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HomeMy WebLinkAboutMINUTES - 02082000 - D1 r� TO: BOARD OF SUPERVISORS ' — Contra FROM: William Walker,M.D.,Health Services Director Costa DATE: February 8,2000 ` County SUBJECT: REPORT ON THE FOLLOW-UP EVALUATION OF THE TOSCO SAN FRANCISCO AREA REFINERY AT AVON SAFETY EVALUATION REPORT SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: ACCEPT the attached report"Follow-up Safety Evaluation of the Tosco Avon Refinery in Martinez, California"written by consultants from Arthur D.Little,Inc. BACKGROUND: The Board requested the follow-up evaluation when the consultants from Arthur D. Little, Inc. presented the report "S"afety Evaluation of the Tosco Avon Refinery in Martinez, California" on April 27, 1999. The safety evaluation took place as directed by the Board Order of March 16, 1999 after the February 23, 1999 flash fire at the Tosco Avon refinery that claimed the lives of four people with another seriously injured. The safety evaluation was performed in March and April of last year. Arthur D. Little,Inc. developed seventy-two recommendations from their findings from the safety evaluation. The Board asked that a follow-up evaluation be performed to ensure that Tosco is addressing all seventy-two recommendations. The Board on August 3, 1999 asked that the two recommendations from the Contra Costa Health Services root cause analysis of the February 23, 1999 accident at the Tosca Avon refinery also be included in the follow-up evaluation. The attached report is the result of this evaluation. Public meetings were held on November 30, 1999 before the onsite evaluation and January 12, 2000 after the onsite evaluation was complete and the draft report had been issued. The onsite evaluation took place the week of December 6, 1999. A public comment period was instituted from January 6 to January 21, 2000. The attached report includes notes from the two public meetings and the comment letters that were received on the draft report with responses from Health Services and Arthur D. Little,Inc. FISCAL IMPACT: None CONTINUED ON ATTACHMENT: YES SIGNATURE: AL RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE _OTHER SIGNATURE(SA&e .+ii Lf47� ACTION OF BOARD ON February 8, 2000 APPROVED AS RECOMMENDED X OTHER X SEE ADDENDUM FOR BOARD ACTION VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE _ X_ UNANIMOUS (ABSENT______J AND CORRECT COPY OF AN ACTION TAKEN AYES: _ NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. Contact Person: CC: Health Services Administration ATTESTED February 8 2000 PHIL BATCHELOR,CLERK OF THE BOARD OF SUPERVISORS AND)QOUNTY AD I ISTRATOR BY v DEPUTY 1 \�E j ADDENDUM TO ITEM D.1 FEBRUARY 8, 2000 On this date, the Board of Supervisors considered the report from the Arthur D. Little Company on the implementation by Tosco-Avon of the recommendations made following the explosion and fire in 1999. Randy Sawyer, Health Services Department, introduced the item and delivered a slide presentation as shown on handout material. John Peirson, Arthur D. Little, Inc.,responded to Supervisors' questions on issues including the survey method and results,bidding units, and the hiring of new operators. The following persons presented testimony: Denny Larson, 500 Howard Street#506, San Francisco, representing Citizens for a Better Environment; Toxie Myers, 2567 Henry Avenue, Pinole. Following further discussion, Supervisor DeSaulnier moved to accept the recommendations and to direct the Health Services Director, in addition to the Hazardous Materials Division, to report to the Board of Supervisors within 60 days with a detailed plan of the follow up and include a proposal to continue to have Arthur D. Little be a resource to the County in that review and evaluate the process itself, provide suggestions to do full facility audits better, and he also requested that within the Industrial Safety Ordinance is there a way to be more proactive to help prevent these incidents from happening in other facilities. Supervisor Gioia seconded the motion and concurred with maintaining Arthur D. Little's involvement. Supervisor Gioia also requested as part of the motion that, as part of the, plan that would return to the Board,having County staff, A.D. Little, and Tosco work aggressively to try to identify those indicators which would reveal whether or not organization changes are being made,and to provide a base for future audits or surprise inspections. He also commented on determining whether behavior is consistent with policies and procedures that Tosco has put into place, and a time frame for the follow up audit. Supervisor Uilkema expressed support for the motion with the additions by Supervisor Gioia, and the inclusion of her request to address the near misses factor. Supervisor Canciamilla noted that the Board was in the process of readopting the Industrial Safety Ordinance and expressed comfort with A.D. Little assisting in the coordination of all these items in the coming year. Supervisor Gerber commented that future reviews and audits need to include more interviews,more direct contact with employees up and down the line. Supervisor DeSaulnier expressed that part of the report back to the Board should be the issue of staffing and looking at how similar types of organizations that have a lot of facilities in their jurisdiction are staffed and whether we are properly staffed. IT IS BY THE BOARD ORDERED that the recommendation is ACCEPTED; and the Health Services Director in addition to the Hazardous Materials Division, is DIRECTED to prepare a report for consideration by the Board of Supervisors within 60 days addressing the issues raised by the Board today including: a detailed plan of the follow up;retaining A.D. Little to assist in that review; suggestions for better full facility audits; a pro-active role within the Industrial Safety Ordinance; having A.D. Little, County staff and Tosco identify indicators to reveal whether organization changes are being made; measurement of behavior changes, including surprise inspections; timeframes for the follow-up audit;the issue of near misses; and the staffing of the Health Services Department. J/ vow +r ul >0 Ul Ul (J) ul >0 cc .. Ul CD 0 0.� CLO 0 00 vom owl oa LLO ��L i s- t� CU tC� tt� •00000 0 %600 %1004) 4) 0 * I 0000 s (1) 0000 0 0 0 '. 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Sawyer r History II Tosco Avon Management • February 23 Accident • Incident Investigations Systems and Safety Evaluation • Board of Supervisors'Action February 27 Randall L.Sawyer • Tosco Response to Board of Supervisors Contra Costs Health Services March 2 Evaluation Performed by • CCHS Contacted Consultants and asked for Proposals Arthur D. Little Inc. History Continued History Continued 9 • AD Hoe Canmittm Was Famed Ad Hoc Committees Continued -William B.Walker,M.D.,Contra Costs Health -Scope of Work Services mor -Seloctlon of Consultant -Leslie Stewart Chair of Hazardous Materials Recommendations to the Board of Commission Supervisors -Larry Zianba,Tosco SFAR Manager -Ralph Sattlar, -Jim Payne,P.A.C.E. -Danny Larson,CBE History Continued Incident Investigations • Arthur D.Little Selected as Independent • Chemical Safety and Hazard Investigation Evaluator Board • Arthur D.Little Performed On-Site -Root Cause Analysis Evaluation(March-April) Cal/OSHA • Three Public Meetings -Compliance • Draft Report on April 15 • Bay Area Air(duality Management District • Report to the Board of Supervisors April 27 -Compliance Tosco Avon Management Systems and Safety Evaluation 1 F Randall L. Sawyer Incident Investigations Continued Public Participation Process • Contra Costa Health Services -Hazardous Materials Commission and -Root Cause Analysis Hazardous Materials Ombudsman • Tosco -Public Comments Submitted -72 Hour Report -Public Meetings -30 Day Report -Board of Supervisors Meeting —Root Cause Analysis Schedule of the Public Participation Schedule of the Public Participation Process During Evaluation Process During Evaluation a • Thursday,April 15,Presentation by Arthur • Wednesday,March 24 First Public Meeting D.Little on the Public Draft Report and -Introduce Arthur D.Little Questions and Answers -Discuss the Scope of Work and Work Plan • Comments on Public Draft Due April 21 • Thursday,April I Clyde Community Center • Hazardous Materials Commission Meeting Public Meeting Thursday April 22 —Update on Evaluation • Board of Supervisor Meeting April 27 —Questions/Comments from audience Tosco's Action Plan CCHS Incident Investigation Recommendations • Tosco Developed Action Plan to Address • August 3 CCHS presented their Incident 72 Recommendations from Arthur D.Little Investigation with a Root Cause Analysis to Final Report the Board of Supervisors • Arthur D.Little and Health Services • Report included findings and Reviewed Tosco's Action Plan recommendations • Monthly Reviews of Tosco's The Board asked if Arthur D.Little,Inc. Implementation of their Plan by Arthur D. could follow-up on CCHS' Little and Health Services recommendations during Follow-up Evaluation Tosco Avon Management Systems and Safety Evaluation 2 G�� Randall L. Sawyer Follow-Up Evaluation Schedule Follow-Up Evaluation Schedule Continued • November 30 Public Meeting • January 12 Public Meeting • December 6-10 tan-Site Evaluation by • End of Public Comment Period January 21 .Arthur D.Little • January 28 Final Report Issued • January ti Draft Report Available and Start • February 8 Report to the Board of of Public Comment Period Supervisors Tosco Avon Management Systems and Safety Evaluation 3 The presentation will cover the following topics: • Objectives of the follow-up assessment • Approach to the follow-up assessment • Key findings TOSCO AVON REFINERY • Follow-up recommendations FOLLOW-UP SAFETY ASSESWIENT • Conclusions Presentation to the Board of Supervisors Febnury 8,2000 Eetlow•p Asa•sr,r�ohh�v+� F••aa++p A�� The main objective for the follow- For the follow-up assessment, we up assessment was to audit used three main ways to gather Tosco's action plan. data and develop findings. •Check status of each action Item Intmisw• aoeum•nts Obe•rvw1«+• •Verify that action Items have been Implemented appropriately • Evaluate whether the action items have This Is the same approach that was addressed the underlying Issues used for the safety evaluation. Feftwwap ftft ,p As We conducted over 50 interviews We reviewed more than 100 with staff from all levels In the documents that had been organization. generated In response to the safety •Over 20 operator Interviews In various evaluation recommendations. operating units •Training materials and records • Safety manuals and programs • Over 10 maintenance personnel • Policies and procedures • Operating and maintenance procedures • Over 10 supervisors and superintendents . Job descriptions •Work plans •Senior refinery management . Newsletters • Meeting agendas and notes • Refinery health and safety staff . Survey documents 8 � f f FONPAs"smiwt-Appr"di FWbw•p Au•si t•Appnwch A four-step approach was used to In determining the implementation assess the progress Tosco had status a number of factors were made in addressing the taken into account. recommendations. •The wording and intent of the • Review the actions Tosco had taken to recommendation address each of the recommendations •The type of recommendation • Determine if the actions meet the Intent of •The time needed to fully achieve the goals the recommendations of the recommendation • Determine If the action Items were Long-term improvement in the safety Implemented culture at the refinery will take an • Recommend further actions,If needed ongoing commitment by Tosco. i wy Ftndinpi K+Y FtnQinpt Tosco has implemented all 72 While all the recommendations are recommendations that were considered implemented, some will developed as part of the safety require ongoing effort by Tosco. evaluation, as well as the two •46 of the recommendations can be recommendations that resulted considered fully closed from the Contra Costa County •8 of the recommendations have been fully Health Services incident Implemented,but Tosco must complete the investigation. the planned actions,which was beyond the scope of the recommendation •20 of the recommendations will require a long-term commitment by Tosco to achieve the desired safety culture change i Key FWinqs FGNnw�p�s Tosca has taken a number of key There are a number of key issues steps to address the safety culture that Tosco should focus on over recommendations. the next year. •Quarterly employee and leadership •Discussions with the Union need to begin meetings on how to restructure the number of • Improved the process for daily operations bidding units at the refinery meetings to focus on safety and Include a .Continue to emphasize respective roles of larger group of staff from all disciplines shift supervisors and lead operators to • Developed safety goals for each reinforce expectations department which are now part of the • Expand on the safety summit program to performance review include more staff and other topics •A monthly health and safety newsletter ro \14D M•a•w++n rr��,f,�,r.,a.aofs eona�uMb•. The follow-up assessment has Tosco has shown a strong suggested follow-up