. Minimum passing scores have been established (80% on written exams, 100% on field exercises). 2. Refresher training for all operators is ongoing on three-year cycles: Year 1 - Process Overview Manuals Year 2 - Process Systems Manuals Year 3 - Process Safety Management Refresher Training documentation is available for all operators. 3. Final qualification for an operating job involves a comprehensive written test and field walkthrough. Minimum scores for written and field tests apply as with all training. 4. Operators who were interviewed indicated that the training they received was understandable and relevant to their job function. 5. Training of new operators continues beyond the initial overview and systems training. Operators also receive continued on-the-job training from experienced operators and supervisors. September 30, 1996 4 EQE International Third Party Audit of Unocal's San Francisco Refinery OBSERVATIONS Contractors 1. Unocal has a comprehensive contractor safety training program. This program identifies the training requirements of contractors, which is dependent upon the nature of their services or work. All contractors are required to complete specified safety training prior to commencing work at the San Francisco Refinery. 2. Information regarding the contractor's recent safety performance is collected from all contractors prior to contract award. This information is used when selecting contractors. 3. Unocal categorizes contractors by the nature of their work or services. Those contractors who work on hazardous processes, or who conduct work that could have an effect on a hazardous process, are assigned a "1" category, which requires extensive safety training. 4. Unocal completes a Safety Program Audit of category 1 contractors before each contract company can begin work in the Refinery. The purpose of this audit is to evaluate the contractor's safety program and to determine compliance of the contractor's program with PSM requirements. The contractor's safe work practices are evaluated for compliance with Unocal requirements. 5. Unocal performs Contractor Safety Program Field Audits to evaluate the safety performance of contractors while they are on-site. The field audits are performed jointly by a Unocal representative and a contractor supervisor. The field audit includes interviews with at least three contractor employees. The field audits verify that safe work practices are followed. Additionally, contractors perform their own field audits to ensure their employees follow safe work practices. Field audits are performed on category 1 contractors at the beginning of the work. Frequency of additional audits is dependent upon contractor's work duration. For long-term contractors (routine maintenance, large projects, etc.), audits are conducted on a quarterly basis. 6. All category 1 contractors are required to complete Bay Area Training Corporation (BATC) training prior to commencing work at the San Francisco Refinery. September 30, 1996 5 EQE International Third Party Audit of Unocal's San Francisco Refinery ' OBSERVATIONS 7. Unocal's contractor safety training includes the following modules: • General Refinery Safety Safe Orientation • Process Safety Overview Groups rSPS #3 Lock, Tag & Ivey • SPS #13 Confined Space • SPS #5 Hot Work Training • Hazardous Waste Training • SFR Electrical Training The contract employee's job function determines which training modules are required. All contractors receive the General Refinery Safety Orientation and the Process Safety Overview for the refinery area(s) in which they will be working. All training, except for SFR Electrical Training, requires completion of a written test (70% correct is a passing score). Incorrect answers are reviewed with the contractor employee. 8. Contractor safety refresher training is performed on a three-year cycle, except confined space training is performed on a two-year cycle and hazardous waste training is performed on a one-year cycle. All interviews with contractor employees verified that their training was current. 9. Contractor employees who were interviewed indicated that the safety training they received was understandable and appropriate for their job function. Training documentation is available for all contractors. 10. Hazards of the process, emergency actions, and personnel protective equipment requirements are reviewed with contractors through the Unocal work permit system, prior to the commencement of work on individual tasks. Verification of completed safety training for specific safe work practices (e.g., lock, tag & key, confined space, and hot work) may be checked before work is allowed to begin. 11. Unique hazards that may be presented by the contract employer's work are discussed during the pre-job meeting, required for all contracts. Hazards associated with the specific work is reviewed during the work permit discussion, prior to the commencement of work. 12. Contractor activities are typically monitored on a daily basis by the Unocal representative responsible for the contract. In some instances, a general contractor (e.g., Bechtel) may supervise the activities of other contactors working for Unocal. The field audits (described in item 5) are utilized to verify that contract employees follow required safe work practices. The Unocal work permit system is used to manage the safe performance of all contractor work. Periodic monitoring of the work, by both Unocal and contractor supervisors, assures that job procedures are followed. September 30, 1996 6 EQE International Third Party Audit of Unocal's San Francisco Refinery OBSERVATIONS Mechanical Integrity ' 1. The procedures, policies, and practices used to assure the integrity of the process equipment at the Unocal San Francisco Refinery are technically sound and well implemented. 