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Home My WebLink AboutMINUTES - 06192001 - D.2 TY): BOARI)OF SUPERVISORS - .• ;.-.. S � •�/�;. •��;,. Contra FROM: William Walker, D.,Ile, Ser-vices llirc�ll�r , ,5 Costa UA'1'Is: .tune l),ZUUl County SUBJECT: REYOR'1' ON THE FOLLOW-UP EVALUA'T'ION OF THE TOSCO SAN FRANCISCO A1LEA REFINERY A'1' AVON SAFRETY EVALUA'T'ION REPORT' NOW OWNED BY ULTRAMAR INC. SPECIFIC REQUEST(S)Oil ILL:COMNIENDAT'ION(S)&BACKGROUND AND JUSTIFICATION RECON"IMENDATION: ACCEPT the attached report "Follow-up Safety Evaluation of the Ultramar Golden Eagle Refinery ill Martinez, California"written by consultants from Arthur D.Little,Inc. (Attachment 1) BACKGROUND: Because of incidents that have occurred at the Tosco Avon Refinery, comrluuhities 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 ill 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 the Arthur D. Little, Inc. to do this evaluation. The evaluation was clone at the same time that Contra Costa Health Services, Cal/OSHA, and the federal Chemical Hazard Investigation and Safety Board were conducting investigations of the incident that occurred on February 23, 1999. Arthur D. Little, Inc. presented the report "Safely Evaluation of lite Tosco Avon Refinery in Martinez, California" to the Board of Supervisors oil April 27, 1999. This report included findings and recommendations as a result of the evaluation. Dwight Wiggins the President of Tosco Refining agreed to implement an action plan that would address all of the recommendations. Arthur D. Little, Inc. presented the "Follow-up Safety L'valrtation of lite Tosco Avon Refinery in Martinez, California" report to the Board of Supervisor on February 3, 2000. The report stated that Tosco had implemented actions to address all of the recommendations and findings that were reported in the "Safety Evaluation of the Tosco Avon Refinery in Martinez, California". Arthur D. Little recommended that Health Services follow-up on fifteen of the items over the next year. Ultramar Diamond Shamrock bought the refinery on September 1, 2000. Jean Gaulin the CLO of Ultramar Diamond Shamrock reported to the Board of Supervisors that they were willing to have Arthur D. Little return to determine, how Tosco and now Uttralnar Inc. (wholly owned company of Ultramar Diamond Shanhrock) were addressing the items that needed ongoing actions to address the original recolluneudaliODS. Mr. Gaulin stated that they would be ready for this evaluation within approximately six months. This would allow Ultramar Inc. time to assess the actions. that were implemented by Tosco to determine that the action plan is addressing the findings and recommendations from the Arthur D. Little, Inc. evaluation. This report by Arthur D. Little, Inc. is the results of the onsite evaluation performed in April 2001. A draft report on this evaluation was issued for a fourteen-day public comment period. Two public comments were received on the draft report. The public continent letters along with the replies are included in Attachulents 2 and 3. FISCAL IMPACT: None CONTINUED ON ATTACHMENT: X YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SI GNAT 1R (S): ACTION OF BOARD ON ,hme 19, 2001 APPROVED AS RECOMMENDED X OTHER X ACCEPTED the report; ADOPTED the recommendations presented in the A.D. Little report; Pursuant to a merger of Ultramar Diamond Shamrock and Valero Energy Corp. REQUESTED that Valero commit to the Board to retain the programs and procedures instituted by Ultramar Diamond Shamrock, including the 72 recommendations of the Arthur D. Little study and continue the ongoing value judgement system and safety culture, and REQUESTED a thire party review in VOTE OF SUPERVISORS aneear, with lead y o leading indicators/near UNANIMOUS (ABSENT ) AND CORRECT COPY OF AN ACTION.TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERV ORS ON THE DATE SHOWN. Contact Person: CC: Randy Sawyer ATTESTED Z 21 J SWEETEN,CLERK OF E BOARD O ERVIS S AND COUNTY INISTRATOR BY ,DEPUTY 1 REQUEST TO SPEAR FORM (THREE (3) MINUTE LIMIT) Complete this form and place it in the box near the speakers' rostrum before addressing the Board. 2 Name: 2311,2- / I,100D Phone: Address: �J� 5�' a fsl/i9�Y city: ,112-e- I am speaking for myself or organization: �2P?GDcaf L� �CL�ief�/ (name of organization) CHECK ONE: V I wish to speak on Agenda Item # Date: 611910/ My comments will be: general for against I wish to speak on the subject of I do not wish to speak but leave these comments for the Board to consider: SPEAKERS 1. Deposit the "Request to Speak" form (on the reverse side) in the box next to the speaker's microphone before your agenda item is to be considered. 2. You will be called on to make your presentation. Please speak into the microphone at the podium. 3. Begin by stating your name and address and whether you are speaking for yourself or as the representative of an organization. 4 . Give the Clerk a copy of your presentation or support documentation if available before speaking. 