actions. commitment to Improvingthe safety iy. 16 of the recommended actions Involve performance at the facil CCHS conducting follow-up assessments •All of the recommendations have been within the neat year to further assess Implemented Improvements In safety culture •Tosco has hired a number of outside firms to assist in Improving the safety • 19 of the recommended actions are performance suggestions for Tosco • A number of programs have been Implemented to Improve communications within the refinery fY ,Y C=sckaM ns Gate SWM There are still some morale issues Tosco management appears to be due to a number of special factors. committed to working over the •Loss of Supervisors to fill operator long-haul to effect a change in the positions safety,culture and performance at •cross-training the refinery. •Staff resignations and staff on long-term disability � •Start-up demands However,there are still members of •The February Incident the operating staff who are Tosco has hired more than 30 new skeptical that the safety culture will operators to address some of these change. Issues. lVianagement will need to be diligent In assuring that the new prorams, polices, and procedures,#hall have been put in place, are implemented on an ongoing basis. Without this diligence, improvement in safety culture can not be assured. H Ar ur D Lftde Follow-up Safety Assessment of the Tosco Arron Refinery in Martinez, California Final Report to the Contra Costa Wealth Services January 28, 2000 Arthur D. Little, Inc. Reference 49388 Y) Notice This report was prepared by Arthur D. Little for the Contra Costa Health Services. The material in it reflects Arthur D. Little's best judgment in light of the information available to us at the time of preparation. Any use that a third party makes of this report, or reliance on, or any decision to be made based on it, is the responsibility of such third party. Arthur D. Little accepts no responsibility for damages, if any, suffered by any third party as a result of decisions made or actions taken based on this report. Final Report Artlur CIS UtUe Table of Contents Me Executive Summary ES-1 1. Introduction 1 A. Objectives 1 B. Background 1 C. Report Format 3 11. Scope and Approach 4 A. Scope 4 B. Approach 5 111. Follow-up Assessment Findings 6 IV. Conclusions 36 Attachment A List of Finding and Recommendations from Initial Evaluation A-1 Attachment B dotes From The January 12, 2000 Public Meeting B-1 Attachment C Comment Letters and Responses C-1 Attachment D initial Safety Evaluation Scope of Work D-1 Attachment E Glossary E-1 List of Tables 1 Follow-up Safety Assessment Findings 7 i Final Report Arthur D Little f :nn.. n:.:n4::;.}'.:r{:::::{.::{.:.:.:0}}ii:r{•:+..::i}}i;ihy;r.;:;rn:.3i;::{.:::::....... ................................................. o Executive Summary The Executive Summary provides a brief overview of the follow-up assessment as well as a summary of the actions that have been taken by Tosco to address the major findings and recommendations from the initial safety evaluation. The reader is encouraged to review the entire report to gain a better understanding of the progress Tosco has made in addressing all of the findings and recommendations. Background A safety evaluation was conducted at the Tosco Avon Refinery in Martinez, California from March 22-31, 1999 at the request of the Contra Costa Health Services. The final safety evaluation report was issued on May 10, 1999. The objectives of the safety evaluation were to. • Evaluate refinery safety management systems, human factors, and safety culture. • Identify safety concerns, if any, at the refinery and develop a list of findings and recommendations. • Prioritize the findings and recommendations in a way that will enable Contra Costa Health Services and the County to make sound safety-related decisions as they affect refinery operations. • Conduct an evaluation that is trusted and considered credible by the public and other key stakeholders. The scope of work for the initial safety assessment was developed by Contra Costa Health Services staff with input from an ad hoc safety evaluation committee, the County Hazardous Materials Commission, the public, and Tosco. The safety evaluation was not intended as a compliance audit and, as such, the report did not imply legal certification of compliance or noncompliance with safety regulations. Rather, the safety evaluation evaluated Tosco's safety management systems in relation to industry practices, and identified potential deficiencies. The safety evaluation identified 72 findings. For each finding, recommendations were developed to address the deficiency. All of the recommendations were intended to provide a way to achieve safety performance improvement. The recommendations were prioritized based on the degree of risk associated with the finding. Arthur D. Little presented the report "Safety Evaluation of the Tosca Avon Refinery in Martinez, California" to the Board of Supervisors on April 27, 1999. This report included findings and recommendations as a result of the evaluation. Dwight Wiggins, President of Tosco Refining, agreed to implement an action plan that would address all of the recommendations. Tosco has met this commitment. ES-1 Final Report Arthur D Little Scope and Approach to the Follow-up Assessment The scope of the follow-up Assessment included four major tasks. • Review and Comment on Tosco Action Plan • Review the Implementation of the Action Plan • Follow-up Assessment • Public Participation The first two tasks were conducted during the months of May through November, 1999. During this period the Arthur D. Little assessment team made a number of visits to the Tosco Avon Refinery to review progress on implementing the action plan. - The follow-up safety assessment was conducted at the Tosco Avon Refinery in Martinez, California from December 6-10, 1999 at the request of the Contra Costa Health Services. Additional follow-up was conducted on January 4, 2000. The objectives of the follow-up assessment were to: • Review the actions Tosco has taken in addressing the findings and recommendations from the initial safety evaluation. • To determine if these actions were adequate to address the findings and recommendations from the initial safety evaluation. • To suggest further actions Tosca could take to enhance the effectiveness of their action plan. • Conduct a follow-up safety assessment that is trusted and considered credible by the public and other key stakeholders. The follow-up assessment was designed and implemented in a manner intended to be impartial and objective. The follow-up assessment results were communicated to Contra Costa Health Services, the public, and Tosca. The assessment was conducted using a team of safety professionals working at the Tosco Avon Refinery over a period of one-week beginning December 6, 1999. Additional follow-up work was done on January 4, 2000. During these periods, the assessment team conducted more than 50 interviews with individuals and groups, and reviewed over 100 documents that had been generated or modified as a result of Tosco's Action Plan. Reviews of the actions taken by Tosco were based on evidence gathered during the follow-up assessment. This evidence was obtained from interviews with key people involved in the - development and implementation of the respective action items, review of documents, and limited physical observations. A four-step approach was used to assess the progress Tosco has made in addressing the recommendations. 1. Based upon the interviews, document reviews, and inspection, a summary was developed that described the actions taken by Tosca to address each of the recommendations. ES-2 Final Report ............................................. �J it 2. The assessment team then determined if the actions taken by Tosco met the intent of the recommendation, and if the action items had been implemented. 3. The implementation status was determined for each recommendation. 4. Recommended further actions were developed as needed. In determining the implementation status a number of factors had to be taken into account such as the wording and intent of the recommendation, the type of recommendation, and the time needed to fully achieve the goals of the recommendation. For example, one of the recommendations from the original evaluation was to "Initiate a comprehensive program to improve the appearance of the refinery and to build pride through effective beautification and housekeeping." Tosco has prepared a five-year plan to improve the appearance of the facility, and has begun to implement this plan. Therefore, the assessment team found that the recommendation has been implemented since the program had been initiated, even though the program will not be complete for five years. Another example would be for the recommendation that stated "Remind managers that they are critical role models and explain what it means to be an effective role model for safety." Tosco has initiated a program of quarterly leadership meetings where they address safety issues and how to be an effective role model. Since this program has been implemented, and appears to be serving to change the culture, this recommendation was considered implemented. However, since it takes time to change the safety culture at a facility, it is critical that these leadership meetings continue to reinforce the importance of safety and how to be an effective safety role model. Conclusions Tosco has implemented all 72 of the recommendations that were developed as part of the initial safety evaluation, as well as the two recommendations that resulted from the Contra Costa Health Services incident investigation. It must be stressed, that while Tosco has developed and implemented a variety of programs to address the recommendations, these programs will need to remain part of the normal work processes at the refinery for years to come if they are truly going to affect the safety culture. It must be recognized that organizational culture is developed over long periods of time and reflects individual and group values and perceptions of the way the Avon Refinery works, as well as the actual policies, written programs, and procedures. While many of the action items Tosco has implemented have resulted in changes in polices, written programs and procedures, not enough time had passed to assess whether or not they have affected the safety culture at the facility. In summary, Tosco has made great progress in addressing the recommendations from the initial safety evaluation and the Contra Costa Health Services incident investigation. Management has made it a top priority over the past eight months to develop and implement policies, written programs, and procedures to address all of the recommendations. In addition, it appears that management is committed to working over the long haul to affect a change in the safety culture ES-3 Final Report A!dur D UtUe n at the refinery. However, the refinery management will need to be diligent in assuring that the programs, policies and procedures that have been put in place are implemented on an ongoing - .basis. Without this diligence, the work that Tosco has begun will not be effective at changing the safety culture at the refinery. ES-4 Final Report L Introduction This section of the report discusses the objectives of the follow-up safety assessment, presents some background information on the initial safety evaluation, and provides the reader with an overview on the format of the report. A. Objectives This report summarizes the results of the follow-up safety assessment conducted by Arthur D. Kittle at the Tosca Avon Refinery in Martinez, California, at the request of Contra Costa Health Services. The objectives of the follow-up assessment were to. • Review the actions Tosco has taken in addressing the findings and recommendations from the initial safety evaluation. • To determine if these actions were adequate to address the findings and recommendations from the initial safety evaluation. • To suggest further actions Tosco could take to enhance the effectiveness of their action plan. • Conduct a follow-up safety assessment that is trusted and considered credible by the public and other key stakeholders. The initial and follow-up safety assessments were not intended as a compliance audit, and as such, this report is not meant to imply legal certification of compliance or noncompliance with safety regulations. The intent of the follow-up safety assessment was to review the actions that Tosco has taken to implement the initial safety evaluation recommendations. B. Background Because of incidents that have occurred at the Tosco Avon Refinery, communities surrounding the refinery, the Contra Costa County Board of Supervisors, and Health Services are concerned about the refinery operating safely. Among these incidents are a January 21,1997 explosion and fire at the hydrocracker and a February 23, 1999 flash fire at a crude unit. These two incidents resulted in the death of five workers and injuries to others. In response to these incidents, the Contra Costa County Board of Supervisors directed Health Services to arrange for a third-party evaluation performed on this refinery. The Board of Supervisors awarded the contract to do this evaluation to Arthur D. Little. The evaluation was done at the same time that Contra Costa Health Service, Cal/OSHA, and the federal Chemical Hazard Investigation and Safety Board was conducting investigations of the incident that occurred on February 23, 1999. The Arthur D. Little evaluation did not look at the February 23, 1999 incident. 