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HomeMy WebLinkAboutMINUTES - 04042000 - D4 L 4q TO: HOARD OF SUPERVISORS FROM: WMIm WeV er,M.D.,Iiog&services Director Contra DATE: Aprff 4,2WO Costa County SUHJEC'r: Report ca r Detatlei Work Pfrut to Follow-'p oe:the Tosco Sea Fnedsoo Area Refinery at Avon 68afety SPECIFIC REQUEST(S)OR RECOMMENDATION(S)h BACKGROUND AND JUSTIFICATION RECOMMENDATION: Accept the attached detailed work plan for following up on the safety evaluation of the Tosca Avon Refinery. The work plan includes the following eight items: • Retaining A. D. Little to assist in reviewing the plan that Health Services has developed on address items from their follow-up that needed further follow-up Suggestions for better full facility audits • A pro-active role within the Industrial Safety Ordinance • Having County Staff, A. D. Little, and Tosco identify indicators to reveal whether work environment audits are being made • Measurement of behavior changes, including surprise inspections • Timeframes for the follow-up audit + Defining Near Misses • Evaluate CCHS staffing BACKG The Board of Supervisors asked for a third party safety evaluation of the Tosco Avon Refinery after the February 23, 1999 accident where four workers died and a fifth was seriously injured. Arthur D. Little, Inc. was hired as the third party consultant to do this evaluation. Arthur D. Little, Inc. issued the report with their findings and recommendations from this safety evaluation on May 10, 1999. The report included seventy-two recommendations. The Board requested that Arthur D. Little, Inc. do a follow-up evaluation to determine how Tosco was responding to the recommendations. The Board also requested that Arthur D. Little, Inc. follow-up on the recommendations from Health Services Incident Investigation including a Root Cause Analysis. Arthur D. Little, Inc. performed the follow-up evaluation in December 1999 and presented their findings to the Board on February S, 2000. The report from Arthur D. Little, Inc. included some follow-up action by Health Services. Arthur D. Little, Inc. also reported that the safety culture at a fic lity does not change overnight, but could take years. The Board asked Health Services to come back within suety days with a detailed plan on how they were going to audit the follow-up actions, along with the above items addressed in the Work Plan, FISCAL IMPACT: There will be additional costs to Health Services for implementing the work plan as described. The costs include the personnel to perform the work plan and for hiring Arthur D. Little, Inc. to work with Health Services. The detail of this work is included in the work plan CONTINUED ON ATTACHMENT: YES SIGNATURE: Cl--*'RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATUREO: i sa� ACTION OF BOARD O Apr i l 4 2000 APPROVED AS RECOMMENDED OTHER X_ See the attached Addendum for Board action and vote , VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS (ABSENT ®) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: denABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. C H••Ith S•vkos AdminW t vUon ATTESTED__. April 4. 2000 PHIL BATCHELOR,CLERK OF THE BOARD OF SUP RVISORS AND CO TY 6MINISTRATO BY ,DEPUTY ADDENDUM TO ITEM D. 4 (Part A ) April 4, 2000 Agenda On this date, the Board of Supervisors considered Item DA A, relative to the Tosco Avon Refinery's safety evaluation and the detailed work plan. Those present included Victor Westman, County Counsel and Lillian Fujii, Deputy County Counsel. Lewis Pascalli, Jr., Director, Hazardous Materials Program,Health Services Department, presented the attached written report. He introduced Randy Sawyer and Jo Haegert- Green, California Accidental Release Response Prevention Specialists. Each reported on a portion of the Health Services Department's Workplan. Mr. Sawyer stated that the requested funds would pay for one Engineer to work with the Accidental Release Response Prevention Team, and a second individual would aid the Team in developing questions regarding the safety culture. The Board discussed the issues. The public hearing was opened, and Denny Larson, Communities for a Better Environment, 1611 Telegraph Avenue, Oakland, appeared to speak. Those desiring to speak having been heard, the Board continued their discussion. Supervisor Uilkema moved staffs recommendation, and requested the Hazardous Materials staff come back to the Board in 120 days with the appropriate material. The motion failed for lack of a second. Following further discussion, Supervisor Gioia moved the report come back to the Board in 90 days. Supervisor Gerber stated that she was not willing to wait 120 days, and requested the motion be amended to request Tosco respond in 30 days. The motion failed for lack of a second. Supervisor Gerber clarified her amendment. She stated she was interested in having Tosco give their response as to whether or not they were willing to pay the$250,000 for the Accident Release Prevention Program, and provide the requested information. She advised the Board perhaps an additional 30 days would be appropriate. Supervisor Gioia stated that was a good suggestion, and moved that staff be directed to work with Tosco and A.D. Little to develop a work plan, with a final work plan to come back to the Board in 60 days. Further, that staff report to the Board in 30 days with Tosco's response to the funding and their cooperation on the elements discussed today for the work plan. Supervisor Gerber suggested an amendment to the motion that would include each Board member receive a report notifying them each time Tosco refused to provide information to the Health Services Department. Supervisor Gioia accepted the amendment. Following further Board discussion, Supervisor Gerber restated the motion as follows: 1. Accept the report; 2. That Health Services provide a report to the Board in 60 days with a final work plan; 3. That Health Services provide a report to the Board in 30 days as to Tosco's responses to the questions posed today, including the $250,000 funding element; 1 4. And that each Board member be notified whenever Tosco refuses a Health Services Department's request, and include an explanation as to whether or not the County can acquire that information, or if the County is requesting information they are uncertain they are entitled to receive. The Board continued their discussion, and the vote on the motion was as follows: AYES: SUPERVISORS GIOIA,UILKEMA,DeSAULNIER and GERBER NOES: NONE ABSENT: SUPERVISOR CANCIAMILLA ABSTAIN:NONE 2 FOLLOW-UP WORK. PLAN FROM THE TOSCO AVON REFINERY SAFETY EVALUATION IN'T`RODUCTION Arthur D. Little, Inc. reported to the Board of Supervisors on the follow-up to the safety evaluation of the Tosco Avon Refinery on February 8, 2000. Arthur D. Little, Inc. reported how Tosco was addressing the seventy-two recommendations from the safety evaluation and two recommendations from Health Services' incident investigation of the February 23, 1999 fire at the Avon refinery. The safety evaluation and the follow-up of the evaluation was performed at the request of the Board of Supervisors. Arthur D. Little, Inc. found that Tosco was addressing all of the recommendations from the safety evaluation and Health Services' incident investigation. Arthur D. Little, Inc. also reported that the safety culture of a facility does not change overnight. Arthur D. Little,Inc. made recommendations that Health Services follow-up on fifteen of the recommendations to ensure that Tosco was continuing to address the recommendations. The Board requested that Health Services develop a workplan to address the following concerns and report back in sixty days. • To retain Arthur D. Little, Inc. to assist Health Services in the review • Suggestions for better full facility audits • A pro-active.role within the Industrial Safety 4r4dihance • Having County Staff, Arthur D. Little, Inc., 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 • Issue of near miss • Evaluate CCHS staffing Health Services developed the following workplan that addresses the issues raised by the Board. The workplan is divided into the following sections: 1.0 Tosco Evaluation Followup 2.0 CCHS,Oversight 3.0 Scope of Work—Arthur D. Little and Tosco 4.0 clear Miss Internal Investigation at Oil Refineries and Chemical Process Facilities 5.0 Accidental Release Prevention Team Resources 1 —D 4 d 9 . an 0. 