2. The practice of pressure equipment inspection is thorough, using well-qualified and ' experienced inspectors and inspection practices, and capable supervision. 1 The maintenance training program is well organized, and the training process for new ' craftsmen is thorough. A "craftsmen training needs analysis process" is in place, and training on identified needs is integrated into the existing training program. ' 4. The quality assurance procedures and practices for the design, fabrication, and installation of new equipment are consistent with industry practices. ' 5. All craftsmen appear to have a good understanding of the role they play in managing change. r6, The control of maintenance materials, including receipt, warehousing, and issuing, appears to be performed well. Positive materials identification is an integral part of Unocal's material control practices. 7. The Metallurgy, Engineering, and Inspection (ME&I) Overview Program is used to monitor the quality of both routine maintenance and project work performed or managed by the Maintenance Department in the areas of piping, pressure vessels, storage tanks, heat exchangers, etc. 8. The odor abatement compressors and engines receive weekly scheduled maintenance. Over the last 28 years, each compressor has received at least seven scheduled complete overhauls. Seventy-two hours of machinist craft training are specifically designated for the odor abatement compressors. Based on the auditors experience, this preventative maintenance frequency is considered appropriate for the type of equipment. Management of Change 1. Unocal has written procedures in lace for managing changes at the San Francisco P P g g g Refinery. The procedures address required reviews, authorization requirements, identification of changes to process safety information (PSI), and verification that required reviews, procedure revisions, and training are completed prior to putting changes in-service. Review of technical and maintenance records indicates that the procedures are followed. September 30, 1996 7 EQE International Third Party Audit of Unocal's San Francisco Refinery ' OBSERVATIONS 2. Unocal has developed two procedures for managing changes. Both procedures meet ' the requirements of the PSM regulation. The primary difference between the procedures is that changes that do not directly affect the process do not require the same level of review and approval as other changes. Changes that do not affect the process are typically made to improve equipment reliability and usually are "transparent" to operations personnel. 3. Interviews with a cross-section of technical, maintenance and operations personnel indicate that they understand the management of change (MOC) procedures and the ' definition of change. 4. Interviews with maintenance personnel indicated that changes are not installed without appropriate authorization. Maintenance personnel obtain clarification when questions arise regarding required review and authorization of changes. 5. MOC training is provided to all Unocal staff, supervisors, and managers through the Management Training Systems (MTS) program. The initial MTS training is a two-day course, with an annual one-day refresher training. 6. It is the responsibility of the Process Supervisor of the process unit (owner of the equipment where the change occurred) to ensure that training and/or communication regarding specific changes are completed prior to placing the change in-service. The scope and complexity of the change determine the level of training or communication. This ranges from formal training sessions, with attendance records, for large or ' complicated changes, to notations in the operating unit logs or instructions for small or routine changes. 7. Unocal does not have a variance process for emergency changes. All changes must follow the MOC process. This approach ensures that all changes receive appropriate review and authorization prior to implementation. 8. Temporary changes are tracked, with dates identified for change removal. Currently, 18 temporary changes are in-service. Of these, three temporary changes are more than 1 eight months past due for removal. ' Unocal's Loss Control Management System 1. Unocal has achieved overall compliance with its' own Loss Control Management system. Programs are in place that address the essential requirements of Elements 1, 15, 16, and 17. Based on interviews and observations, the auditors believe Unocal's Loss Control Management system maintains a positive "Safety Culture" at the San Francisco Refinery. September 30, 1996 8 EQE International Third Party Audit of Unocal's San Francisco Refinery OBSERVATIONS 2. Unocal has a comprehensive safety policy that addresses the full range of safety- related issues, including spills and releases, and incidents with environmental effects. Management participates in the safety process through monthly department safety meetings. There are 33 monthly department safety meetings. 3. All managers are required to conduct quarterly inspections of the operating units. Documentation is available that confirms that these inspections occur. Many managers, including the General Superintendent of Operations, conduct more frequent tours. Although the management tours are effective in visibly demonstrating the importance of safety to plant personnel, some field personnel perceive them as "paper exercises" necessary for managers to "punch tickets" (i.e., to show they have completed the requisite number of tours). Several managers conduct effective tours. For example, the General Superintendent of Operations uses scheduled tours to communicate with field operators, and has an "open door" policy for discussion of issues identified during the tours. 