1 Final Report ArUur D LiitUe The initial Arthur D. Little safety evaluation was conducted at the Tosco Avon Refinery in Martinez, California from March 22-31, 1999. The final safety evaluation report was issued on May 10, 1999. The objectives of the initial safety evaluation were to: • Evaluate refinery safety management systems, human factors, and safety culture. • Identify safety concerns, if any, at the refinery and develop a list of findings and recommendations. • Prioritize the findings and recommendations in a way that will enable Contra Costa Health Services and the County to make sound safety-related decisions as they affect refinery operations. • Conduct an evaluation that is trusted and considered credible by the public and other key stakeholders. The scope of work for the initial safety assessment was developed by Contra Costa Health Services staff with input from an ad hoc safety evaluation committee, the County Hazardous Materials Commission, the public, and Tosco. The scope of work for the initial safety evaluation is provided in Attachment C. The initial safety evaluation was not intended as a compliance audit and, as such, the report did not imply legal certification of compliance or noncompliance with safety regulations. Rather, the safety evaluation evaluated Tosco's safety management systems in relation to industry practices, and identified potential deficiencies. The emphasis of the initial - safety evaluation was on process safety to evaluate the management systems in place to prevent catastrophic events that could impact workers and the community. The safety evaluation identified 72 findings. For each finding, recommendations were developed to address the deficiency. All of the recommendations were intended to provide a way to achieve safety performance improvement. The recommendations were prioritized based on the degree of risk associated with the finding. Arthur D. Little presented the report "Safety Evaluation of the Tosco Avon Refinery in Martinez, California" to the Board of Supervisors on April 27, 1999. This report included findings and recommendations as a result of the evaluation. Dwight Wiggins, President of Tosco Refining, agreed to implement an action plan that would address all of the recommendations. Tosco has met this commitment. As part of the safety evaluation there was a requirement that Arthur D. Little monitor progress on the implementation of the action plan that was developed by Tosco to address the recommendations, and that a follow-up assessment be conducted in December, 1999 and January, 2000. This report presents the results of the follow-up assessment. 2 Final Report y'"y C,, -C... G. report Format Section H of the report describes the scope and approach for the follow-up assessment. Section III presents the follow-up assessment findings. The findings are presented in a text table which provides the text of each recommendation, a description of the actions taken by Tosco to address the recommendation, the implementation status, and a set of comments and suggested fallow-up actions. Section IV presents the overall conclusions from the follow-up assessment. The report contains a number of attachments that provide: a. A listing of the initial safety assessment findings and recommendations; b. The notes from the January 12, 2000 public meeting; c. A copy of all comment letters received on the draft report and written responses to these comments; d. The initial safety study scope of work; and e. A glossary of terms. 3 Final Report z II. Scope and Approach This section presents the scope and approach for the follow-up safety assessment. - A. Scope The scope of work for the follow-up assessment is composed of four separate tasks. Each of the tasks is described below. Review and Comment on Tosco Action Plan—Arthur D. Little reviewed with Health Services the Tosco Action Plan developed to address the recommendations and findings from the initial safety evaluation. Arthur D. Little reviewed the written action plan and provided comments to Health Services. Review the Implementation of the Action Plan—Arthur D. Little staff visited the refinery a number of times between the initial and follow-up assessment to review Tosco's progress on implementation of the action items. During these visits the Arthur D. Little staff reviewed documents generated as part of the action plan and reviewed progress with the refinery on the overall implementation. Follow-up Assessment- Arthur D. Little conducted a follow-up assessment to determine how Tosco was addressing the findings and recommendations from the initial evaluation and the Contra Costa Health Care Services incident investigation recommendations and to evaluate if the actions taken by Tosco were addressing the findings and recommendations. This assessment occurred in December 1999 and January 2000. The follow-up assessment involved reviewing documents, conducting interviews, and site inspections. Public Participation—Public participation is a key element of the follow-up safety assessment scope. The public participation steps include: • A Chemical Hazard Investigation and Safety Board meeting to present a progress report on the ongoing implementation activities and progress, which occurred in September 1999; • An initial public meeting before the follow-up assessment to get public input on the approach. This occurred on November 30, 1999; • A public meeting to discuss the draft findings of the follow-up assessment, which did occur on January 12, 2000 (Attachment B contains a set of notes from this public meeting); and • A Board of Supervisors meeting to present the final report on the follow-up assessment. This hearing will occur in February, 2000. 4 Final Report The public comments received on the draft follow-up safety assessment are included in Attachment C, along with responses to these comments. B. Approach A four-step approach was used to assess the progress Tosco has made in addressing the recommendations. 1. Based upon the interviews, document reviews, and inspection, a summary was developed that described the actions taken by Tosco to address each of the recommendations. 2. The assessment team then determined if the actions taken by Tosco met the intent of the recommendation, and if the action items had been implemented. 3. The implementation status was determined for each recommendation. 4. Recommended further actions were developed as needed. In determining the implementation status a number of factors had to be taken into account such as the wording and intent of the recommendation, the type of recommendation, and the time needed to fully achieve the goals of the recommendation. For example, one of the recommendations from the original evaluation was to "Initiate a comprehensive program to improve the appearance of the refinery and to build pride through effective beautification and housekeeping." Tosco has prepared a five-year plan to improve the appearance of the facility, and has begun to implement this plan. Therefore, the assessment team found that the recommendation has been implemented since the program had been initiated. Another example would be for the recommendation that stated"Remind managers that they are critical role models and explain what it means to be an effective role model for safety."Tosco has initiated a program of quarterly leadership meetings where they address safety issues and how to be an effective role model. Since this program has been implemented, and appears to be serving to change the culture, this recommend was considered implemented. However, since it takes time to change the safety culture at a facility, it is critical that these leadership meetings continue to reinforce the importance of safety and how to be an effective safety role model. Reviews of the actions taken by Tosco were based on evidence gathered during the follow-up assessment. This evidence was obtained from interviews with key people involved in the development and implementation of the respective action items, review of documents, and limited physical observations. 5 Final Report A1''Hur D L'rtUe III. Follow-up Assessment Findings The findings in this section are presented separately for safety management systems, human factors, and safety culture, consistent with the initial safety evaluation. In addition, a section has been added at the end of the findings table that covers the Contra Costa Health Services recommendations from their incident investigation. The findings provide a discussion of the - actions Tosco has taken to address each of the recommendations from the initial safety evaluation and the Contra Costa Health Services incident investigation. The findings are based on evidence gathered during the follow-up assessment. This evidence was obtained from - interviews with key people involved in the development and implementation of the respective actions, interviews of other people throughout the refinery organization, review of documents, and limited physical observations. The remainder of this section is a text table that presents the initial safety assessment recommendations, a summary of the actions taken by Tosco to address the recommendation, the - implementation status as determined by the Arthur D. Little team, and a set of comments and suggested further actions. 6 Final Report ::::::...............r:;::;;;;:;:.;.....::::...: .. ..... ip �°�..• � � a�, � a � �,n cam'`� C o � U � c� % � © >,� 'y� c� CT` Gd jo ,$ G Cam, O ✓ 0, i4ACO O ✓ " y 7 ty p C" * qN 4� '� i %O ? 0. 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G CL a6sa ch " 0 � a rna E 3 6a as a 4+ o "*y� �..9 C C 5 . m C C . yC} 'Qactl�'+ C a ba m G V� ��" ted 4a 42 •` bah ' a Ca 46. baa 3 ,t° °314 1w0 ` � r- 0 a 6�3 vii cA ya baa C7 6a ' nt a m 63 �a Ca E e. rn Ca O a 6�i o u .� ' R 42 10 Q •rr" r k a 63 CL 4J a o 4w a C a ca 63 F.i yqy C C ' y �;421M ' a ` as m ' " O 'a y y m .a > 10 0 CL wa c c 4 r ca s �p w a •20i. y 6a �a a y a Ca a a a a > > H -8-04 waa .� a d baa vis ts. v $ J.s ra' �+ 1 �On M to) LL r— U F y t :: ar C6 t O s i7 G. 73 Q .' . o+ y4y��di 4 1 4 f � i `L TI h r � r .att tt t.:tg .t .::.:x �c•::n: :::,. .....:: .._.... c} IV. Conclusions Tosco has implemented all 72 of the recommendations that were developed as part of the initial safety evaluation, as well as the two recommendations that resulted from the Contra Costa Health Services incident investigation. It must be stressed, that while Tosco has developed and implemented a variety of programs to address the recommendations, these programs will need to remain part of the normal work processes at the refinery for years to come if they are truly going to affect the safety culture. It must be recognized that organizational culture is developed over long periods of time and reflects individual and group values and perceptions of the way the Avon Refinery works, as well as the actual policies, written programs, and procedures. While many of the action items Tosco has implemented have resulted in changes in polices, written programs and procedures, not enough time had passed to assess whether or not they have affected the safety culture at the facility. A number of the positive steps that Tosco has taken to address the initial safety evaluation recommendations include: • Quarterly employee and leadership meetings. • Improved the process for the daily operations meeting where safety issues are now the primary topic. These meetings also focus more on the activities that are occurring at each of the units and input is solicited from each of the disciplines (i.e., environmental, health and safety, maintenance, etc.). • Clean-up of facility including removal of abandoned equipment, replacement of older equipment, and beautification of the facility. • Development of written safety goals for each department that are included in the managers' performance review. • The Health and Safety Newsletter which is sent to all employees on a monthly basis. • The Standard Operating Procedures workbooks. • Certification Training for operators. • Human Factors survey work done for a number of areas at the refinery. • Safety Summit was felt to be a great success by those that attended. There are a number of key issues that Tosco should focus on in the next year. These include: • Discussion with the Union need to begin within the next year on how to restructure the number of bidding units at the refinery to assure adequate operator training across units that are integrally related. • Continue to emphasize respective roles of shift supervisors and lead operators to reinforce what each party can expect from the shift supervisor. • Expand on the safety summit program to include more staff and other topics. 