00 c 03 ob od 4.4 v ° ita ` oncn `w Z a ` gra tp Oto o 1616, Its � ` " 4) Owl d 3 kd � U 00 w � QC14 75 cc v uCO v ta,Fy N w p do � to cr •�. o �.. C �..,,C.,} oj W 4t y (� � •� � � •� � � w '� 'd � °� � •� H ni " -•� �, :" `� � .� ami °' � � ess v. cp, 4' eIz s , ani �a�r �b' •° — � cc c b 10 0 sp •• > c) ren cra 14U. U W 'e~n ,' U "0 N en Ilk x C� 0. �r.. cZo OHO i r+ lu u y H 5 00 '04 rA a� "ca ' , 84 OR U Fes . c -�s a LW acs -/f4 lir-- -cam . U co lu rA :t4 0 00 C� ns 4- Su ed 00 � SCS O '"` ay cu v •'�„ y '� � `� �� ..+ � •> � zn cd C a aG -S on 0 � � �, ���' a � c� � chi a •� ° � •� � �' "G"¢��+ ` " -C! 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'S > ; 0 o ro ' � ro � n� o .0 o 42 t4 m � „ w ° o 24-4 t0, � � � , r -Au ca ern ?ti t« �cj,, �' 3 Cd � � y � � '� �j � G �•, "d Is •e E•CJ .'S`. 6i d G, td3 Q Q tw �i �t � yr��od N G � � � , T, C0 2.0 CCHS OVERSIGHT 2.1 ExISTING OVERSIGHT ACTIVITIES Contra Costa Health Services Department (CCHS) is the administering agency for the California Accidental Release Prevention (CaIARP) Program regulations, Title 19 Division 2 Chapter 4.5 of the California Code of Regulations. CCHS is therefore responsible for reviewing Risk Management Plans (RMP's) submitted by applicable stationary sources and for conducting audits and inspections of those stationary sources' risk management programs, per Sections 2745.2, 2775.2, and 2775.3 respectively of the CaIARP Program regulations. The CaIARP Program regulations do not provide a frequency for audits but inspections must be conducted every three years. CCHS is also responsible for administering Chapter 450-8 of County Ordinance 98-48. This ordinance requires CCHS to review Safety Plans and conduct Safety Program audits at applicable stationary sources within one year of the effective date of the ordinance. The ordinance requires CCHS to monitor the progress of any root cause analyses (RCA) conducted by stationary sources in response to a Major Chemical Accident or Release (MCAR). The ordinance also allows CCHS to conduct a RCA or an incident investigation following a MCAR. CCHS will complete the CalARP Program and Chapter 450-8 of Co. Ord. 98 requirements in accordance with the following internal policies and protocols I: • Auditsllnspections Policy • Conducting Auditsllnspections Policy • Conducting the RMP/Safety Plan Completeness Review Protocol • Conducting Employee Interviews Protocol • Public Participation Policy • Incident InvestigationlRoot Cause Analysis Policy Section 450-8.016(B)(1) of Co. Ord. 98-48 also required CCHS to issue a human factors guidance document. CCHS will audit applicable stationary sources against the guidance included in Section B of the Contra Costa County Safety Program Guidance Document issued in January 2000 as part of the Safety Program audit described above. A majority of the administering agency requirements of both the CaIARP Program regulation and Chapter 450-8 of Co. Ord. 98 are "proactive". Audits, inspections, and completeness reviews are "proactive" activities used by CCHS to identify and resolve potential deficiencies in safety programs (e.g., training, hot work permit, human factors) prior to an incident. CCHS also defined expectations for the human factors program, which was a "proactive" activity. Incident investigation and root cause analysis are considered primarily "reactive" activities by CCHS (i.e., the programs are initiated t The policies and protocols are available for review at the CCHS Hazardous Materials Programs office. 13 �7 following an accident or near miss; however, the purpose of the programs is to identify the causes and prevent recurrence of the accident or near miss). Monitoring the progress of RCA's is also considered primarily a"reactive" activity conducted by CCHS. 2.2 PROPOSED OVERSIGHT ACTIVITIES The Contra Costa County Board of Supervisors asked staff to develop a work plan to consider supplementing existing CCHS oversight activities with unannounced inspections. The County Board of Supervisors also asked CCHS to identify indicators to assess organization changes and measure behavior changes at Tosco. Section 2.2.2 of this work plan describes "Work Environment Audits" which include both the existing oversight activities and additional activities not currently authorized elsewhere. 2.2.1 Unannounced Inspections Unannounced Inspections are addressed in a separate report to the Board of Supervisors. 2.2.2 Work Environment Audits 2.2.2.1 Definitions Active Failures -Errors or violations committed by people at the human-system interface such as operators and maintenance personnel. Direct Indicators —The outcome of a safety management program (e.g., accident data) NOTE: There are several limitations to monitoring accident data alone. The data is subject to fluctuations: there may be differences in reporting criteria that can result in over or under reporting, and the data is limited in assessing risk of high severity, low likelihood incidents. Latent Conditions-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. (i.e.,"the accident waiting to happen). Lead Indicators — Key performance indicators (objective and subjective) that may predict the effectiveness of a safety management program. These indicators may facilitate measurement of the implementation of the safety management program (i.e., are they really doing it) and the effectiveness of the safety management program (i.e., are the programs working for the facility). NOTE: Questions that only assess whether certain procedures exist are not Lead Indicators Safety Culturez — The ,Safety Culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of 2 Health&Safety Executive(HSE)ACSNI Study Group on Human Factors, Third report: Organising for safety, 1998 14 /f behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management (i.e., "the way we do things around here"). NOTE: The attributes that collectively define Safety Culture (e.g., attitudes, perceptions) are influenced by internal factors and external factors (e.g., regulating agencies). Work Environment-A dynamic system composed of the physical characteristics (e.g., buildings, plant, and equipment); the organizational structure and policies (e.g., Safety Program); and the Safety Culture. 