5. Limit your presentation to three minutes. Avoid repeating comments made by previous speakers. (The Chair may limit length of presentations so all persons may be heard) . REQUEST TO SPEAR FORM (THREE (3) MINUTE LIMIT) DE Complete this form and place it in the box near the speake rostrum before addressing the Board. Name• Joe— V ��'�� Phone: -7D T- 663- Address: 63-Address: 16 56 ra SS city: Orcl�.l a I am speaking for myself ✓ or organization: -PAC a - 1 8 -s (name of organization) CHECK ONE: I V I wish to speak on Agenda Item # Date: (0 l Z� My comments will be: general for against I wish to speak on the subject of I do not wish to speak but leave these comments for the Board to consider: SPEAKERS 1. Deposit the "Request to Speak" form (on the reverse side) in the box next to the speaker's microphone before your agenda item is to be considered. 2. You will be called on to make your presentation. Please speak into the microphone at the podium. 3. Begin by stating your name and address and whether you are speaking for yourself or as the representative of an organization. 4 . Give the Clerk a copy of your presentation or support documentation if available before speaking. 5. Limit your presentation to three minutes. Avoid repeating comments made by previous speakers. (The Chair may limit length of presentations so all persons may be heard) . REQUEST TO SPEAK FORM (THREE (3)MINUTE LIMIT) Complete this form and place it in the box near the speakers' rostrum before addressing the Board. 000 Name: /"! !KC �CL' Phone: �Z/� - 6 VD 7 Address: C/o IST D luuk- City: 1/,9 619-VI Z-L,6Y- I am speaking for myself or organization: (name of organizaCon) CHECK/ONE: y I wish to speak on Agenda Item# D Z Date : & l� 0 My comments will be: general X for against 1 wish to speak on the subject of I do not wish to speak but leave these comments for the Board to Consider: i 1 SPEAKERS 1. Deposit the"Request to Speak" form (on the reverse side) in the box next to the speaker's microphone before your agenda item is to be considered 2. You will be called on to make your presentation. Please speak into the microphone at the podium. 3. Begin by stating your name, address and whether you are speaking for yourself or as the representative of an organization. 4. 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VJ 0C) �. cu N i cz V a a 4-0 _ cz 4�3 i CD c� .C: CD 1 cz C: �. o C: E CZ cn ca cz .� E cz cz (n z '..- 1 1 . r r Arthur Q Little Follow-up Safety Assessment of the Ultramar Golden ' Eagle Refinery in Martinez, California r r Final Report to: Contra Costa Health Services June 8, 2001 1 Arthur D. Little, Inc. jReference 73437 Notice ' This report was prepared by Arthur D. Little for the Contra Costa County 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—June 8,2001 i ArtJur Q Little ' Table of Contents 1 Egg e Executive Summary ES-1 I. Introduction 1 A. Objectives and Scope 1 B. Background 1 C. Report Format 3 II. Scope and Approach 4 1 A. Scope 4 B. Approach 4 LIII. Second Follow-up Assessment Findings 7 A. Outstanding Recommendations 7 B. Safety Culture 7 IV. Conclusions 22 A. Outstanding Recommendations 22 B. Safety Culture 22 1 Attachment A List of Finding and Recommendations from Safety Evaluation A-1 (May 10, 1999) Attachment B List of Findings and Recommendations from the First B-1 Follow-up Safety Assessment (January 28, 2000) Attachment C Glossary C-1 List of Tables 1 1 Follow-up Safety Assessment Findings for Outstanding Recommendations 9 2 Follow-up Safety Culture Assessment Observations 14 l Final Report—June 8, 2001 1 I� Q Q dG�C� 1 Executive Summary ' The Executive Summar provides a brief overview of the results of the follow-up safety YP P Y assessment, which addresses the 15 recommendations where additional follow-up was required, and a qualitative evaluation of the safety culture at the Golden Eagle Refinery. The reader is encouraged to review the entire report to gain a better understanding of the progress made by Tosco and now Ultramar in addressing all,of the findings and recommendations. Background A safety evaluation was conducted at the Tosco Avon Refinery in Martinez, California in March, 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. 0 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 safety evaluation identified 72 findings. For each finding, recommendations were developed to address the deficiency. 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. ' In December 1999, a follow-up safety assessment was conducted to determine how Tosco was doing at implementing the 72 recommendations from the safety evaluation. 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. 