37 Final Report In summary, Tosco has made great progress in addressing the recommendations from the initial safety evaluation and the Contra Costa Health Services incident investigation. Management has made it a top priority over the past eight months to develop and implement policies, written programs, and procedures to address all of the recommendations. In addition, it appears that management is committed to working over the long haul to affect a change in the safety culture at the refinery. However, the refinery management will need to be diligent in assuring that the programs, policies and procedures that have been put in place are implemented on an ongoing basis. Without this diligence, the work that Tosca has begun will not be effective at changing the safety culture at the refinery. 38 Final Report _6 -60 Attachment A List of Findings and Recommendations for the initial Safety Evaluation Final Report j 1 � x � s _i5a I15sR � 03 cd cz sk 15 © � 'ti y C td !3 V1 '� �••� u as GL'43 � tb d � o 1153 33se bD .� � .. 'off uG cCiG mai r + .c " c tin "Q 5 * 0 " c13 " use ^to a Cons y `° �, `� crdOR 'ruyb, cin °a3 ot4. Ln �'} t� H041 u �40- N Wil '10 Y+ 0 R1S � ✓ CA gq ;J 34 U} > *^ Od C vs U � v dv a U Or- 0 .0 cr ° ° cC 9't = .w U 'O G b11 O Wv, ~ ~ U It 75 0 -5 cl p�pj� w �5a a b o,a '� a c a a, Cl. tz V � i �n a c c U U U C ., � v, p--0 t c � q 0' c O c �ma, acw• c oUa.A u >, U ocU 'c U ° c U * U o�cao x > •N c � -c >' C ter. '' � CV.. 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F+ r•+ m a3 rr C) o �,'?✓ a°� � '".%• 6J t) -0JS � R1 45 t3 s IA vs tr, �: � � !: � •.C+ � � F � � � � �'� yy G cid E7 � a�'�i baa o o � � � w �+�, •� �o ;� � �. � � � r •4 a• c ,� al G or N G N U ..................... . ......... ................. •q 77 a t O U 4C? C C�3 w C3. � •,�• d0 C's .. •y U � w .0 � ta U C vi y C C C, tw7 C 2 LC CIS .0 U 0 > � 4."� NbU0 0to w U o w vim. tp .� C rn p C ° ,,,,, o a � � E" � C Zj Cs ect �, U � O iS3 •`"; a� Cl. sw o ew > cu C '2 — CL-a . � � '� .ia ,U" � N � C •,G vCi C �" � C � C O.t—� .3� v ° ate arbo G y d� Cq y ctf w cel bo3 tf tu5 ev 2 Cl .� U, .ra O F ..... ::: w.. :.,., Attachment B Notes from the January 12, 2000 Public Meeting Final Report tJg Tosco Avon Management Systems and Safety Evaluation Public Meeting -January 12,2000 Public Comments Meeting Summary. • Michael Dent introductions, agenda, mailing list • Randy Sawyer(CCHS Presentation - very nice) • Dr. Ivor John (A.D. Little Presentation—Follow-up Safety Assessment/Public Draft Deport) • Issues: Ability of workers to stop unsafe work, MOC procedures(organizational), Mgmt commitment, improvements in safety culture, timing of follow-up assessment, additional follow-up assessments, Surge Pond electrical maintenance, National Electric Code violations. • (Morale issues) • Randy—follow-up plans Public Comments: • John Lee: Pleasant Hill. Page 10, Item#9. Periodic audits of the hot work permits. Intense activity during start-up of contractor auditing. What percentage of permits are field-audited as well as paper audited. Ivor- Internal audit program of hot work and permit. In place and continued. Benefits of using outside contractor during t/a is worked together with refinery resulting in learning for facility. We did see statistics of auditing. Definitely a sound internal audit program. • Ralph Sattler: Martinez, CSE. Do you feel that the time you had for the follow-up evaluation was sufficient for you to perform a thorough evaluation? Ivor-yes. On-site between March-December. John-yes. • Ralph: At the last public meeting , former employee commented on unsafe practices... Did you follow-up or get in touch with this gentlemen to determine whether these unsafe practice still existed? John: Ivor discussed surge pond issue in process. NPDES sample point prior to pond, therefore not a risk to human health. Other work—no MSDS. Now available. Other— unsafe work issue went to health and safety committee. Several weeks surveying other waste treatment facilities, expanded written PPE and procedure. Was it an unsafe B-1 Final Report f� exposure—no. Did they address other issues. --yes. Tosco evaluating whether it should be considered confined space. E-mails—communication sent from supervisors back to employee not very supportive of concerns. Not a good way to communicate-- recommend communication training for supervisors. Also NEC violation. OSHA investigating each issue in letter. (Legal issues, etc.) • Ralph: Tosco revised RMP as result of evaluation. What impact does that have on Tosco for RMP submitted? Randy: Tosco revising plan in response to CCHS comments. When CCHS does CalARP and ISO audits, we will actually audit facility. • Ralph: Safety culture. Tosco owns 2 plants. Rodeo and Avon. Are they implementing Avon recommendation at Rodeo. Is safety culture being addressed at both plants? Randy: 2 plants do have different safety cultures. Some changes have been carried over to Rodeo if applicable. • Ralph: How many staff resigned and for what reasons? Long-term disability? IVOR: Resigned higher than years prior. Statistically not high industry-wide. John: Hard to know reasons for resignations. Long-term disability due to stress (close to victims of incident) • Ralph : Overheads available? ( Yes) • Ralph: Recommend follow-up report a year from now. Include County follow-up in evaluation. John: Refinery operator's comments are very insightful, "The rocket is launched. The engines are running full-steam,but we are still on the platform." Tosco is committed... Invested$100 millions for clean-up (beyond our recommendations). Putting money where their mouth is. Change will take time. • Ralph: Skeptical operators.... Would be really good to be back in a year. • Ray Broomal(?): Martinez. I resigned from Tosco because I believed Tosco wouldn't change. I appreciate your follow-up on the issue of the ponds. My purpose was to address the problem of the ponds, but more to expose the huge inertia of the refinery to continue in former direction. Fingers and toes crossed that Tosco will change. Thank you for your efforts. • Paul Craig (CSE): Plenty of early warning signals (EWS) that Tosco was an accident waiting to happen. How does the community obtain EWS that there might be future problems? Ought to be plenty of time to detect change. We need to institutionalize ability to detect change. Please provide us, the community, with the ability to detect EWS. Concerned about company focused on short-term profit being able to sustain long-term commitment to safety. Randy: CalARP and ISO audits, notice of deficiencies/compliance. John: Communities do struggle with limited outside information. You can look at OSHA recordable incident data. BAAQMD, EPA, trends. If you continue to see same finding, they are not addressing root cause problems. B-2 Final Report J . _... �v • Paul: We also have a county that has quite a bit of capability. We would like to see them continue. John: The only county I have worked with that has an ISO is this county. It is a very strong program that should allow County to find EWS. Ivor: CalARP: Unprecedented ability for local county to conduct formal audits. Other programs (OSHA PSM, and RMPP) CaIARP provides strong ways for community to be involved. • Dennis Cuff: Follow-up to Mr. Sattler on turnover. Unusual for Tosco, not unusual for industry. How many people have left and how many are on leave and how does that compare? Ivor: Need to look at people and positions. Some supervisors, operators, health & safety.... We didn't do thorough audit. We looked at percentages. I think we could get that information. • Ray: I would also thank the people at Tosco who are, I am sure trying with all their might who are working on making the changes. This has got to be such a difficult job from them. Thanks to Tosca for trying to make it work. • Ralph: Turnover comparison to industry is not relevant to Tosco, if Tosco's historical experience is low turnover, then higher turnover is significant. John: Agreed. This has been a difficult year for Tosco. In a year or so, it would not surprise me to see turnover rates go back to where they were previous to the incident. • Ralph: Turnover is a concern if the people leaving are skeptical that changes will occur. Ivor: Management recognized need to replace operators. Thousands of applications. Also considered contract operators. We were looking at how management addressed issue of loss of employees. We pointed out skeptics to show that not every one agrees, but skeptics are in minority. • Ralph: EWS; How will you find EWS if it will take you S years to evaluate all CalARPs Randy: 3 years for all CalARPs. Annual HMBPs. Other agencies (OSHA, BAAQMD). John: Additional OSHA funding for unannounced audits. It's a good thing. • Michael: My office is available to help the public use the information. • Kevin King: Brother in law. Roland.Blue. On his behalf, I would like to ask about the safety of the contractors. Have you addressed contractor safety issues? Ivor: We were looking at recommendations, which did not include contractor safety. Go back to the original investigation to see contractor issues addressed. • Kevin: In your opinion, do contractors have ability to stop work, raise red flag? B-3 Final Report Ivor. We looked at maintenance activities. Contractors were given same attention. .Daily Safety meetings. • Kevin: Has Tom O'Malley been back to see what's happening since he was here in the beginning of the process? Randy: We will ask. B-4 Final Report Attachment C Comment Letters Received on the Draft Follow-up Assessment Report and Responses Final Report t c, 00 COMM U files for a Safe rin v irvx men t 623 larcyette St., Murdnex CA 54553 925-370-9729 FAX; 925-371"672 page(s)---- January 19, 1999 Brandy Sawyer Ccintra festa County Health Services Dept. FAX 646-2073° COMMENT ON THE 1111/00 ADL PRBSFNTA:FION ON"1(WO PROGRESS FROM: COMMU`t ITIM X)R A SAFE EN V RONNEW CSE was messed with the progress at TOS M. , as reported by ADL atthe 1/11/1.1 public meeting. Thugs definitely s€em,on a goal . prat h. AD1.'s presentation on "corporate culture" emphasi2ed that a goad process is underway, but noted it's too soon to expect results. 'rhe rocket-launch nwtaphor seetned apt. 'rhe engines are at power, but lift-of has not yet occurred. This leads CASE to conclude that continued tracking of TOSCO by ADL is extremely imports nt. We encourage the County to contract with ADL to return in perhaps a year to assess progress. We think that it will help if TOSCO knows that Alar. will be looking over their shoulder on a sustained basis. We encourage the County to recognize than TOSCO probably will need to be closely trached for a number of years.ADL seems to us well qualified to help vAth the job. We,amain concerned haat TOSCO as an Institution may be rm)re prcoccupied with near-term bottom-litre issues than other refineries In our regiorL That preoccupation may have been respruisible for corner-cutdag than lead to the deterioration that resulted in the tragic explosion. The County must assure it is in a position to anticipate similar problems in the ftttayre, and taa uike early action. That will require sustained County support of necessary staff operations. A&W-1 * �► r,� Pawl Craig at:ui Ralph Sattler Conmwntles for a SaMe Environment, Maninev C--1 t WILLIAM B. WALKER, M. D. " HAZARDOUS MATERIALS PROGRAMS HEALTH SERVICES DIRECTOR Lewis G. PASCAE.UJR.,Est2, 4333 Pacheco Boulevard DIRECTOR Martinez, California "••- 944553-2295 C `./ N• i kA COSTA Ph (925) 546-2286 Fax (925) 646-2073 HEALTH SERVICES , January 28,2000 Mr.Paul Craig and Mr.Ralph Sattler Communities for a Safe Environment 623 Lafayette Street Martinez,CA 94553 Dear Mr. Craig and Mr. Sattler: Subject: Tosco San fancisco AmAefinery at Avon Follow-up on the Safety Evaluation Thank you for your comments on the draft report Follow-up Safety Evaluation of the Tosco Avon Refinery in Martinez, California prepared by Arthur D. Little, Inc. Contra Costa Health Services agrees that the process that Tosco has begun is a long-term process. The Board of Supervisors hired Arthur D. Little, Inc. to do the original safety evaluation of the Tosco Avon Refinery, which was completed in May, 1999. The Board of Supervisors then asked Arthur D. Little, Inc.'to do a follow-up evaluation on the progress that Toscowas making to address the recommendations from the original evaluation. Arthur D. Little, Inc. has now completed this evaluation. Contra Costa Health Services will follow-up on the recommended actions as suggested by Arthur D. Little, Inc. Contra Costa Health Services will also be performing a California Accidental Release Prevention Program and a Safety Program under the Industrial Safety Ordinance Audits this year. The audits and the follow-up on the recommended actions will help to ensure that Tosco continue their progress in developing a good safety culture. . If the Board of Supervisor determines that additional oversight by a third party is warranted,they may request additional follow-ups by Arthur D.Little,Inc. Enclosed is a copy of the final report by Arthur D. Little, Inc. for Mr. Craig. A copy of the - report has been sent to Mr. Sattler under a different cover letter. If you have any questions, please contact me. Sincerely, Randall L. Sawyer Accidental Release Prevention Specialist Enclosures(1) cc: John Peirson,Jr. -Arthur D.Little,Inc. + Contra Costa Community Substance Abuse Services + Contra Costa Emergency Medical Services + Contra Costa En*onrnental Health + Contra Costa Health Pian Contra Costa Hazardous Materials Programs •Codtra Costa Mental Health • Contra Costa Public Health • Contra Costa Rilgional Medical Center • Contra Costa Health Centers + C-2 Ralph J.Sattler 1204 Ulflnian Way Martinez,CA 94551-1973 Telephone: (925)229-0693 Fax:(925)229-2274 January 20,20(X) Re.Arthur D.Little Follow-up Safety Evaluation of the Tosco Avon Refinery Public comment subtrnssion I want to express my appreciation to the County for their decision to hire an outside consultant, A nhur V. Utle,(ADL)to conduct the initial evaluation of Tosco polices and environment as it relates to the safety of it's workers and our community.ADLs evaluation was recently completed and found that Tosco appears to be on the right tack. however,d y made a very valid point in saying that change takes time. Oversight is required to assure that the changes that Tosco has implemented continue and Haat they achieve their pew ws. Not all of the changes that Tosco has either implemented or agreed to implement Piave been completed. Arthur D. Little(ADL)in my opinion has done an excellent job and I and Communities for a Safe Envies urges the County to have AUL conduct a follow-up evaluation of Tosco in twelve months. Following are my commma on some of the specifics addressed in their re-evaluation report and on the comments made at the public meeting in January,2000. 