2.2.2.2 Authority The Work Environment can be viewed as a three-legged stool with the first leg being the physical system, the second leg being the organizational structure and policies, and the third leg being the Safety Culture. All three legs are needed for the stability of the Work Environment. CCHS currently reviews many of the attributes associated with the physical system and with the organizational structure and policies during the Safety Program audits described in Section 2.1. CCHS also currently reviews a few of the attributes associated with Safety Culture during the Safety Program audits described in Section 2.1. One particular area where overlap between Safety Program audits and Work Environment audits may exist is in the human factors program element of the Safety Program. Stationary sources subject to Chapter 450-8 of Co. Ord. 98-48 are required to develop and implement a written human factors program in accordance with the Contra Costa County Safety Program Guidance Document. The guidance document requires sources to consider a list of Latent Conditions when implementing the elements of the human factors program. The Latent Conditions list included in the guidance document is divided into four main categories: the individual, the activity/task, the physical environment/workplace, and the organization/management. One example of a Latent Condition that may also be an indicator of Safety Culture is that of a perceived imbalance between production and safety. The Latent Conditions checklist would determine whether this perception could cause an employee to violate rules or conduct an Active Failure (e.g., an employee may NOT shut a unit down when limits are exceeded for fear of the repercussions). The Work Environment audit would determine whether this is a perception or belief that is widely held by personnel throughout the organization (i.e. whether the perception contributes to a negative Safety Culture). CCHS believes that additional authority is necessary to completely assess the attributes associated with each of the three elements of Work Environment.. Therefore, CCHS recommends that the County develop an explicit agreement with Tosco defining the authority of CCHS to conduct a Work Environment audit and the mechanisms for reimbursement and resolution of findings. 2.2.2.3 Objectives 15 Develop questions (including interview questions) that may indicate a positive or negative Work Environment, including Safety Culture at a facility. The audit questions are to be developed, at a minimum, by County staff with input from A.D. Little representatives and Tosco Avon personnel. Develop the framework (e.g., authority, limitations) for applying the indicators at a given facility. The questions may be appropriately applied independently, during Safety Program audits, during CaIARP Program audits, or during unannounced inspections. 2.2.2.4 Defining Limitations As defined, Work Environment includes physical characteristics, organizational structure and policies, and Safety Culture. The attributes associated with these three elements can be difficult to measure directly. Direct Indicators (e.g., accident history) used alone can be misleading. Therefore, CCHS must develop or adopt Lead Indicators to use in conjunction with Direct Indicators in assessing Work Environment. By definition, Lead Indicators are measurable/tangible and can therefore be audited. However, the following limitations exist when using Lead Indicators to assess Work Environment. These limitations must be clearly understood and considered in the audit process (i.e., developing list of indicators, developing recommendations to address real findings — not just indicator). NOTE: The first three limitations are more applicable to indicators developed to assess physical system and organizational structure and policies rather than Safety Culture. • The indicators are attributes of ta facilities with a positive Work Environment (and low accident rates). However, the appropriateness and success of these activities/programs is dependent upon the facility. Two different facilities may have two completely different and acceptable approaches to addressing a particular problem. If the indicators are based primarily upon only one approach, one facility may do well while the second facility may do poorly. It is therefore possible that a facility could have a positive Work Environment and do poorly when audited against the indicators. • It is possible that a facility could do well when audited against the indicators but have a negative Work Environment (i.e., all of the indicators are there but the overall program is less than the sum of its parts). — This could be attributed to the facility adjusting their activities to do well on an audit of indicators. — This could also be attributed to having a list of indicators that only assess "existence", not effectiveness. The facility may have adopted many of the activities/programs that are usually associated with positive Work Environment. However, these activities/programs are ineffective given their existing workforce (i.e., facilities must have a method in place to determine whether the programs are working for them). 16 YX y_y-CV, 8d • Addressing a deficiency of an indicator does NOT necessarily address a deficiency of Work Environment. For example, the balance between production and safety is a perception that directly influences Safety Culture (an element of Work Environment). An indicator of this balance is the comparison of group rewards given for safety and for production. An audit may identify that a facility gives large monetary rewards for production and token rewards for safety (e.g., hats, pens). The recommendation/action item should be to address the perception of production versus safety rather than to simply revise the rewards system (i.e., the facility could revise their rewards system and have little to no effect on the perception of production versus safety). • Safety Culture, by definition, includes values, attitudes, and perceptions. These attributes are fluid (i.e., an employee's attitudes can fluctuate depending upon the influences). The Safety Culture indicators, probably in the form of employee interview and survey questions, must be crafted to minimize those fluctuations. The indicators will also have to be crafted to minimize the tendency for employees to give what they think is "the right" answer rather than"the real" answer. 2.2.2.5 Developing A List of Questions (Indicators) CCHS shall develop a list of indicators (Lead Indicators and Direct Indicators), including interview and survey questions, to supplement the existing Safety Program audit protocols. CCHS shall accomplish this by combing existing indicator lists found in literature with positive attributes associated with each of the three elements of Work Environment (i.e., physical system, organizational structure and policies, and Safety Culture). 2.2.2.5.1 Identifying existing questionnaires CCHS shall identify existing lists of Lead and Direct Indicators and consider them for incorporation into the Work Environment audit protocol. Examples of existing lists include the following: • International Nuclear Safety Advisory Group-Basic Safety Principles for Nuclear Power Plants Safety Series No 75-INSAG-3, International Atomic Energy Agency, Vienna 1988 ($40.00 ordered 2/24/00 received 3/3/00) • Safety Series No. 75-INSAG-4, Safety Culture, A Report by the International Nuclear Safety Advisory Group, February ($20 ordered 2/24/00 received 3/3/00) • BS 8800 1996 Guide to Occupational Health & Safety Management Systems($40-$80) • Health & Safety Executive Safety Climate Survey Tool (Software $320) 17 • Confederation of British Industry, Developing a safety culture: Business for Safety (1990) ($20-30) • Olson J., Development of Programmatic Performance Indicators, USNRC, NUREG/CR-5241, 1988 • HSE, ACSNI Study Group on Human Factors, Third Report: Organising for safety, 1998 [`able 10.1: A safety culture prompt-list] (CaIARP team library) • BS EN ISO 14001: 1996 Environmental management systems — Specification with guidance for use($40480) • International Safety Rating System, International Loss Control Institute (1988) (out of print — but ordered 2/24/00 through Amazon.com. Unavailable as of 3/9/00) • International Safety Rating System: Working Copy, International Loss Control Institute (1988) (special order $25 2/24/00 through Amazon.com. Unavailable as of 3/9/00) • International Safety Rating System (ISRS) (DNV Technical