4. Safety is the first topic on the agenda at every management meeting, including regular operating meetings where the objective is to discuss operating issues. 5. One important indicator of the San Francisco Refinery "Safety Culture" is the degree of comfort operating personnel feel shutting down process units if a safety hazard, or potential safety hazard, exists. In the opinion of the auditors, based on interviews with management, supervision, and field operators, operating personnel are comfortable shutting down the process units for safety reasons. ' 6. While the refinery has established a near-miss reporting system, interviews indicated that not all near-miss incidents are reported. In particular, operating personnel expressed reluctance to report near-miss incidents that involved their own operating errors, when the error did not directly result in any noticeable damage or release, due to concern about being disciplined for their error. Since near-miss incidents that are not reported can not be evaluated, opportunities for P PP safety improvement could be missed. Catacarb Release Action Plan 1. Twenty items were identified on the December 2, 1994, Corrective Action Plan. All 20 items were reviewed and considered closed by the auditors. Unocal has records documenting actions taken for each item. 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En c c ° vi " va > o ro cUo a, a. ° c' v ' a� ."oo G 0 a 3 5 n 0 ° v .- �L H w v ua• cca v C4 cid :: .� A A -c E- t�G •- U N i � M rn W U oQa U U 00 U 00 U oo +~n 00 0. oo vi oo cn _ ~ u w v ... ..s T cU C O c .� c t `G cts y a v c 00 ca aD c CO CT ON '"�.CI U U •+�„ C U AUi c N 1-1 tn N z` ............:....... co m to c 4. 03 br aoi '°Q a d 0 fd V V O U W ^o 3 v e n o O w w cv 40 cr ". y y C w �� co ci� ° o 'r� Ccr p N N cd Off. A cz U y O c>, s G a "' in a Lo U Q O co co O m i, .0 7 C E •G ;hi •pp�83 .0 = p ° a d ca O a+ O a ni OCAbb 4. E Cr0 a = N 8 o w o °' w tl� oo y `� � w � v, •� O �1 y �j z C UO00 O Ci � � rQi � � •� '� � N CA ZZ -u cri cr a 4 cd 0 .; v G M U o .., 4 a o C yyv ^D r7•a 4> N U cq O .. w sy C 'O 0 Cz " w aUi aUi v 7 •� vi c D L 0.> t 0i U 0 C at -a a 00 cra In ON a c a� ■ Method Third Party Audit of Unocal's San Francisco Refinery ' METHOD The following work description was provided to the Audit Monitors Group prior to beginning on-site audit activities. This information was previously presented in the EQE International document "Protocol for Conducting Third Party Audit of Unocal's San Francisco Refinery," dated August 12, 1996. The flowchart that immediately follows this work plan lists the major steps that were followed to accomplish the Third Party Audit of Unocal's San Francisco Refinery. Each step ' is summarized below. This approach is applicable for audit elements 2 through 8. Audit elements 1 and 9 required follow-up of specified action items. Desk Audit of Plans The desk audit involves a detailed review of the written plan. The purposes of the desk audit are: ' To allow the auditor to become familiar with the specific requirements of Unocal's San Francisco Refinery plan for each audit element. To audit the plan against the regulatory guideline (if applicable). This is the first step to determine compliance. ' To develop a detailed plan for conducting the audit. Once the specific requirements of the plan are known, the auditor will add, delete, or otherwise modify the lists of record reviews, interviews, and inspections to be done ' during the audit. Develop Record Review, Interview, and Field Inspection Schedule and Material The audit consists of evaluating Unocal's activities against standards. One standard to be used during the audit is the applicable PSM regulation. The second standard is Unocal's ' specific plan (policies and procedures). The plan defines the specific actions that Unocal employees are expected to follow. Once the auditor determines these required actions, a detailed work pian must be developed to verify that these actions are accomplished. This is done by reviewing applicable records, interviewing selected employees, and making observations (inspections). This work plan will include: A list of records to review and the review criteria. A list of Unocal personnel to interview and an outline of questions to ask P ' during the interview. These questions are designed to determine if the interviewee has a working knowledge of the plan and his or her specific duties under the plan. September 30, 1996 1 EQE International l Third Party Audit of Unocal's San Francisco Refinery IMETHOD A list of observations the auditor will make to verify certain aspects of the plan. Review Representative Sample of Identified Records Auditors review records to determine if required actions have taken place. In some cases, few records are available. In other cases, the number of records available is quite large. When the number of records is large, a representative sample is reviewed against the auditing criteria to give the auditor an estimate of what would be expected if all the records were audited. The term "population" refers to the pool of records that exists. For instance, if Unocal's plan requires a certain type of training for every employee, and they have 600 employees, then the population of potential records for that specific type of training is 600. In another case, the plan may only require that a handful of employees, say 20, receive a certain type of training. ' In this case, the population size is 20. The term "sample" refers to the records in a given population that the auditor actually reviews. There are several methods for determining the sample records. EQE will be using a random number generator