1 ES-1 Final Report—June 8,2001 �TRBMT Q dmQ i i 1 Arthur D. Little, Inc. presented the "Follow-up Safety Assessment of the Tosco Avon Refinery in Martinez, California" report to the Board of Supervisor on February 8, 2000. The report stated that Tosco had implemented actions to address all of the recommendations and findings that were reported in the "Safety Evaluation of the Tosco Avon Refinery in Martinez, California". ' Arthur D. Little, Inc. recommended that Health Services follow-up on fifteen of the items over the next year. I Ultramar Inc. (Ultramar), which is a wholly owned subsidiary of Ultramar Diamond Shamrock (UDS), bought the refinery on September 1, 2000. Jean Gaulin the CEO of UDS, reported to the Board of Supervisors that they were willing to have Arthur D. Little, Inc. return to determine how Tosco and now Ultramar were addressing the items that needed ongoing actions to address the original recommendations. Mr. Gaulin stated that they would be ready for this assessment within approximately six months. This would allow Ultramar time to assess the actions that ' i were implemented by Tosco to determine that the action plan is addressing the findings and j recommendations from the Arthur D. Little, Inc. evaluation. � 1 i This report presents the results of the second follow-up safety assessment at the Ultramar Golden Eagle Refinery. Scope of the Second Follow-up Assessment The scope of this second follow-up assessment included three major tasks. ' • Follow-up Assessment on Outstanding Safety Evaluation Recommendations. i • Qualitative assessment of the change in safety culture since the initial Safety Evaluation. i 0 Public Participation. The follow-up safety assessment was conducted at the Golden Eagle Refinery in Martinez, California from April 16-19, 2001 at the request of the Contra Costa Health Services. I The objective of the study was to review progress made in implementing the recommendations that Arthur D. Little, Inc. made during the 1999 follow-up safety assessment "Follow-up Safety Assessment of the Tosco Avon Refinery in Martinez", California" January 28, 2000 that needed continued oversight, and to do a qualitative assessment of the change in the safety culture at the refinery, which is now owned by Ultramar. The follow-up assessment was designed and implemented in a manner intended to be impartial ' and objective. The assessment was conducted using a team of two safety professionals working at the Golden Eagle Refinery for a period of four days. During that time, the assessment team conducted more than 50 interviews with individuals and.groups, and reviewed over 60 , documents. Reviews of the actions taken by Ultramar 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. 1 ES-2 Final Report—June 8,2001 1 1 ' Conclusions Ultramar has continued to implement all of the safety systems that Tosco put in place as a result of the May 10, 1999 Safety Evaluation that Arthur D. Little conducted for Contra Costa County ' Health Service. Ultramar has also been reviewing the safety systems that Tosco developed and making improvements in many cases. ' The January 28, 2000 Follow-up Safety Assessment identified 15 items, where additional follow- up was recommended. For all 15 items, Ultramar has either completed the item, or they were continuing to work on the implementation process. A number of these 15 items will require a few years to fully implement. ' The Ultramar refinery management team appears to be strongly committed to the process necessary to achieve a change in the safety culture at the refinery. This commitment is evidenced by the vastly improved attitudes and perceptions of the workers, the sustained effort being put into the Health and Safety programs, policies, and procedures, as well as the refinery's mission statement and core values. In the area of safety culture, the assessment team observed a dramatic change in the attitudes and perceptions of the refinery workforce since the original evaluation was conducted in May 1999. Many interviewees commented that "the culture has changed 180 degrees", or "the difference ' here is like night and day". Employee morale was much higher, and the attitude of the workers was much more positive. ' Most of the interviewees attributed this to the change of refinery ownership from Tosco to Ultramar that occurred in September 2000. Yet from our review of documentation and our experience from previous visits to the refinery, Tosco did make progress in safety performance, ' mainly through improvements to the management systems, during the period following the stand down until the Ultramar acquisition. The recordable and lost time injury statistics did improve during this period, and Ultramar was able to capitalize on the initial achievements made by Tosco. However, it was clearly evident from the interviews that the workers have benefited greatly from the more supportive management style that Ultramar brings. ' Ultramar has established a clear safety message as part of the mission statement. Safety is recognized as the first "core value" along with environmental performance, reliability and profitability. Employees have embraced the core values and the perception of workers was that management actions are consistent with these core beliefs. The emphasis on reliability (ahead of short-term profitability) has resulted in direct and indirect ' benefits to safety. The direct benefit comes from the improvement to mechanical integrity, and the indirect benefit comes from improved employee morale.. Seeing this corporate investment provides assurance of a long-term commitment, and it creates a pride of ownership for the ' employees. y In summary, there has been a vast improvement in the