package $250. Contacted 2/28/00) • Complete Health and Safety Evaluation (CHASE) (Health and Safety Technology and Management Ltd. Contacted 2/28/00) • Management Safety Systems Assessment Guidelines in the Evaluation of Risk(MANAGER) • DuPont safety systems • 5-Star(British Safety Council) • Coursafe(Edward Alandale Associates Ltd.) • Safety and health audit reporting package (SHARP) (Safety and Reliability Consultants Ltd.) • Contra Costa County Safety Program Guidance Document, Attachment A: Latent Conditions Checklist(CalARP team library) • Characteristics of Outstanding Calibration Program and Support, Sample of Fuzzy Performance Indicators(Battelle) • A.D. Little Safety Evaluation audit protocol (get from A.D. Little) • Du Pont's"Plant Preparation Factor"(CalA.RP Team Library) • CCPS Process Safety Management quantitative measurement software (available mid-2000 for approximately$795.00) • CCPS Guidelines for Performance Measures for Continuous Improvement of Process Safety management Systems (available late 2000) NOTE: Several of these lists are proprietary and are protected by copyright. CCHS will contact distributors and discuss the limitations associated with using their lists (e.g., they may request that their lists not be made publicly available). 18 . ..... . ...................... . . . 211 V14 2.2.2.5.2 Identifying activities to promote a positive Work Environment CCHS shall supplement the existing lists found in literature by defining additional attributes associated with a positive Fork Environment and identifying indicators of those attributes. For example, the following four attributes are usually associated with a positive Safety Culture: • Control • Co-operation • Communication • Competence There are a number of other attributes that can also be included within, or considered independent from, control, cooperation, communication, and competence. For example, • Senior management commitment • Clean and comfortable working environment • Perception of risk • Job satisfaction • Workforce composition • General health promotion `Where are indicators for each of these attributes. Verification of these indicators will include both an audit of activities and programs as well as employee interviews and surveys to determine employee perceptions. For example: Control • Has the facility identified key objectives of their safety program and do they review their progress against the objectives? • Does the facility address previously identified deficiencies and follow-up on action items implemented to resolve those deficiencies in a timely manner? • Has the facility established performance standards that link employee responsibilities to s ec'fic outputs? • Does the facility correctly assess achievement of the goals established in the performance standards (i.e., having a quantitative objective, but no quality objective, for senior management to visit the workplace may not be effective)? 3 Health&Safety Executive(HSE), Successful health and safety management,HSG 65, 1997 19 torr cro �3 • Are employees (including those with Health and Safety duties) held accountable for their responsibilities (i.e., do their job descriptions include the duties and are they appraised against those responsibilities)? • Is good safety performance by employees vital to career progression? 2.2.2.5.3 Review and Incorporate Tosco's Performance Indicators Tosco implemented key performance indicators (KPI's) as a result of A.D. Little recommendation Number 11. CCHS shall review the existing KPI's for appropriateness and consider incorporating those KPI's into the CCHS list of incidators. 2,2.2.6 Verifying the List of Questions(Indicators) CCHS shall review the list of questions (indicators)developed above to determine the following: 1. Does the list include indicators of implementation and of effectiveness? 2. Are the indicators measurable? 3. Can the indicators be assessed objectively? NOTE: answers to interview questions may be subjective as opposed to objective 4. Can the indicators be assessed reliably? 5. Is there a clear"positive"or"negative"associated with each indicator? 2.2.2.7 Applying Work Environment Indicators The protocol for conducting Work Environment Audits will be similar to the protocol for Safety Program Audits (e.g., qualitative assessment, reading written documentation, and inspecting the process). However, there are important differences between the questions currently applied for determining compliance with Chapter 450-8 of Co, Ord. 98-48, and the indicators that will be applied to audit Work Environment. One difference is that the questions in the existing protocols are requirements of compliance whereas the questions in the Work Environment protocol are simply indicators (i.e., as described in Section 2.2.2.4 Defining Limitations, fixing the indicators will NOT necessarily improve Work Environment and answering no to an indicator does NOT necessarily prove negative Work Environment). A second difference in applying the protocol for Safety Program audits and in applying the protocol for the Work Environment audit is that during Safety Program audits, CCHS uses employee interviews to verify written documentation and records. CCHS will use employee interviews and surveys during the Work Environment audit to assess perceptions or attitudes (i.e., in the first case we use employee interviews to confirm a fact supported by documentation and records and in the second case we are confirming the "perception or attitude" which may or may not be supported by documentation and records.) 20 0 _/X CCHS will provide the facility with a list of the indicators used in the assessment and with the results of the audit. CCHS will also document the progression from "deficiencies in the indicators" to potential "deficiencies in the Work Environment. NOTE: The review may show that external influences are contributing to a negative Work Environment. The stationary source may have limited ability to correct these factors. 3.0 SCOPE OF WORK 3.1 SCOPE OF WORK WITH ARTHUR D. LITTLE,INC. On February 8, 2000 the Board of Supervisors requested that Health Services work with Arthur D. Little, Inc. on developing indicators for auditing the work environment at the Tosco Avon Refinery. The Board also requested that Arthur D. Little, Inc. to work with Health Services on following up on action that Tosco is taking. The action Tosco is taking is in response to the Arthur D. Little, Inc. safety evaluation recommendations. The following is the scope of the work to accomplish these requests. 3.1.1 Follow-up Requirements from the Tosco Avon Refinery Safety Evaluation Review and comment on the Action flan that Health Services has develop on following up of the safety evaluation. The review will include following: • Review and comment on the authority under which Health Services will implement this follow-up • Review and comment on the audit plan that Health Services will use to address the follow-up items (this will include the review of documents, records, and interviews) • Review and comment on the results of Health Services audit of the follow-up action items. This review is to ensure that Health Services has addressed the original concerns and findings from Arthur D. Little,Inc. safety evaluation 3.1.2 Work with Contra Costa Health Services on Developing and Implementing Work Environment Indicators Contra Costa Health Services has developed a plan to develop work environment indicators. The scope of work for Arthur D. Little, Inc. includes the following: • Review and comment on Health Services work plan • Assist Health Services in developing the work environment indicators — Health Services would develop the indicators and Arthur D. Little, Inc. would