1, The Public numting: a. In talking with,AIM,personnel after the meeting.they expensed the opinion that the plant manager is committal to changing the safety milture and to operating the plana to high health and safety stwx1ards. I was told that Tosco has spent and has committed to spend millions of dollars to improve their Avon plant- b They commented that dmge takes time. it is too soon to tell that the:changes implemetKed by Tosco will be on-going. C. Fourteen of the recomnmAztions made and that we being implemented require follow-up by the County. Page 1 c-3 Ralph J. Sattler 1204 Ulfinian Way Martinez,CA 94553-1973 Telephone: (925)229-0693 Fax: (425)229-2274 d. A gentlernem who is related to one of the contract workers killed questions the lack of the evaluation addressing contract employees. fie Was told that Tosco is applying the same standards to both direct employees and to contract employees. No.23 addresses contract employees. "Tosco Safety and You"train;to provide additional iaronnation onvarious process wits and that process overviews epee Available in the Control Roam of Each Unit. If'they are performing the same work,both Tosco and contract employees must have the same training and qua]iflcationa. Asking the unit oerator if they bane questions implies a Lesser degree of knowledge and should not be acceptable. e. Commits were;made in the presentation that Tosco employees are now clear that they have the authority to shutdown an operation that they consider unsafe. This is addressed in#74 on page 33 and 34. it my opinion,it is still.a major concent. We have heard conflicting.stori,es from both current and former Tosco employees as to their perception of their right and authority to stop work if they feel it is unsafe anti to their perception of the consequences in doing so. CCHS must - conduct periodic interviews as recommended to assure that employees understand they azo=mired to stop/shutdown any work they deem unsafe. 2. The re-evaluation report. a. Page 3,#7. Complete human factors&facility siting hazard reveiwa for all covered processes. The recommendation is that Tosco complete the human factors&facility siting checklists for the remaining 3 units prior to the fall PHAs. The county should require that the checklists are completed and reviewed and approved by the county by no later than Juste,2000. Page 2 C-4 a Ralph J.Sattler 1204 Ulfbfw Way .Uhrdozz,CA 94553-1973 Telephone:(925)229-0693 Fax.(925)223.2274 b. Page 17,#30. Establish a document control system that provides assurance that ah safety management documents are current,consistent ad accurate. Recomnmdation:Tosco should continue to work on the Popes and Procedures Manual to ftalize this document as soon as,possible. This is an exatuple of ont of several recommm4ations made by ADL where the Counny needs to specify time deadlines for the completion of the recommendation. Q Page 21,#41 _Revise the incident investigation procedure to provide further guidance for deciding haw"lessons " should be shared. The revised mcttient investigation procedure includes a section called communicating results. This provides a CAMANCE for sharing results with employees,other fhctilities and to Centra Costa Health Services. In my opinion.the procedure should state speciflo requirements to assure that the "lessons learned"and the results of the investigation are communicated.I fod the term"guidance'°'to be too ambiguous and not addressing a commitmwt to full disclosure of the results of the investigation. d. Page 21,#42-...to identify remote controls for fire isolation are difficult to mess or activate. e. Recommendation:Contra Costa Health Services(CCSH)should followup within a year to assess Tosco's progress in impkmunting the solutions. A year? Way tots kmgi 11w alternative systems must be impleme-nted now and verification ttande by the COSH that this Imo been done. According to the assessment, lives au&or severe injury to employees are at stake. f_ Page 22,#46-11w CCHS needs to confirm that Tosco has in4ilemcated the short term recommendations of the human factors assesstrAw. A time litre needs to be establial d with identified priorities for the implementation of the long-tam recomnymdations. Page 3 C-5 r Ralph J. Sattler 1204 Ulfbian Way Martinez,CA 94353-1973 Telephone:(925)229-0693 Fax:(925)229-2274 g. Page 22,23,#47 -Develop a procedure to encore that maintenance issues relating to the proper functioning,of warning lights&alarms are addressed immediately upon submission. .....check for warning light&alarm maintenance requests which are 30 days old. The planner then flags the item&brings it to the imrraediate attention of maintenance. Malfunctioning warning,lights and Warm IMMEDIATE repair and must hrnedon properly. Allowing warning lights do alarms to malfunction for up _. to& beyond 30 days bas the potential of lending to iqury add the deaths of `raw employees as won as harm to the community. While It b not exactly they am,this is the type of malibnetions that led to the death of Mlebeel (11ansmamIll This is ora example of unsafe conditions. Work needs to be shutdown and the warning lights and alarms rrepal AUL included in their comments 14 rewmmer4adons which require review and oversight by the CCHS deprtmmt. Many of their comments made reference to a review in one year. In my opinion,some of those items need to be reviewed and address in a shorter time frame. Both AUL and CCHS neer to set specific deadlines for the completion of some of these recommendations. Linder separate cover, Cotes for a Safe Environment has rec omnended that the County has Arthur D.Little conduct on-going evaluations of Tosco to assure that the recommendations made and that are being implemented by Tosca continue.As AUL stated,changes happen over time. We need to assure that these changes ruin in place and those that have not bean . completed yet are completed within a reasonable time Brame. ADL's evahnatiem addresses only the Tosco Avon plant. Tesco operates the Rodeo plant which has bad recent upsets. Rodeo shares some:of the same management as Avon. 7`h ere is a real concern that Rodeo safety culture and operation is nat being given the same priorities by Tosco as that of their Avon plant. Avon is under the immediate scrutiny of both the county ad the pubh e. Rodeo is not subject to the warns+scrutiny at this time and it appears that Tosco has not imposed the same standards for Rodeo as are being impletneoted at Avory.T&County needs to apply the same oversight to both plants_ Page 4 C-6 <1'c Vit.t.tAM U. YYAI.KER. M I.J. HAZARDOUS MATERIALS PROGRAMS EALTH SERVICES DRECTOR IS G. 1?ASCAI.I.I.JR..EtiCL 4333 Pacheco boulevard E r is Martinez, California C O 1 -T R.A COSTA Ph (925) 646-2286 Fax (925) 646-2073 HEALTH SERVICES t. January 28,2000 Mr.Ralph Sattler 1204 Ulfinina Way Martinez,CA 94553-1973 Dear Mr.Sattler: Subject: Tosco San Francisco Area Refinery at Avon Follow-up on the Safety Evaluation Thank you for your comments on the draft report "Follow-up Safety Evaluation of the Tosco Avon Refinery in Martinez, Califomia" prepared by Arthur D. Little, Inc. Contra Costa Health Services agrees with your statement that "Tosco appears to be on the right track." Contra Costa Health Services also agrees that it takes time for the changes being made to have an effect on the safety culture at the refinery. presented below are responses to your questions or comments. These responses have been prepared by Contra Costa Health Services and Arthur D.Little,Inc. The public meeting: a. In talking with ADL personnel after the meeting, they expressed the opinion that the plant manager is committed to changing the safety culture and to operating the plant to high health and safety standards. I was told that Tosco has spent and has committed to spend millions of dollars to improve the Avon plant. No response required. b. They commented that change takes time. It is too soon to tell that the changes implemented by Tosco will be on-going. No response required. C. Fourteen of the recommendations made and that are being implemented require follow-up by the County. No response required. d. A gentleman who is related to one of the contract workerg killed questions the lack of the evaluation addressing contract employees. He was told that Tosco is applying the same standards to both direct employees ,and to contract employees. No. 23 addresses contract employees. "Tosco Safety and You" training to provide additional information on various process units and that process overviews are Available in the Control Room of Each Unit. If they are URI • Contra Costa Community Substance Abuse Services • Contra Costa Emergency Medical Services • Contra Costa Environmental Health + Contra Costa Health Plan • Contraosta Hazardous Materials G Programs •Contra Costa mental Health Contra Costa Public Health Corina Costa RSgiorsai Medical Center • Centra Ceuta Health Centers C-7 • Page 2 January 28,2000 , performing the same work, both Tosco and contract employees must have the same training and qualifications. Asking the unit operator if they have - questions implies a lesser degree of knowledge and should not be acceptable. Each of the contractors that work at the facility must pass a safety evaluation that Tosco performs before hiring the contractor. This evaluation looks at the qualifications of the staff, the training programs that the contractor has and the overall safety record of the contractor. Recommendation A-06.a was designed to assure that the contract employees receive training on the process area where they will be working. It was not intended to address the contractor worker's qualifications,but rather to assure that the contract workers understood the hazards associated with the process unit where they were working. As part of the "Tosco Safety and You" training that contract workers receive, Tosco has expanded it to include an overview of the various processes, and to address the hazards associated with each of the process units. The information provided in the control rooms is there for all the workers, both Tosco and contractors. The policy also requires that contractors and Tosco employees ask the unit operators if they have questions or are not sure about issues associated with the process operations, and how they may affect the work they are performing. Maintenance workers,both contractor and Tosco,should not be expected to have the same level of knowledge about the process unit operations as the process operators. It should be noted that the process operators are responsible for assuring that maintenance activities at their units are done in a safe manner. e. Comments were made in the presentation that Tosco employees are now clear that they have the authority to shutdown an operation that they consider unsafe. This is addressed in#74 on page 33 and 34. It is my opinion, it is still a major concern. We have heard conflicting stories from both current and former Tosca employees as to their perception of their right and authority to stop work if they feel it is unsafe and to their perception of the consequences in doing so. As part of the follow-up assessment, the team asked almost all of the people interviewed if they felt they could stop a job if it seemed unsafe to them. In every case, the answer was yes. There are signs that have been placed throughout the refinery that tell staff to stop work if they feel it is unsafe. This practice has been reinforced in all of the employee meetings and safety newsletters. It is clear that management is committed to allowing workers to stop work if they feel it is unsafe. CCHS must conduct periodic interviews as recommended to assure that employees understand they are required to stop/shutdown any work they deem unsafe. V C-8 • Page 3 