attitudes and perceptions of workers at the ' Golden Eagle Refinery since September 2000. It should be noted that many of the building blocks for improving safety were put in place by Tosco. During the 18 months of operation following the stand down, Tosco revised many of the policies and procedures, and implemented 1 ES-3 Final Report—June 8, 2001 Aditr Q Little i many programs to address specific safety concerns raised in the safety evaluation. However, it is , evident from the employee interviews that there was only minor improvement in the safety culture during that time. Following the Ultramar acquisition, the morale of employees has improved tremendously as they are being empowered by management to take ownership of their ' work, including safety. By providing the framework for active employee participation, Ultramar is benefiting from a dramatic improvement to morale and a greater willingness to become , involved. 1 1 ES-4 Final Report—June 8, 2001 1 I. Introduction 1 At the request of the Contra Costa Health Services, Arthur D. Little, Inc. conducted a follow-up ' safety assessment at the Golden Eagle Refinery in Martinez, California from April 16-19, 2001.'- This 001. This introduction discusses the objectives of the follow-up safety assessment, presents some background information on the initial safety evaluation (May 1999) and the follow-up safety ' assessment (December 1999), and provides the reader with an overview on the format of the report. A. Objectives and Scope The objective of the study was to review progress made in implementing the recommendations that Arthur D. Little, Inc. made during the 1999 follow-up safety assessment "Follow-up Safety Assessment of the Tosco Avon Refinery in Martinez", California" January 28, 2000 that needed I continued oversight, and to do a qualitative assessment of the change in the Safety Culture at the refinery, which is now owned by Ultramar, a wholly owned subsidiary of Ultramar Diamond Shamrock (UDS). ' The :scope of the assessment included the following: g ' • Review how Ultramar was addressing and implementing the recommendations and the findings from the "Safety Evaluation of the Tosco Avon Refinery in Martinez, California" ' report dated May 10, 1999. To evaluate if Tosco and/or Ultramar had addressed, as appropriate, the actions that needed further evaluation, which were identified in the "Follow-up Safety Assessment of the Tosco Avon Refinery in Martinez, California", January 28, 2000 report. • Conduct a qualitative evaluation of the safety culture of the Golden Eagle Refinery to assess the change in the safety culture from the 1999 Safety Evaluation. 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 the Arthur D. Little, Inc. to do this evaluation. The evaluation was done at the same time that Contra Costa County Health Service, Cal/OSHA, and 1 Final Report—June 8,2001 ArtJur Q Little the federal Chemical Hazard Investigation and Safety Board were conducting investigations of ' the incident that occurred on February 23, 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 evaluation 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 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. Tosco agreed to implement an action plan that would address all of the recommendations. 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. The follow-up assessment was conducted in December 1999 and January ' 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 Tosco could take to enhance the effectiveness of their action plan. 2 Final Report—June 8,2001 ' • Conduct a follow-up safety assessment that is trusted and considered credible by the public and other key stakeholders. ' Arthur D. Little, Inc. presented the "Follow-up Safety Assessment of the Tosco Avon Refinery in Martinez, California" report to the Board of Supervisor on February 8, 2000. The report stated ' that Tosco had implemented actions to address all of the recommendations and findings that were reported in the "Safety Evaluation of the Tosco Avon Refinery in Martinez, California". Arthur D. Little, Inc. recommended that Health Services follow-up on fifteen of the items over ' the next year. Ultramar bought the refinery from Tosco on September 1, 2000. Jean Gaulin, the CEO of ' Ultramar Diamond Shamrock, reported to the Board of Supervisors that they were willing to have Arthur D. Little, Inc. return to assess the progress Tosco and now Ultramar were making on the action items and recommendations from the first follow-up Assessment, in December 1999. ' Mr. Gaulin stated that they would be ready for this assessment within approximately six months. This would allow Ultramar time to assess and modify as necessary, the actions that were implemented by Tosco to determine if they addressed the findings and recommendations from 1 the Arthur D. Little, Inc. evaluation. This report presents the results of the second follow-up safety assessment at the Ultramar Golden Eagle Refinery. ' C. Report Format Section II of the report describes the scope and approach for the second follow-up assessment. ' Section III presents the second follow-up assessment findings for both the follow-up recommendations and the qualitative safety culture assessment. 