in review and comment on the indicators • Arthur D. Little, Inc. will review Health Services audit plan for addressing the work environment, including the following: How Health Services will perform the audit, including the interview questions and the presentation of the questions 21 How Health Services will perform the audit, including the survey questions and the presentation of the questions • Arthur D. Little, Inc. will review the results of the work environment audit and comment on the audit and the audit report 3.2 SCOPE OF WORK WITH TOSCO The Board asked for Health Services to work with Arthur D. Little, Inc. and Tosco in developing the indicators for evaluating the work environment at Tosca. If the Board determines that they wish for Health Services to implement the work that would be necessary to develop the work environment indicators and then audit the Tosco Avon Refinery using these indicators, the following actions would be necessary: • Develop the scope of work with Tosco that includes developing the work environment indicators and auditing of the facility using the indicators -- Health Services would locate or develop the necessary indicators and ask Tosco to review and comment on them Health Services would also ask for comments from Contra Costa County CAER Group, Inc. and the Hazardous Materials Commission • Put together an plan that would be used to audit the work environment at Tosco Avon Refinery • Develop a contract with Tosco that includes the scope of work and reimbursement to Health Services for the costs of developing the work environment indicators,the audit, and Arthur D. Little,Inc. involvement The work in developing the work environment indicators would begin after the Board approves the action. Health Services would then work with Tosco on developing a contract to reimburse Health Services for the work on developing the work environment indicators, an audit plan, auditing the work environment, and Arthur D. Little, Inc. costs. 4.0 NEAR MISS INTERNAL INVESTIGATION AT OIL REFINERIES AND CHEMICAL PROCESS FACILITIES 4.1 INTRODUCTION Internal reporting of near misses is critical in the prevention of accidental releases. How a facility investigates near misses and then resolves the findings from investigations, is an indication of the safety culture of the facility. Contra Costa Health Services believes that the following items are important in the prevention of accidents: • Internal reporting of near misses is critical in preventing accidents. • Appropriate and thorough investigations of near misses need to be performed. • Resolving the findings from the investigations of near misses will prevent future accidents. • The Industrial Safety Ordinance, California Accidental Release Prevention Program, and CaUOSHA's Process Safety Management require facilities to have an Incident Investigation Program that includes near misses. Contra Costa Health Services will audit the facility's Incident Investigation Program during their regular audits and unannounced inspections. 22 • A facility that has open communications and does not assign blame will have a safety culture that allows for a good near miss internal reporting system. Reporting near misses in a public forum will create a safety culture where the operators, maintenance personal, staff, and management will feel that they are being blamed for having and reporting near misses. This could decrease the number of near misses reported internally and ultimately increase the possibility of future accidents. This paper will provide answers to the following questions based on interpretations of Contra Costa Health Services (Contra Costa Health Services has used applicable information from the American Institute of Chemical Engineers Center for Chemical Process Safety and Great Britain's Health&Executive in the development of this paper.): • What is the difference between an incident,an accident,and a near miss? • What are examples of near misses? • Why is reporting near misses important? • Is it good or bad to have many near misses reported? 4.2 DEFINI'T'IONS People are often confused about what is considered an incident, an accident, and a near miss. It is therefore important to define the following terms to help understand what a near miss is and what a near miss is not. Incident is broadly defined as an unplanned, unusual, and out of the ordinary event with the potential for undesirable consequences.) Accident is defined as an incident that is accompanied by act1w negative consequence.) Near miss is defined as an incident that could, but actually did not, result in negative consequences.1 Negative consequence is defined as an event that resulted in deaths, injuries, or significant property damage onsite, or known offsite deaths, injuries, evacuations, sheltering in place, property damage, or environmental damage.2 Anomaly is an unusual set of circumstances which, left unrecognized or uncorrected, may result in an accident.' As indicated by these definitions, both accidents and near misses are subcategories of incidents. (Note: Some definitions of near miss include anomalies.) 4.3 WHAT ARE EXAMPLES OF NEAR MISSES? Examples of typical near misses follow: • Excursions of process parameters beyond established"critical"control points • Activations of emergency shutdown systems • Releases of material in reportable quantities that did not have negative consequences 23 • Activations of hazard control systems such as safety protective systems (e.g., process safety valves, blowdown systems, chemical release or fire mitigation equipment such as fixed water-spray systems and halon systems).' 4.4 WHY Is REPORTING NEAR MISSES IMPORTANT? Near misses are usually far more frequent than actual accidents, and they provide an early warning of underlying problems that sooner or later will lead to an accident. By reporting and investigating near misses, changes can be made to prevent an accident. The United Kingdom's Health and Safety Executive's Accident Prevention Advisory Unit (APAU) established the following ratio from studies in five organizations in the oil, food, construction, health, and transport sectors: There is one major or over 3-day lost- time injury for every seven minor injuries and for every 189 non-injury events.$ These indicators are not necessarily related to process incidents, but for purposes of this paper, the major injuries are equivalent to accidents and the minor injuries and non-injury events are equivalent to near misses and anomalies. A key feature of an effective health and safety policy is to examine all unsafe events and the behaviors that give rise to them. This is a way of controlling risk and measuring performance. What is not reported cannot be investigated. What is not investigated cannot be changed Much has been written,debated, and contemplated regarding the relationship and ratio of near misses to accidents. This ratio is often represented as a triangle(see figure A below). As shown on this triangle, near misses are in the middle with anomalies below the near misses. Fatal Injuries Serious injuries Miner Injuries Near Miss Events Unsafe Behavior and/or Acts Errors/Deviations Figure A 24 Although the actual ratio does vary depending on the source of the data, there is general agreement on the concept. Internal reporting and investigating at the near miss level gives increased opportunities to detect and correct potential hazards. The successful result of investigating incidents is a decrease in the total number of incidents in the smaller triangle below in figure B. Fatal Applying lessons learned from �.