to select the sample for large populations. This method is similar to a "quick pick" for the California lottery. For the lottery, the population size is 51 and the sample size is 6. Note that all Unocal Environmental or Property Loss incident investigation reports from ' January 1993 through June 1996 were reviewed during the course of this audit. Conduct Personnel Interviews Personnel interviews provide a substantial amount of information on the effectiveness of a written plan. Written plans can appear to be quite good when compared to a regulatory guideline, but still be ineffective. For a plan to be judged effective, the personnel that have responsibilities and duties under the plan must demonstrate a knowledge of those duties and the capability to perform them. The auditor develops the interview questionnaires and/or interview audit criteria before conducting the interview. ' Duringformal interviews, the auditor will take notes against the questionnaire or audit g criteria. Immediately following the interview, the auditor will develop more detailed notes, rincluding any follow-up that may be prompted from the interview results. 1 September 30, 1996 2 EQE International Third Party Audit of Unocal's San Francisco Refinery ' METHOD Perform Field Inspections ' Field inspections (observations) are the final tool the auditor uses to verify the audit results. These inspections provide a consistency check for the picture that develops from the previous ' audit activities. Note: Representatives of the Audit Monitors Group attended field inspections. Compile Exception ReportslDevelop Findings and Recommendations The audit activities will uncover a significant amount of information about Unocal's implementation of the plan being audited. The findings that result can be both positive or negative. For instance, the auditor may find that a written plan complies with regulatory 1 requirements. The auditor may also find that a training element of that plan has not taken place. The Observation Section of this report summarizes the significant findings of the audit, both positive and negative, by audit element. The negative findings, or deficiencies, are included in the Exception Section of this report. September 30, 1996 3 EQE International Audit Activities Flowchart Develop ' Protocol Desk Audit of Plans Develop Record Review,Interview and Inspection Schedule Review Representative Sample of Identified Records Conduct Personnel Interviews ' Perform Field Inspections i iCompile Exception Reports Develop Findings and Recommendations ' 300040-01Wctflow.ppt (8/96) Contractor Experience 1 Third Party Audit of Unocal's San Francisco Refinery CONTRACTOR EXPERIENCE EQE International (EQE) is a leading international firm that is dedicated to providing ' consulting services in risk assessment and risk management. EQE's clients come from every sector of the hydrocarbon and chemical processing industries, including refining, petrochemical, specialty chemicals, oil and gas exploration and production, and transportation. ' Our methods and technologies are tailored to suit each organization's needs. The hallmarks of our approach are an understanding of the client's problem, an ability to address issues on an integrated and practical basis, and the flexibility to provide truly useful engineering-based ' solutions. ' The following individuals from EQE composed the Third Party Audit team: Mr. Steve Bruce, Technical Manager, San Francisco, California, was the primary auditor for the Operating Procedures and Training elements. Mr. Bruce has more than 17 years of experience in the petroleum industry, including extensive experience in refinery, pipeline, and terminal operations, and in refinery process development and engineering. Prior to joining ' EQE, Mr. Bruce was Operations Manager for a 40,000 BPD oil refinery in Southern California. He also served as Operation Manager for a six-million-barrel bulk petroleum storage terminal at the Los Angeles Harbor. ' Mr. Marc Evans, Technical Manager, San Francisco, California, was the primary auditor for the Contractors, Management of Change, and Catacarb Release Action Items elements, and was the EQE Project Manager for the audit. Mr. Evans has more than 15 years of experience in the petroleum industry, including extensive experience with designing and operating refinery and petrochemical units. Mr. Evans has facilitated more than 40 PHA studies for a ' range of refining, petrochemical, and gas processing facilities, as well as developed and presented workshops in the HAZOP and What-If/Checklist PHA techniques. ' Mr. Doug Hobbs, Technical Manager, Houston, Texas, was the primary auditor for the Mechanical Integrity element. Mr. Hobbs has more than 20 years of engineering and plant management experience in the petrochemical and refining industries. He has extensive ' experience in the area of mechanical integrity for processing facilities, including interpreting equipment inspection data, approving repair plans, establishing inspection frequencies, and specifying inspection methods. ' Mr. Dave Jones, Vice President, San Francisco, California, was therima auditor for the P rY Review of Good Neighbor Audit, Incident Investigations, and Unocal's Loss Control Management elements. Mr. Jones has more than 22 years of experience in the petrochemical industry, and was the Chairman of the API task force that developed Recommended Practice ' 750, "Management of Process Hazards." He has led more than 70 HAZOPS, covering a wide range of refining and petrochemical units. September 30, 1996 1 EQE International EQE INTERNATIONAL ' Corporate Headquarters , 44 Montgomery Street,Suite 3200 San Francisco,CA 94104-4805 USA. 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