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 evaluation findings and recommendations (May 10, 1999). B. A list of the follow-up safety assessment findings and recommendations (January 28, 2000). C. A glossary of terms. 3 Final Report—June 8,2001 i II. Scope and Approach This section presents the scope and approach for the second follow-up safety assessment. , A. -Scope , The scope of work for the second follow-up assessment is composed of three separate tasks. ' Each of the tasks is described below. Follow-up Assessment on Safety Evaluation Recommendations - Review how Ultramar was ' addressing the recommendations and the findings from the "Safety Evaluation of the Tosco Avon Refinery in Martinez, California" report dated May 10, 1999. This review should determine that Ultramar has an action plan that either continues what Tosco was implementing or has modified ' the action plan to work within the Ultramar organization. Also, evaluate if Tosco and now Ultramar are addressing, as appropriate, the actions that needed further evaluation from the "Follow-up Safety Assessment of the Tosco Avon Refinery in Martinez, California" report, dated ' January 28, 2000. Assessment of Safety Culture —Conduct a qualitative evaluation of the Safety Culture of the , Golden Eagle Refinery to assess the change in the Safety Culture from the 1999 Safety Evaluation. Public Participation—Public participation is a key element of the second follow-up safety assessment scope. The public participation steps include: , • A public meeting to discuss the draft findings of the second follow-up assessment and to take public comments. This public meeting will occur in May 2001. ' • A Board of Supervisors meeting to present the final report on the follow-up assessment. This hearing will occur in June 2001. , B. Approach ' The onsite work associated with the second follow-up safety assessment involved two major tasks. The first focused on determining the actions taken by Ultramar for the outstanding , recommendations generated as part of the first follow-up safety assessment. The second major task was to conduct a qualitative evaluation of the safety culture at the facility. The approach to each of these tasks is described below. 4 Final Report—June 8, 2001 ' 1. Assessment of Outstanding Safety Evaluation Recommendations To evaluate the progress on implementation of the outstanding recommendations during the April 2001 follow-up assessment, the team replicated the approach used in the December 1999 follow-up assessment. 1 More than 30 individuals were interviewed over a one-week period, and over 50 documents were reviewed. All interviews were held on a strictly confidential basis. To protect the people interviewed, information derived from the interviews is not attributed to the contributor. A three-stepapproach was used to assess the progress Ultramar has made in addressing the PP P b b outstanding recommendations. 1. Based upon the interviews, document reviews, and inspection, a summary was developed ' that described the actions taken by Ultramar to address each of the.outstanding recommendations. 2. The assessment team then determined if the actions taken by Ultramar met the intent of the recommendation, and if the action items had been implemented. ' 3. The implementation status was determined for each of the outstanding recommendation. In determining the implementation status a number of factors had to be taken into account such as the wording and intent of the outstanding recommendation, the type of recommendation, and the time needed to fully achieve the goals of the outstanding recommendation. ' 2. Safety Culture Assessment There is a growing body of literature that emphasizes the importance of a company's culture for superior safety performance. The organization's culture forms the basis for everything that is valued in the company, including safety. A supportive culture is essential to the prevention of ' injuries and illness for employees, the economic viability of the organization and preventing accidents that may effect the community. 1 Safety culture is the product of the individual and group values, attitudes, competencies, and patterns of behaviour that determine the commitment to and the style and proficiency of an organization's health and safety programs. Safety culture is, "The way we do things around here". Workers interpret safety culture through their work environment and life experiences. Critical aspects of the influence of management practices and programs in safety on the behavior of workers include: • What is measured and rewarded • How persuasion and coercion are exercised • How leaders model behavior and telegraph expectations 5 Final Report—June 8,2001 ArUur Q Little i • How workers are trained and supported , • How accidents and near misses causes are investigated and resolved • Where accountability for safety performance really resides The change of ownership from Tosco to Ultramar in September 2000 was a singular event that added an additional challenge to the