� �"� near misses investigations acts to eliminate this group of serl0l15 IDjurie5 Minor Injuries Near Miss Events Unsafe Behavior ador Acts Erro rs/Deviations Figure B Internal investigation of near misses represent a valuable way to learn lessons from operational experience, since they have the potential for providing much information about the systemic causes of accidents as accident themselves. However, it is unusual to find effective near miss reporting systems within the process industry. This is because the success of a near miss reporting system depends critically on the voluntary reporting of events that would otherwise have gone unnoticed. A culture that is highly supportive in terms of emphasizing the value of this type of information and minimizing the use of blame and punishment as a method of error contro13 is an important element of success to a near miss internal reporting system. To ensure internal reporting, any event that is unusual or out of the ordinary, whether or not harm resulted from its occurrence, (As defined earlier, incidents include accidents and near misses.) it is important that all near misses be intemally reported so that corrective action can be established before similar occurrence results in an accident. Therefore, barriers to incident reporting (e.g., fear of management or governmental reprisal) need to be removed to promote timely internal reporting by employees at any level of the organization.5 25 1 ly ez) A frequent cause of failing to learn lessons is a "blame culture" that discourages individuals from providing information on long-standing system problems that cause frequent near misses.3 Many chemical plant operators are uncomfortable reporting an error of omission, such as forgetting to properly reset a double-block-and-bleed arrangement. The normal tendency would be to restore the valves to the proper position quickly and quietly. A near miss of this type might normally go unreported, yet it may be a potential flag for discovering and eliminating a latent hazard.' The operator may have difficulty with reporting an error of omission even in a positive safety culture (it is human nature to avoid highlighting one's own mistakes, so the challenge is to create an environment where people are not threatened by such reporting) and a "blame culture" would make this reporting even more difficult. The immediate supervisor of the group experiencing the event determines the actual practices and attitudes toward open reporting and discussion of near misses. Upper levels of corporate management can set general policy,but the actual performance in this area is highly dependent on local supervision. If local supervisors perceive rightly or wrongly that upper levels of management are not interested in near misses or that reporting near misses could reflect poorly on them, the near misses will not be reported. Operations personnel are not likely to consistently report near miss events in the absence of proactive and sustained support from management. Management must make a special effort to set a climate that will encourage reporting of undesirable events. The natural urge is to suppress embarrassing mistakes in order to avoid making the boss angry when he or she receives bad news.' A fragile balance exists between a manager's responsibility to achieve reporting of near misses and the responsibility to discipline for incidents for where nonperformance or inappropriate behavior are a factor.' Collecting information on serious injuries and ill health should not present major problems for most organizations, but learning about minor injuries, other losses, and hazards can prove more challenging. There is a value in collecting information on all incidents to learn how to prevent more serious events. Accurate reporting can be promoted by. • Training which clarifies the underlying objectives and reasons for identifying such events • A culture which emphasizes an observant and responsible approach and the importance of having systems of control in place before harm occurs • Open, honest communication in a just environment, rather than a tendency merely to allocate blame • Cross-referencing and checking first-aid treatments, health records, maintenance or fire reports and insurance claims 4.5 IS IT GOOD OR BAD To HAVE MANY NEAR MISSES REPORTED? The internal investigation of near misses and the effective resolution of the findings from these investigations will decrease the number of accidents at a facility. Internal near miss reporting is necessary to reduce accidents and occurs in a safety culture that is positive and proactive. Because internal near miss reporting is crucial in the prevention of accidental releases, facilities are encouraged to internally report, investigate, and resolve 26 the findings from the investigations. Determining that a certain number or type of near misses reported internally is an indication of a poor safety culture could discourage a facility from investigating near misses and resolving the findings from the investigation. Reporting near misses to an agency will discourage individuals working in facilities from internally reporting near misses. A better indicator than the number of internal near miss reported would be how the facility investigates and resolves the findings from the investigation. If a facility has many near misses reported and investigates the near misses thoroughly and resolves the findings from the investigation, this would be an indication of a positive safety culture. 4.6 CONCLUSIONS Near misses are incidents that could, but actually do not, result in negative consequences. Accidents are incidents that are accompanied by actual negative consequences. Near misses and accidents are subcategories of incidents. Examples of near misses include the following: • Excursions of process parameters beyond established"critical"control points • Activations of emergency shutdown systems • Releases of material in reportable quantities that do not have negative consequences • Activations of hazard control systems such as safety protective systems (e.g., relief valves, blowdown systems, chemical release or fire mitigation equipment such as fixed water-spray systems and halon systems).' Near miss reporting is beneficial to preventing accidents. Near misses that are reported internally, investigated, and then followed up on can reduce the number of accidents that occur at a facility. It is necessary that a facility creates a culture in which near miss reporting is done without fear of reprisal. The first level of supervision attitude and practices strongly influence the success of near miss reporting. The first level supervisors may not be able to implement a near miss internal reporting program without management's visible support. 5.0 ACCIDENTAL RELEASE PREVENTION TEAM RESOURCES The Board requested that Health Services look at the necessary resources for the following: • To develop indicators for the work environment, including working with Arthur D. Little, Inc. and Tosco in the development of these indicators • To audit the work environment at the Tosco Avon Refinery using these indicators • To Follow-up on the items (as requested) from the Arthur D. Little, Inc. follow-up to the safety evaluation of the Tosco Avon Refinery, including having Arthur D. Little, Inc. review and comment on the work plan and the results of the follow-up by Health Services Health Services reviewed the work being performed by the Accidental Release Prevention Team and the existing resources, and the additional work and resources that 27 . -0 would be necessary to complete the work that the Board may ask Health Services to perform. 