January 28,2000 As part of the Risk Management chapter of the County's Industrial Safety Ordinance CCHS has established a guidance document. The guidance document lists latent conditions' that are incorporated into a checklist. The real issue with workers being able to shut down an unsafe act is the manner in which a facility balances production and safety. The latent condition would be that the facility sends the wrong signals, or at least employees perceive the signals to mean that the facility has a disproportionate emphasis on production (i.e.,they are willing to sacrifice safety). "Production versus safety" concerns represent one of several possible latent conditions at a source. The ordinance and the guidance document require sources: a) to determine whether the latent conditions in the checklist exist in their source and b) to rectify them. NOT1J: sources do not have to apply the checklist,but they do have to address every issue in the checklist. As part of the audit methodology, we will "sample" latent conditions in the checklist and determine: a) does the latent condition exist at the source? b) how did the stationary source determine whether it exists? c) what did the stationary source do to rectify the latent condition? If CCHS is able to identify latent conditions that the source either did not identify or did not rectify, CCHS believes that the human factors program (and therefore their Safety Program) is deficient and that they are out of compliance with the ordinance. CCHS will also be auditing the prevention elements of the refinery. If the refinery incorporates into their prevention elements that workers can stop work if it is unsafe to proceed, then the refinery will need to follow their own policies and procedures to be in compliance with the California Accidental Release Prevention and Risk Management Programs and the Risk Management portion of the Industrial Safety Ordinance. ' Literature commonly refers to active failures and latent conditions in describing where human factors and error originate and occur. Active failures are errors and violations committed by people at the human- system interface such as operators and maintenance personnel. These failures are usually unique to a specific event and have immediate effects. Latent conditions arise due to decisions made throughout the organization(e.g.,marketing personnel,designers,managers)and outside of the organization(e.g., regulating agencies). Latent conditions exist in all systems and may lie unrecognized until combining with active failures to result in an incident. The same latent condition may contribute to a number of different accidents. An example of active failures and latent conditions is"the design of a scrubbing system may not be adequate to handle all credible releases. If an active human error initiates the production of an excessive volume of product the system may allow toxic materials to be released to the environment." C-9 • Page 4 January 28,2000 CCHS will interview the employees as part of the auditing process to make sure that the refinery complies with the California Accidental Release Prevention Program and the Industrial Safety Ordinance. This includes asking the question. "Do you feel that you are able to shut down work or a process if it is unsafe to proceed. 2. The re-evaluation report. a. Page 3, #7. Complete human factors & facility siting hazard reviews for all covered processes. The recommendation is that Tosco complete the human factors &. facility siting checklists for the remaining 3 units prior to the full FHA's. The county should require that the checklists are completed and reviewed and approved by the county by no later than June,2000 Tosco plans to complete the full PHAs for these three units in the year 2000 although they are not required by law to be done for another two years. It is better to conduct the human factors and facility siting checklists as part of a full PHA then to do them separately.The follow-up action for A-02.a has been modified to include a requirement that the human factors and facility siting checklists be completed as part of the full PHAs for the three remaining units by the end of the year 2000. A recommendation has been added that CCHS should follow-up to assure completion of these PHAs at the end of December,2000. b. Page 17, #30. Establish a document control system that provides assurance that all safety management documents are current, consistent, and accurate. Recommendation: Tosco should continue to work on the Policies and Procedures Manual to finalize this document as soon as possible. This is an example of one of several recommendations made by ADL where the County needs to specify time deadlines for the completion of the recommendation The follow-up action for A-11.a has been expanded to include a requirement that the Policy and Procedures Manual be complete by the end of July, 2000, and that CCHS should follow-up to assure completion before the end of August,2000. C. Page 21, #41 — Revise the incident investigation procedure to provide further guidance for deciding how"lessons learned"should be shared. The revised incident investigation procedure includes a section called communicating results. This provides a GUIDANCE for sharing results with employees,other facilities and to Contra Costa Health Services. C--10 10a, . • Page 5 January 28,2000 In my opinion, the procedure should state specific requirements to assure that the "lessons learned" and the results of the investigation are communicated. I find the term "guidance" to be too ambiguous and not addressing a commitment to full disclosure of the results of the investigation. The choice of the word "Guidance" in the assessment text for recommendation A-141 was incorrect.The revised Incident Investigation Program policy has a section that spells out the communication requirements.This covers requirements for communicating to employees, other Tosco facilities, and the County. The assessment text has been modified to better reflect the communication requirements. d. Page 21,#42 - . . . to identify remote controls for fire isolation are difficult to access or activate. Recommendation: Contra Costa Health Services (CCHS) should follow-up within a year to assess Tosco's progress in implementing the solutions. A year? Way too long! The alternative systems must be implemented now and verification made by the CCHS that this has been done. According to the assessment,lives and/or severe injury to employees are at stake. The recommendation discussed in the comment is for item #43. The alternative systems that Tosco has identified require engineering, procurement and then installation. Some of the items have long procurement lead times. The follow-up action for B-02.a has been modified to recommend that CCHS follow-up before the end of October 2000 to assure that the engineering solutions have been implemented. f. Page 22, #46 —The CCHS needs to confirm that Tosco has implemented the short-term recommendations of the human factors assessment. A time line needs to be established with identified priorities for the implementation of the long-term recommendations. Some of the short-term recommendations will be implemented within the next few months. However, some of them require engineering, procurement and installation,which will require until the end of the year 2000. The follow-up action for B-04.a has been modified to recommend that CCHS follow-up before the end of August, 2000 to assure that the short-term recommendations are being implemented and that a plan has been developed for implementing the long-term recommendations. An additional recommendation has been added to have CCHS follow-up within one year to assure that Tosca completed the installation of the short-term recommendations, and is making progress on implementing the long-term recommendations. C-11 +r Page 6 January28,2000 g. Page 22, 23, #47 — Develop a procedure to ensure that maintenance issues relating to the proper functioning of warning lights & alarms are addressed immediately upon submission. check for warning light&alarm maintenance requests which are 30 days old. The planner then flags the item&brings it to the immediate attention of maintenance. Malfunctioning warning lights and alarms IMMEDIATE repair and must function properly. Allowing warning lights & alarms to malfunction for up to & beyond 30 days has the potential of leading to injury and the deaths of Tesco employees as well as harm to the community. While it is not exactly the same, this is the type of malfunctions that led to the death of Michael Glansman!!! This is an example of unsafe conditions. Work needs to be shutdown and the warning lights and alarms repaired! Tosco has a program in place for safety critical alarms and warning lights. This program requires that operators submit an emergency work order to have these items repaired.Emergency work orders are processed immediately, the items are fixed within one to three hours depending upon the complexity, and the staff needed to complete the repair. Recommendation B-04.c was developed to address non-safety critical alarms and warning lights, which sometimes were not fixed for months. The assessment text has been expanded to address this clarification. ADL included in their comments 14 recommendations which require review and oversight by the CCHS department. Many of their comments made reference to a review in one year. In my opinion, some of those items need to be reviewed and addressed in a shorter time frame. Both ADL and CCHS need to set specific deadlines for the completion of some of these recommendations. Based upon the comments outlined above, speck dates have been set for completion of some of the follow-up actions as well as verification by CCHS. Under separate cover, Communities for a Safe Environment has recommended that the County has Arthur D. Little conduct on-going evaluations of Tosco to assure that the recommendations made and that are being implemented by Tosco continue. As ADL stated, changes happen over time. We need to assure that these changes remain in place and those that have not been completed yet are completed within a reasonable time frame. Enclosed you will find a copy of the response letter that CCHS made to Paul Craig and yourself as representatives from Communities for a Safe Environment. ADL's evaluation addresses only the Tosco Avon plant. Tosco operates the Rodeo plant which has had recent upsets. Rodeo shares some of the same management as Avon. There is a real concern that Rodeo safety culture and operation is not being given the same priorities by Tosco as that of their Avon plant. Avon is under the immediate scrutiny of both the county and the public. Rodeo is not subject to the same scrutiny as this time and it appears that Tosco C-12 • page 7 January 28,2000 has not imposed the same standards for Rodeo as are being implemented at Avon. The County needs to apply the same oversight to both plants. As you are aware the operational cultures at the two refineries are different since only recently has Tosco acquired the Rodeo refinery. The Avon refinery was a concern to the Board of Supervisors because of the accidents with fatalities on February 23, 1999 and January 27, 1997. The Rodeo refinery has not had accidents with fatalities for many years. Two third party safety audit of the Rodeo refinery did occur in 1997. One was done under the Good Neighbor Agreement and the second was done through the County. If you wish to get a copy of the audit report that was done through the County, please contact me. Again, I thank you for your comments. I acknowledge the time and effort it takes to do a thorough review of the draft report that was required to come up with the above comments. Enclosed you will find a copy of the final report from Arthur D. Little, Inc. If you have any questions,please contact me. Sincerely, Randall L. Sawyer Accidental Release Prevention Specialist Enclosure(1) cc: John Peirson,Jr.