safety culture evaluation. During the interview process, the. ' team asked those interviewed to comment on changes that occurred during the Tosco ownership and the Ultramar ownership. Rather than try to attribute progress to one or other of the two companies, the team was more interested in understanding how the organizational issues and ' management characteristics of the two companies affected safety culture. To re-evaluate the safety culture during the April 2001 follow-up assessment, the team replicated the approach used in the original evaluation two years previously. Our objective was to explore the attitudes, values and perceptions of managers and employees from across the organization, including contractors, and to assess how they have changed over the two-year period. I More than 50 individuals were interviewed over a one-week period. All interviews were held on a strictly confidential basis. To protect the people interviewed, information derived from the ' interviews is not attributed to the contributor. Interviews were conducted with several categories of employees, including: • Senior management ' • Middle management • Supervisors • Workers • Safety, health, and environmental personnel • Contractors ' The interview process consisted of six parts, as follows: • An introduction to include the confidentiality of the interview and the purpose for conducting the interview. • A review of what they perceive their role to be in the safety program. ' • A review of how the person interviewed perceives the current state of safety at the refinery and how it has changed during the last two years. ' • A review of how they would perceive an ideal state of safety. • An open-ended opportunity to contribute views related to safety. • A closing and opportunity to contribute later. ' The interviews were used as the primary basis for establishing our observations regarding safety culture. Other directly relevant information was obtained from direct observations in the field ' and review of various documents. Information collected through interviews was compared with the information collected during the initial safety evaluation to assess any changes in the safety culture. ' 6 Final Report—June 8, 2001 ' III. Second Follow-up Assessment Findings IThe findings in this section are presented separately for the outstanding recommendations and qualitative safety culture assessment. A. Outstanding Recommendations The findings for the outstanding recommendations provide a discussion of the actions Ultramar has taken to address each of the recommendations from the December 1999 follow-up safety assessment. The findings are based on evidence gathered during the second 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., Table 1 presents the initial safety evaluation recommendations where further action or follow-up ' was recommended as part of the December 1999 follow-up assessment, a summary of the actions taken by Ultramar to address the recommendation, and the implementation status as determined ' by the Arthur D. Little team. B. Safety Culture The safetyevaluation of the Tosco Avon refiner conducted Arthur D. March-Ma y d ed by Little in y of 1999 examined safety management systems, human factors and safety culture. The safety evaluation identified many deficiencies in the management systems, and it was noted that the organizational culture evident at the refinery was not conducive to safety excellence. Many of the recommendations included in the final report were designed to address cultural issues. However, it was recognized that it would take time to achieve observable changes in the safety culture at the refinery. After conducting a follow-up assessment in December of 1999, the Arthur D. Little team reported that Tosco had made a good faith effort to implement the safety evaluation t recommendations. Significant progress had been made in repairing the management system deficiencies, and Tosco had taken steps aimed toward making improvements to the safety culture. In particular, they had initiated their own safety culture improvement program using the ' services of a reputable safety consultant. While recognizing the positive direction Tosco was taking, the Arthur D. Little team noted that it was too early to comment on whether the safety culture had improved and whether the actions taken by Tosco would be successful in achieving positive change. All of the findings related to safety culture which were included in the first Arthur D. Little Safety Evaluation (dated May 10, 1999) were re-evaluated during this follow-up assessment. Table 2 presents the results from the safety culture assessment. The safety culture observations from the assessment are broken down into the following categories. 7 Final Report—June 8, 2001 ' Ardur Q Little i 1 • Management Commitment and Support 1 • Employee Participation and Realization of Potential • Organizational Structure and Job Security 1 * Roles and Responsibilities 6 Continuous Improvement 1 • Communications 0 Personal and Professional Development • Recognition and Rewards 1 For each of the categories, the table provides a list of the safety culture findings from the May 10, 1999 safety culture evaluation, as well as a set of observations regarding the state of the ' current safety culture at the refinery. 