5.1 EXISTING RESOURCES As of March 29 there are two full and one half-time Accidental Release Prevention Specialist (one other person works part-time on policies and reviews). Two new people , will be joining the staff on April 3 and 4 to give the Accidental Release Prevention Team four and half equivalent personnel. The work that is now included under the Accidental Release Prevention Programs includes the following: • California Accidental Release Prevention Program(currently 57 Facilities) — Working with facilities in writing and revising Risk Management Plans — Reviewing facility Risk Management Plans — Writing Notices of Deficiencies — Auditing facilitie's accidental release programs — Writing Audit Reports — Holding public meetings and responding to written public comments as needed — Performing Self Audits — Determining Fees + Industrial Safety Ordinance(7 facilities) — Working with facilities in writing and revising Safety Plans — Reviewing Safety Plans — Writing Notices of Deficiencies — Auditing Safety Programs — Writing Audit Reports — Holding public meetings and respond to written public comments — Monitoring the progress of Root Cause Analysis — Doing Incident Investigations and Root Cause Analysis as needed — Working with Community Development Department on applying Chapter 84-63 Land Use Permits as requested — Presenting annual report to the Board of Supervisors on the Industrial Safety Ordinance — Determining Fees • Additional Job Assignments — Providing resources to the Hazardous Materials Incident Response Team — Reviewing Environmental Impact Reports for Risk of Upset — Working with Community Development for concerns of a chemical accident — Working with the Community Warning System — Working on EPA grants dealing with EMPACT — Providing resources to community members(and others) — Providing resource to other County staff(e.g.,ombudsperson) 28 5.2 Potential additional work as a result of Board Action on April 4, 2000 • Unannounced Inspections(one additional person) • Work Environment Indicators/Audit — Developing indicators — Conducting work Environment Audit — Holding public meetings and developing reports • Develop Contracts with Arthur D. Little -- Work with Health Services on addressing the follow-up actions from the safety evaluations - Work with Health Services and Tosco in developing Work Environment Indicators • Develop Scope of Work and Contract with Tosco in developing the Work Environment Indicators and audit 5.3 ADDITIONAL RESOURCES NEEDED Health Services considered the work that would be required to finish the above items within the next twelve months and estimated the number of hours that it would take to complete this work. To complete the additional work as outlined above (with the exception of the unannounced inspections) it would take an additional person working in the Accidental Release Prevention Program. Health Services would also need to contract with a psychologist or a third party to help develop the questions and presenting the questions in interviews and surveys to evaluate the safety culture at a facility. This psychologist or third party may also be necessary in assisting Health Services to determine the results of the interviews and surveys. The estimate of the additional costs to complete this work would be $250, 000. Guidelines for Investigating Chemical Process Incidents,American Institute for Chemical Engineers Center for Chemical Process Safety(CCPS) x California Accidental Release Prevention Program Regulations,CCR Title 19,Division 2,Chapter 4.5, Section 2750.9 3 Guidelines for Preventing Human Error in Process Safety,American Institute for Chemical Engineers Center for Chemical Process Safety(CCPS) d Successful Health and Safety Management,Health&Safety Executive s Guidelines for Process Safety Documentation,American Institute for Chemical Engineers Center for Chemical Process Safety(CCPS) 29 tr'• f-o TO: BOARD OF SUPERVISORS a Contra FROM: William Waller,M.D.,Health Services Director Costa County DATE: 4 APR 00 SUBJECT: Unannounced Inspection Policy of the Hazardous Materials Programs Division SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: 1. Approve the attached Unannounced Inspection Policy of the Hazardous Materials Programs Division; 2. Approve the addition of one (1)contract CalARP Specialist and one(1)Hazardous Materials Specialist;and 3. Approve the allocation of the $200,000.00 in costs to implement this policy to the CaIARP facilities. BACKGROUND: At the 3 AUG 99 Board meeting the Health Services Department presented the Root Cause Investigation of the Tosco Avon's 23 FEB 99 incident. The Board directed the Department's Hazardous Materials Programs Division to develop a policy on Unannounced Inspections at facilities handling hazardous materials having the potential to cause significant injury to workers, the community and the environment. The attached 30 MAR 00 memo provides information on the development and specifics of the policy. FISCAL IMPACT: The costs to implement this policy for the training,two (2)new positions and set up are estimated to be $200,000.00. We recommend that these costs be allocated to the CaIARP facilities which will be the focus of the Unannounced Inspection Policy. CONTI ON ATTACHMENT: YES SIGNATURE: sRECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE (S): ACTION OF BOARD O APPROVED AS RECOMMENDED OTHER XX See the attached Addendum for Board action and vote . VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS {ABSENT AND CORRECT COPY OF AN ACTION TAKEN AYES: �:—Ma S: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. Conta on: Health Services Administration ATTESTED April 4 , 2000 PHIL BATCHELOR,CLERK OF THE BOARD OF SyFERVISORS AND COON DMINiSTRATOR ® _,DEPUTY ADDENDUM TO ITEM DA (Part B) April 4, 2000 Agenda On this date, the Board of Supervisors considered Item D.4 B,which pertains to the Unannounced Inspection Policy of the Hazardous Materials Programs. Those present included William Walker, M.D., Health Services Director; Lewis Pascalli, Jr., Director, Hazardous Materials Program, Health Services Department; Victor Westman, County Counsel; Lillian Fujii, Deputy County Counsel; and Randall Sawyer, California Accidental Release Response Prevention Specialist, Hazardous Materials Program,Health Services Department. The Board discussed the issues. The public hearing was opened, and the following people appeared to speak: Denny Larson, Communities for a Better Environment, 1611 Telegraph Avenue, Oakland; Maria Alegria, Contra Costa Latino Leadership Council. Those desiring to speak having been heard, the Board continued their discussions. Following that discussion, Supervisor DeSaulnier moved to direct staff to begin the process of noticing and filling at least the two positions, and to come back to the Board in 30 days within other suggestions, including a report on what other jurisdictions do and what their goals and designs are when they do them, and to invite any of those agencies to come before the Board and testify. Supervisor Uilkema seconded the motion. The vote on the motion was as follows: AYES: SUPERVISORS GIOIA,T TILKEMA,DeSAULNIER and GERBER NOES: NONE ABSENT: SUPERVISOR CANCIAMILLA ABSTAIN: NONE Ct- NTRA COSTA HEALTH SERVICES HAZARDOUS MATERIALS PROGRAMS 30 MAR 00 To : Contra Costa County B Supervi ors From : Lewis G. Pascalli, Jr., D` e r, aterials Programs Subj : POLICY, STAFFING F ING REQUIREMENTS FOR UNANNOUNCED INS ONS BACKGROUND: At the 3 AUG 99 Board presentation of our Tosca Avon's 23 FEB 99 Incident Root Cause Investigation,the Board directed the Health Services Department's Hazardous Materials Programs Division to develop a policy for Unannounced Inspections at facilities having the potential to cause serious injury to workers and the community. This is a report on the attached policy. The Health Services Department is authorized under current regulations to