-Arthur D.Little,Inc. c-13 �s ?i Attachment D Scope of Work for the Initial Safety Evaluation Final Report Tosco San Francisco Area Refinery ` Management Systems and Safety Evaluation Of the Avon Facility Statement of Scope Objective The objectives of this Process Safety Management Systems and Safety Evaluation are to do a thorough evaluation of the management practices and safety culture at the Tosco Avon Refinery, and to determine what would it take for the facility to start up in a safe manner within sixty days from March 12, 1999. Background Because of incidents that have occurred at the Tosco Avon Refinery, communities surrounding the refinery,the Contra Costa County.Board of Supervisors, and Health Services are concerned about the refinery operating safely. Among these incidents are a January 21,1997 explosion and fire at the hydrocracker and a February 23, 1999 flash fire at a crude unit. These two incidents resulted in the death of five workers, and injuries to others. In response to these incidents, the Contra Costa County Board of Supervisors has directed Health Services to arrange for a third-party evaluation performed on this refinery. This evaluation is being done at the same time that Contra Costa Health Services, Cal/OSHA, and the federal Chemical Hazard Investigation and Safety Board are conducting investigations of the incident that occurred on February 23, 1999. Cal/OSHA is investigating the initiating cause of the incident and whether the refinery was out of compliance with regulations Cal/OSHA enforces. This is a thorough investigation regarding protection of workers' health and safety at the unit involved in the incident. The Chemical Hazard Investigation and Safety Board and Contra Costa Health Services will each conduct a root cause analysis of the incident. These analyses will determine the initiating causes of the incident, how the incident occurred, and its underlying root causes. The underlying root causes will determine which process safety management systems failed that led to this incident. The investigations will look at training, operating procedures, mechanical integrity, contractor safety,process safety information, communication, the design of the equipment,hot work permits, and safe work permits. The findings and recommendations will address the management systems that failed on February 23, 1999 and what needs to be done to correct these failures. Requirements The Management Systems and Safety Evaluation will evaluate the refinery's human factors and systems concerning the management practices and safety culture at the refinery D-1 Final Report Scope of Work The evaluation will be conducted at the Tosco San Francisco Area Refinery at Avon. 1. Evaluate how the refinery's management safety systems, safety culture, and how human factors are incorporated in the training of operating, maintenance, other staff, management personnel, and contractors. The process safety management systems to be addresses are: Operating .Procedures, Training, Management of Change Pre Start-Up Safety Reviews, Incident Investigation, Hot Work, Contractors, Emergency Response Program, Compliance Audits, Employee Participation, and Process Hazard Analysis. This evaluation should include,but not be limited by the list in Appendix A and the items listed below: a. How is management intent, as expressed in internal policies, carried out at field level? b. How are procedures developed? What does Tosco do when work falls outside of the written procedures? c. How is bottom-up input provided for, and on what range of subject matter? How are disagreements resolved? d. What systems are in place to assure that management policies and/or procedures are carried out? Do these include audits? e. What accountability exists at each level of the organization? Who is accountable for what and to whom? L How have the reduction and reorganization of personnel, including contract personnel effected the plant safety? 2. Public Participation — the evaluation will include public participation. The public participation process is being developed by the County. The contractor should expect that the process will include public meetings at which the contractor will explain the firm's plan, progress, and_results. The meetings will be an opportunity for the contractor to listen to the public's concerns and consider incorporating them in the evaluation. The contractor should expect to attend and make reports at meetings such as the following (precise details will be made available in the County's public participation plan): a. An initial meeting before starting the evaluation; b. Weekly meetings during the evaluation to report the progress being made and to receive input from the public; c. A public meeting to discuss the draft findings of the evaluation; d. A meeting of the Board of Supervisors, to present the final report. 3. The contractor will conduct a follow up evaluation to determine how Tosco is addressing the findings from the initial evaluation and to report on the progress that is being made in addressing the findings. This evaluation will occur at a date to be determined by the contractor. The contractor will prepare a plan for evaluation and will submit this plan to the Project Manager from Contra Costa Health Services for his/her review. Included in Appendix A are examples of items to be considered in this evaluation. The contractor should use this list to assist in determining the evaluation of Tosco's current program for addressing management systems, safety practices, and the safety culture of the Avon Refinery. D-2 Final Report ---car. Appendix A Self-evaluation Questionnaire for Managers Considering'Ways To Improve Human Performance4policy Issues 1. Is upper management's commitment to employee health and safety clear? What policy statements communicate this commitment to employees? Do workers understand these policies and are they convinced of upper management's sincerity? 2. Do supervisors and workers believe that safety has higher(or at least equal) status with other business objectives in the organization? How does the company promote a"safety first" approach? 3. Have supervisors and workers been specifically told to err on the safe side whenever they perceive a conflict between safety and production? Will such decisions be supported throughout the management chain? 4. Is management of worker health and safety an essential part of a manager's daily activities? How are managers held accountable for their health and safety record, and how do the rewards and penalties compare to those for production performance? 5. Is health and safety regularly discussed in management meetings at all levels? Do such discussions involve more than a review of injury statistics? What actions are taken4f an injury occurs? Are near misses discussed, and is any action taken to prevent recurrence? 6. In the areas of design, construction, procurement, operations, maintenance, and management are there clearly defined procedures for evaluating the human factors aspects of: • New and modified processes? • New and modified equipment? • New and modified procedures? • Special, abnormal, and one-of-a-kind procedures? 7. Are human factors resources available in the organization, and are they readily available to help resolve procedural issues? Do they periodically review the adequacy of the standards in conjunction with other groups (engineering, operations, maintenance, etc.)? 8. Are adequate time and resources allocated to human factors? How is human factors integrated into the procedure writing process? 9. Do workers help identify error-likely situations in existing designs/procedures? Are they also involved in the review of new designs/procedures? How is worker input used? Are worker suggestions implemented? 10. Are workers encouraged to discuss potential human errors and near misses with their supervisors? Are such worker disclosures treated as evidence of worker incompetence, as unwarranted criticism of management, or as valuable lessons to be shared and acted upon? What criteria and procedures exist for reporting and investigating accidents and near misses? Are they followed consistently? Do the investigations go into enough depth to identify the root causes of worker errors? How are the human factors engineering deficiencies identified 4 This a modified list from the Chemical Manufactures Association's(CMA)book titled A Manager's Guide to Reducing Human Errors Improving-H-uman Performance in the Chemical Industry. D-3 Final Report during the investigation of an incident corrected at (1) the site of the original incident, (2) similar sites at the same facility, and (3) similar sites at other facilities? 11. Are supervisors trained and encouraged to identify error-likely situations, unsafe behaviors, and personal problems that may adversely affect a worker's performance? What actions are taken if a problem is identified? 12. Are data on human errors collected and made available to managers? Have the data been used as the basis for any management decisions? Are the data collected routinely or are they only collected after an accident? Job and Task Issues 13. Have critical jobs and tasks been identified? Have the mental and physical aspects of such jobs been analyzed for both routine and emergency activities?What has been done to reduce the likelihood and/or consequences of potential human errors in the performance of these jobs? 14. Have jobs and tasks been designed to maintain worker interest and involvement? Are assignments rotated to even out workloads and increase worker experience? How have activities with safety implications been emphasized? 15. Are the worker's individual responsibilities clearly defined? How do these relate to team responsibilities? How is worker performance monitored and measured? Procedural Issues 16. Is a complete, current set of procedures available for workers to use? How are specific, up-to-date procedures maintained? Do the workers themselves help review/revise the procedures? How often? Are known errors allowed to remain uncorrected? 17. Are procedures written for the right level of knowledge and understanding by the workers, considering their education, background, experience, native language, etc.? Is a step-by-step format used? Are diagrams, photographs, drawings, etc. used to clarify the written text? Are cautions and warnings clearly stated in prominent locations? Does procedure nomenclature match equipment labels? Are there too many abbreviations and references to other procedures? 18. Do worker practices always comply with written procedures? How are differences detected and resolved? Who can authorize changes and deviations from the written procedures? Does such authorization include a review of the safety implications of the change or deviation? Do cautions always precede action steps in the procedures? 19. Are work permit systems correctly used? How are contractors included in such systems? 20. Are the emergency procedures clearly written? Are they practiced regularly? How many "immediate" actions are required? Are the procedures designed so workers can cross-check each other's performance of the necessary tasks? 21. Are checklists used for critical procedures? Is only one action specified per numbered step? Are any instructions embedded in explanatory notes? Are the steps in the correct sequence? Do steps requiring control actions also specify the correct system response? D-4 Final Report Worker Issues 22. Did human factors specialists help develop worker hiring and assignment policies? How are the results of job and task analyses converted into appropriate criteria for worker selection based on physical abilities, aptitudes, experience, etc.? 23. Is there a written training policy applicable to all workers? What safety objectives are established and how is attainment of such objectives monitored? 24. Are training records kept? How are retraining needs identified? How are workers trained on new processes, equipment, and procedures? What training is given to workers changing jobs or taking additional responsibilities? What training is given to new workers? How is training effectiveness assessed? 25. Are pre-employment and periodic health assessments performed for workers who must meet and maintain defined medical standards? Is a worker's health evaluated before he/she is allowed to return to work after an illness? 26. Are there programs for identifying and helping workers with substance abuse or mental health problems? What counseling, support, and professional advice is available to workers during periods of ill health or stress? What is the company policy on reassigning or terminating workers who are unable/unfit to perform their jobs? D'5 Final Report 4 Attachment E Glossary of Terms Final Report Glossary Accident An undesired event that results in harm to people,damage to property or the environment,or loss to Rrocess. Action item A formal term used to describe the measures developed in hazard identification studies,incident investigations,safety inspections and/or audits. These may include recommendations to modify the design,changes to procedures and/or other administrative controls. Anecdotal evidence See evidence. Audit A systematic,independent review to verify that management systems conform with established guidelines or standards.It employs a well-defined review process to ensure consistency,and to allow the auditor to reach defensible conclusions. Bidding system Term used by represented labor to describe the way in which a person may ,gain promotion b "bidding"for open positions. Bottom-up communication This term is used to describe communications that are initiated from the lower levels of the organization,Communications may be written or verbal. Catastrophic event An event which is a major uncontrolled emission,fire, or explosion, involving one or more highly hazardous chemicals,that presents serious danger to employees and/or the community. Causal factor A major contributor to an incident(component failures,unsafe conditions, human errors)that,if eliminated,would have either prevented the incident or reduced its severity.A different root cause may be identified for each causal factor. Compliance audit An audit conducted to determine a facility's degree of compliance with a regulatory standard and other applicable policies and procedures. Compliance Monitoring The activities conducted by a facility to monitor compliance with regulations, and internal policies and procedures.These