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IY.. •� E" L' 'L U i Ili C h N O N .-: L O ^ y U L c � 3 _ � o �' 'I%;;,: 3 ,G L' c Q�{Vii: C3 U U E 10 �c w o O U c L 3 � •L '. : c U 72 0 Fj C'S r,- 3 T g. L m T o v 3 .' ':Y.. p 6 > U C U N :D C E E CA CZ, .O 0 C L U `� C O to C ti vi E -p r O U O U ti w tp. w C rico Y m o c if;Fy'� > O rfi!" J.. c r N Y3 'T , C U C O t cd LL 1 IV. Conclusions 1 Ultramar has continued to im lement all of the safety systems that Tosco put in lace as a result P Y Y P P of the May 10, 1999 Safety Evaluation that Arthur D. Little conducted for Contra Costa County Health Service. Ultramar has also been reviewing and improving on many of the safety systems that Tosco developed. A large number of the 72 recommendations presented in the May 10, 1999 Safety Evaluation required a long-term commitment by the refinery management to implement. The majority of the long-term action items were developed to foster a change in the safety culture at the refinery. Safety culture change is typically a slow and long-term process. The Ultramar refinery management team appears to be strongly committed to the process necessary to achieve a change in the safety culture at the refinery. This commitment is evidenced by the vastly improved attitudes and perceptions of the workers, the sustained effort being put into the Health and Safety programs, policies, and procedures, as well as the refinery's mission statement and core values. The remainder of this section is divided into two parts. The first discusses the conclusions regarding the assessment of the 15 outstanding recommendations from the January 28, 2000 Follow-up Safety Assessment. The section part discusses the conclusions regarding the qualitative safety culture assessment. A. Outstanding Recommendations The January 28, 2000 Follow-up Safety Assessment identified 15 items, where additional follow- up was recommended. For all 15 items, Ultramar has either completed the item, or they were continuing to work on the implementation process. A number of these 15 items will require a number of years to fully implement. i B. Safety Culture In the area of safety culture, the assessment team observed a dramatic change in the attitudes and perceptions of the refinery workforce since the original evaluation was conducted in April 1999. Many interviewees commented that "the culture has changed 180 degrees", or "the difference here is like night and day". Employee morale was much higher and the attitude of the workers was much more positive. 1 Most of the interviewees attributed this change to the change of refinery ownership from Tosco to Ultramar that occurred in September 2000. Yet from our review of documentation and our ' experience from previous visits to the refinery, Tosco did make progress in safety performance, mainly through improvements to the management systems, during the period following the stand down until the Ultramar acquisition. The recordable and lost time injury statistics did improve 22 Final Report—June 8,2001 I ArfJur Q Little i during this period, and Ultramar was able to capitalize on the initial achievements made by Tosco. However, it was clearly evident from the interviews that the workers have benefited greatly from the "kinder, gentler" management style that Ultramar brings. One of the most consistent themes that no ees emerged was that employees longer feared for their g P Y g jobs. Interviewees believed that Ultramar was committed to the long-term viability of the refinery, and this.would result in job security. The immediate investments made by Ultramar and , the effort to recrit qualified workers provided confirmation that Ultramar is committed to the long term. The other factor, which contributes to this, is the more supportive management style characteristic of the Ultramar managers. Rather than fearing for their jobs on a daily basis, workers were much more at ease knowing they would not be dismissed or placed on suspension for the slightest mistake or infraction. It should be noted however, that a small number of employees remain skeptical about the safety program at the refinery. They expressed a"wait and see" attitude. The gasoline market conditions are favorable for the refining industry at this time, and the question was asked whether the same commitment will be evident when margins are tighter. This is a valid concern, but the consensus of opinion and the weight of evidence during the follow-up assessment indicated that the refinery has turned the corner in terms of safety culture. The challenge from here is for the organization to build on the successes of recent months, to address the safety issues that are still present, and to avoid complacency as the refinery begins to demonstrate a more respectable safety record. The basic organizational structure at the refinery has not changed greatly over the two-year period. This has provided stability for the workers during the period of