accomplish inspections at facilities handling and storing hazardous materials. These inspections are either advanced noticed or unannounced. The larger facilities, except for exigent circumstances, are usually given advanced notification of these inspections because of the logistics involved in coordinating the staff, documents; and resources at the facility. The attached policy sets the prospective of our execution of Unannounced Inspections at facilities that fall under the California Accidental Release prevention Program. Presently there are 27 CalARP facilities which may be eligible for these Unannounced Inspections. The policy enumerates the bases for performing these inspections and the general protocol that will be followed in conducting them. STAKEHOLDER INPUT: The development of this policy was done with input from the various stakeholder organizations having an interest in the process and outcome. The input was obtained through meetings, or by in-depth telephone conversations with representatives of these organizations. The stakeholders also had an opportunity to review drafts of the policy. The organizations contacted were: 1. Contra Costa Building and Trades Council; 2. Boilermakers Local 549; z:,t 3. Cal-OSHA; 4. Communities for a Better Environment; 5. Bay Area Air Quality Management District; 6. Federal Environmental Protection Agency; 7. Consolidated Fire; 8. Public Utilities Commission; 9. Contra Costa Sheriff; 10. Paper,Allied-Industrial, Chemical& Energy Workers Intl Union; 11. Chevron; 12. Equilon; and 13. Tosco. TRAINING REQUIREMENT: There will be a requirement for staff training prior to our ability to carry this policy forward. The training will involve the majority of our CalARP and Hazardous Materials Specialist staff and most likely will involve up to 40 hours at a specialized training facility. STAFFING REQUIREMENTS: The implementation of this Unannounced Inspection policy will have a significant impact on the staff resources currently available to the Hazardous Materials Division. Based on the estimated time required for the training of staff; and the preparation, execution and follow-up of the inspections,we are estimating that there will be a need for the allocation and funding for one (1) full time CalARP and one full time(1)Hazardous Materials Specialist positions plus set-up costs. FUNDING REQUIREMENTS; The costs to implement this policy for the training,personnel and set-up are estimated to be $200,000.00. We recommend that the costs for this policy be distributed to the CalARP facilities. 2 .6 RECOMMENDATIONS: We recommend that the Board 1. Approve the Unannounced Inspection policy; 2. Approve the addition of one (1)CaIARP and one(1) Hazardous Materials Specialist staff positions; and 3. Approve the allocation of the casts to implement this policy to the CalARP facilities. ADDRESSEES: JOHN GIOIA,DISTRICT I GAYLE B.UILKEMA,DISTRICT 2 DONNA GERBER,DISTRICT 3 MARK DE SAULNIER,DISTRICT 4 JOE CANCIAMILLA,DISTRICTS 3 CONTRA COSTA HEALTH SERVICES DEPARTMENT HAZARDOUS MATERIALS PROGRAMS UNANNOUNCED INSPECTIONS POLICY Background: It is the policy of the Contra Costa Health Services Department's Hazardous Materials Programs Division(HMP),within the resources available to the HMP and under circumstances warranting them,to conduct Unannounced Inspections(LSI)at facilities handling hazardous materials. Over the last several years, accidents at facilities handling hazardous materials have resulted in the loss of life and impacts on the surrounding community and to the environment. The HMP is charged under the California Health& Safety Code; and the California Code of Regulations,Title 19, with the responsibility of regulating and overseeing facilities handling hazardous materials. The regulation and oversight is accomplished, in part, by inspections at the facilities. These inspections can be carried out either by giving advanced notification to the facility to coordinate the resources needed for the inspection; or by not giving advanced notification(unannounced inspections). Facilities Subiect to Unannounced Inspections: While UIs may be made at any facility handling hazardous materials within the incorporated and unincorporated areas of Contra Costa County and subject to the regulatory oversight of the HMP,this policy shall be applicable to those facilities under the HMP's California Accidental Release Prevention Program(CalARP). These facilities handle hazardous materials that are classified as regulated substances. Regulated substances are considered either toxic specific or highly flammable. Bases for Unannounced Inspections: The HMP may select facilities for unannounced inspections based on any of the following criteria: 1. Accident history of the facility, 2. Accident history of other facilities in the same industry; 3. Quantity of regulated substances present at the facility; 4. Location of the facility and its proximity to the surrounding community; 5. The presence of specific regulated substances; 6. The hazards identified in the CaIARP Program Risk Management Plan or the Safety Plan; 7. Complaints from the facility's employee(s) or their representatives; and •e Vii'''%r1U 8. A plan providing for neutral,random inspections. Inspection Protocol: The Unannounced Inspection Team(UIT) will be comprised, at a minimum, of one (1) Hazardous Materials Specialist and one (1) Cal ARP Specialist. A member of the UIT will be designated as the lead for the particular engagement. The UIT will arrive at the facility in the morning of a regular workday and request to see the facility's Health and Safety Manager (HSM) or designee. The HSM will be informed that the HMP is conducting an UI at the facility and ask for an Opening Conference (OC) to include the HSM, the chair or other designated member of the facility's Safety Committee, the employees' representative; and other facility staff as designated or needed. At the OC,the UIT will give an overview of the inspection process to be followed and present the HSM with a list of documents that will be reviewed, a list of locations and facility areas that will be inspected; and a list of staff(including contractors) the UIT wants to interview. All staff interviews may be conducted solely between the UIT, the staff member and his or her employee representative. During the course of the inspection, if any significant issue or question should arise, the UIT will bring it to the facility management for resolution. If the matter is resolved before the inspection is completed,this will be noted at the Closing Conference (CC) and become part of the written report submitted to the facility. The UIT will review documents, review designated locations and areas, and interview staff. At the conclusion of the inspection, the UIT will request a CC at which the general findings of the inspection will be discussed. After the CC, a draft report of the UI will be completed and sent to the facility within thirty (30)calendar days. The facility will have fourteen (14) calendar days, after receipt of the draft report, to correct any factual misstatements and send the suggested corrected draft back to the HMP's UIT. The final report will be issued and sent back to the facility within thirty (30)calendar days and become part of the HMP's facility file. A matter may come to light during a UI which requires a referral to another regulatory agency. Should this occur, the referral will be made to the appropriate agency at the earliest time practicable. Report to the Board of Supervisors: A report will be made to the Board of Supervisors on the progress of the UI Program in conjunction with the Annual Performance Review and Evaluation requirements under the Industrial Safety Ordinance.