activities may include process monitoring using equipment or record-keeping,inspections,audits,and corrective action proEams. Continuous Improvement The activities established to ensure continuous improvement with respect to safety performance.These activities may include identification of key performance indicators,performance goals,and documentation of performance. Control panel An assembly of indicators and recording instruments;pressure gauges, warning lamps,and other visual or audible signals used for of monitoring and controlling a system. Control room Location where operators monitor and control the operation of a process unit (s). Document control system The procedures and/or processes used to ensure that important documents (including safety-related documents)are developed,updated and circulated in a controlled manner. Document stewards and Terms used by Tosco to identify the persons responsible for developing and coordinators updating the documents. Emergency A sudden and unexpected event calling for immediate action.The event may be an uncontrolled release of a hazardous substance which cannot be controlled at the time of the release by em to ees in the immediate area. Emergency procedures Procedures used by unit operators when a process parameter(s)deviates outsides the range of normal operations.These procedures include the steps that should be taken to bring the unit back into the normal range,and the ste s needed to shut down the unit if the excursion cannot be rectified. E-1 Final Report _;l,g Emergency response drill Reports generated by the facility following emergency drills conducted to test critiques the emergency response procedures.The critiques provide feedback for continuous improvement of the emergency response plan. Emergency response program Facility program that includes procedures for identification of emergencies, evacuation,notification,response,medical treatment and first aid,and the inspection/testinginspection/testing of eMergency equipment. - Employee participation Written program required by the PSM standard that defines how employees participate in the facility's safety management programs. Evidence(anecdotal and factual) Information gathered by the evaluation team,used to support findings.The information may be anecdotal(e.g.,people's opinions)or factual(e.g.,based on written documents or physical inspections). Facility siting Term used in the OSHA PSM standard referring to the location of process controls,emergency equipment,etc.,in relation to the process hazards. Factual evidence See evidence. Focus group discussion A group interview in which the interviewer leads the group through a discussion of a specific topic of interest. Hazard A hazard may be defined as an unwanted event.Typical hazards include fire, explosion,release to the environment,and chemical exposure. Human Factors The design of machines,operations,and work environments so that they match human capabilities,limitations,and needs. Includes any technical work(engineering,procedure writing, worker training, worker selection,etc.) related to the human factor in operator-machine sstems. Incident Includes Accidents and Near Misses Incident investigation This is the formal process used to investigate accidents and near misses.The incident investigation procedures are developed by each facility to meet their own specific needs. Inherent Safety A process is inherently safer if it reduces or eliminates the hazards associated with materials and operations used in the process and this reduction or elimination is permanent and inseparable. Injury and Illness Prevention A Cal-OSHA standard applicable to high hazard facilities.It involves Program programs for hazard identification,hazard correction,training, responsibilities and accountabilities. Inspection An inspection is the process of physically examining a facility or equipment item. Layered safety program Term used by Tosco to describe a safety inspection program in which managers at all levels Safety inspections, Limit of safe operation Upper and lower limits for a range of process parameters that define the bounds of safe operation.The parameters may include flow,pressure, temperature,etc.The PSM standard requires operators to establish limits of safe operation for the process parameters including pressures,temperatures, flows,etc.When a process parameter gets outside the safe operating limits, the steps needed to be taken by an operator are generally described in the emergency rocedures. Maintenance priority code A code used to define how important the maintenance activity is.For example, safety-critical items may be designated 5,while replacing a light bulb may be rated as a 2. Management of Change A formal management process to control the hazards associated with a change.Change may include changes to equipment,to chemicals,to the technology,and/or to staffing levels. Mechanical Integrity The mechanical integrity of a process involves the maintenance of process equipment,the inspection and testing of vessels, and the quality assurance of arts and materials. Near-miss An undesired event which,under slightly different circumstances could have resulted in harm to people,damage to property or the environment,or production loss. E-2 Final Report w.w ... ..... ...N :::::::.:..::..:.... ..... 774 Nuisance alarms Alarms defined as being irrelevant to the situation at hand and which could not be shut off easily. O erator Certification See Operator Qualification. Operating procedure A written procedure includes the instructions and steps involved for safely conducting activities involved in operating a process. Operating procedures cover normal operations,temporary operations,startups,shutdowns,and -emergency operations. Operator Qualification Unit operators are"qualified"to operate the equipment in a process area after they have been trained and tested in the applicable operating procedures. Testing may include written tests and/orjob-site skill tests. Operator Qualification Packages Tosco Avon has assembled Operator Manuals that include operating procedures, a training workbook,and testing methods.These are sometimes referred to as o erator ualification packages. Organizational change Any change in staffing relevant to the organization being evaluated.For example,organizational change would include layoffs,staffing additions,re- assignment of duties,as well as the wa in which contractors are used. Organizational culture Organisational culture is the product of the individual and group values, attitudes,competencies,and patterns of behavior that determine the commitment to and the style and proficiency of an organisation's programs. Safety culture is, "The way we do things around here". Workers interpret safety culture through their work environment and life ex eriences. Performance appraisal A formal review process conducted on a routine basis to evaluate the work performance of a person in the organization. Permits for safe work and hot Internal check lists that are used to review the work activities of a"job"and work the steps needed to control any hazards that may be associated with the work. Work permits need to be authorized by the appropriate personnel in the organization having the authority to do this. Process hazard A hazard associated with the operation and maintenance of a process unit. (See hazard Process Hazards Analysis A technical study conducted by a qualified team to identify potential hazards PHAs associated with a process unit. PHA Action Item A formal action item, generated by the PHA team,which is intended to control a hazard associated with the operation of a process unit. PHA revalidation The OSHA Process Safety Management standard includes a requirement to revalidate PHA studies every five years. Process safety This term refers to the protection of people and property from episodic and catastrophic incidents that may result from unplanned or unexpected deviations in process conditions. Process Safety Information(PSI) The information compiled by an organization to describe the chemicals, equipment,and technology of a process unit. Process Safety Management This is the application of management systems to the identification, (PSM) understanding, and control of process hazards to prevent process-related incidents and injuries. Process Safety Management See Safety Management Systems Systems Program implementation The steps taken by an organization to ensure that a management program is used by the workers.Implementation may include training of workers and/or routine refresher meetings and audits to ensure that the program is continually in effect. Protocol A written document used to guide the data gathering tasks of an audit, assessment or evaluation. PSM compliance audit An audit conducted to determine compliance with OSHA's Process Safety Management standard and other applicable PSM policies. E-3 Final Report n t PSM system description The term used by Tosco SFAR to describe the written management system for a PSM program element(e.g.,incident investigation or management of change). Risk Risk may be defined as the chance to experience an undesired event(e.g., damage or harm).Risk is measured in terms of potential severity and likelihood of occurrence.Degree of risk may be quantified in terms of low, medium or high. Risk Management Program The combination of management programs designed to prevent accidents, to (RMP) evaluate the potential consequences of accidents that may occur,and the programs developed for emergency response, Root Cause The prime reasons,such as failures of some management systems,that allow faulty design,inadequate training,or improper changes,which lead to an unsafe act or condition, and result in an incident. If root causes were removed,the particular incident would not have occurred. Root cause analysis The technique used to investigate the root cause of an incident Safety communications Written and verbal communications that specifically relate to safety. Examples include memos to staff,posted bulletins,newsletters,and safety meetings. Safety compliance audit An audit that is conducted to address compliance with safety guidelines and standards. See audit). Safety culture The safety culture of an organization is the product of individual and group values,attitudes,competencies, and patterns of behavior that determine the commitment to,and the style and proficiency of, an organization's health and safety programs. Organizations with a positive safety culture are characterized by communications founded on mutual trust,by shared perceptions of the importance of safety,and by confidence in the efficacy of preventive measure. Safety goals Specific targets that may be set for an individual and/or organizational unit with measurable targets for safety performance. Safety incentive program A formal program that may be developed and instituted to provide positive incentives to reward favorable behavior related to safety. Safety Management Systems Comprehensive sets of policies,procedures,and practices designed to ensure that barriers toepisodic incidents are in place,in use,and effective. Safety message The underlying message that is communicated to workers from the combination of safety communications. Safety performance Safety performance may be measured in terms of the numbers of incidents, accidents,near misses,amount of lost time,or in terms of the efforts made to prevent accidents and injuries. Shutdown procedures Procedures used to shutdown a process unit.For a refinery process unit,these would usually cover"normal shutdown"and"emergency shutdown". Startup procedures Procedures used to startup a process unit.For a refinery process unit,these would usually cover"normal startup"and startup following an emergency shutdown. Top down communication This term is used to describe communications that are initiated from the upper levels of the organization(senior management).Communications may be written or verbal. Training matrices Matrix of training requirements for each position in an organization and the schedule of retraining. Training needs assessment An assessment conducted to determine what training is needed for each person in an organization.The training could be required by regulation, corporate policies, and/or as a good practice. Unsafe operations Any operation that could lead to a release of a hazardous substance,an injury or equipment damage.Unsafe operations can occur when a process parameter deviates outside its normal range for safe operation, E-4 Final Report Unsafe work Any work activity that, in the judgement of an employee or contractor,could lead to a release of a hazardous substance,an in`ur ,or equipment damn e. Upset An unpredictable event that results in a process parameter deviating from its normal ran&e for safe operation. Verification The measures taken by management to ensure that programs,policies and procedures are being implemented as intended. Work orders A work order is a set of instructions typically issued by an organization to manage and control maintenance activity.The work order will include the steps to be taken,the controls required to ensure safe operation,and the steps needed to document that the work was com feted. E`5 Final Report