ownership change, and Ultramar has stated that they intend to add staff to reduce their dependence on contractors. The changes they have made to the organization are strategic in nature, being directed at providing resources to the operational units. For example, maintenance planners have been re-assigned to the areas, and area production teams have been formed to provide a mechanism for each area to identify problems and develop solutions locally. ' The Ultramar management style encourages employee participation in decision making and problem solving. Workers are encouraged to identify problems and they are generally provided assistance and resources to help solve their problems. Workers at the unit level reported that communications through middle management have improved. Management is more receptive to hearing workers concerns and issues and workers generally receive feedback regarding the issues they raise. Employees no longer feel they will be reprimanded for reporting safety concerns, stopping unsafe work, or shutting down units when safety limits are exceeded. Employees receive a clear safety message through the written and spoken words of management, and in the actions they observe. Workers are looking out for their own safety and beginning to look out for each other. Senior managers are now more visibly committed to safety, and they are role modeling safety by example. We heard of several examples where managers have supported employees for stopping jobs until everyone is satisfied that there are no remaining safety concerns. 23 Final Report—June 8, 2001 1 Ultramar has established a clear safety message as part of the mission statement. Safety is. recognized as the first "core value" along with environmental performance, reliability and Iprofitability. Employees have embraced the core values and the perception of workers was that management actions are consistent with these core beliefs. "If we take care of safety and reliability, and we act with integrity, the profits will follow." The emphasis on reliability ahead of short-term profitability) has resulted in direct and indirect P Y � P Y) benefits to safety. The direct benefit comes from the improvement to mechanical integrity, and the indirect benefit comes from improved employee morale. Seeing this corporate investment provides assurance of a long-term commitment, and it creates a pride of ownership for the employees. 1 24 Final Report—June 8, 2001 1 Attachment A List of Findings and Recommendations for the Initial Safety Evaluation (May 10, 1999) i i 1 i 1 1 1 1 1 1 1 t 1 Final Report—June 8,2001 r o x 06 G 0 s enCO- r R O s G O .^J �' � G r '�• � � y 'O '� J N � w N o1)O J 1 i N,G r cs O '7 � •Y G to 7 p s y 2S U O GG J G O, ✓v v p. C G• bQ N O N � •.. C U C 'O O' G a� '✓ `" cf. U y Gfl J ✓ � T ca T ✓ � X41 7, Op N �� F � ''v w ✓ N .-• G w y W � pt7 pU C' C G Q• '7 v J 1 Q � '� y G G c4 G "' G � O ✓ " 'D � G A O i0 G ✓ U O N J i N G ✓j G y U v v �.. ! G 'ry✓ cs —CY G N Nn �W � "G y np 't'p,. 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U �D o G pv tn t3 •? c3 r-4 > G `� T G '� cyn ,Q W a 3 s T •a to E r .o G e N - = ++ ci '`�• G G r 6tJ � J C J O rte. rp J �-' r.. r r T C5 '�U cn G O U cS G Q �CC y N it y N G U y p s v C 0 � . C v c',s O-, T G'• C c O L In: ,LT,, O C- N yGj =� y N y, U L G G �' O C 3 •T r �+4 C U t0 -0 •G G N n r 0 U W C V N C U Q s ccz j U ' G4 C .'r.' % r U O p rG ? 'G G•,� ,U ti r tIz r- 1 .,� C r G T C O N G •V C !� F U ?� ''3 j ,� N •� C j T r la) Vi y G G GA 0O +.• 7 t C O rG y «+ 0. A^ VKz. J G i GA JC', U Q _T O ?' O � C �+ '3 Vr -0 acu 6�J y tU- G1-„U1 cc ,y rn J G U O O � p O c• 0.�N c J-- F .L n_„ W co C. y C� v, t+; •�.1 tU.• ) � t l3 U N i7 G•..� GA i J G �' N T > J U OJ FS G � ter.+ 61 G y G .r p cct C U X C3 '� C v � cG.. C .�. p G C • G!} an C U o} G4•3 T T C=. 3 U ,.a. C U O G•i C O qcj '� O G > c' G N T1 �" O O - �"" -yam c p •> - c � r n O G � •' 1 G 0 � •r U U 'G G E!'! E 1 J v 1 'a N 00 . 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G o �, or N O W ^O U w i•y jG i f T C G v ,p✓G j �G i U In �' .-' r G S, C U i ep'• � ~T'- G G N G 7, G r., i •J• w \\ '�'� r G •7 f .Uv %•' % °+ � � � '.G J �'•. .G � ';n .�;. �� '�•�, .5 G C' j � !? � f ,Tj G .. G i a �, G � w � � W r � G � =� 3 y W �• � ti � . v .G � E. ei w ti %s { G o C o E o c � � � o w • 'W o GA � o � -- � w � ' G c �` •" '� G G °' on•w � �, ^"., < G W v G 7 r "r.+ p t, J h •l• G O �• T i G y !; 'l Q •.'r% !, Cir G ..� 'v wta � � T.v f' GG G) hG � y 'WN o CA✓ v ✓ < ;n UZi ' 'r N •.+•. U v r '�, 7 , F"" v � T . "� �' �.+ W •..:+ C J r J G1'r G v G G N G O p 7.,' W G N 'fl ct) 'G r G •r y ci ,.A •r. G r, it v i cUJ U N N 'f N N G w W r LLL 4 i U rG toG "I A y. J G 'r, G •�G � 3 v r O G 7� � U J. '` W G � 'O U ?,` O G � •^'C T i '' G Q (b! -•' � i v ;L G i `G N 6D •'°� t � � � •� � � b° G c- 17 v.G E" •�Jn cA 7A �• j, G N ! C .f G G U N � � G � 7` pA 'n •3 G � F G CCS > I-- Ob r. N O y •� � G � N ' � n p W N h `r ✓ ' W C •� r�,,, v ;•3 0 1. W U- ✓ N p • •f a c� tj cn 0 V. 0 00 N cl G • v G O .y a N G J N ! G T N N G G np•p � G N .� G o n " r' '' N `� ✓ V G p � .•3, � o 0 3 -� � J ON ••. i �, i G !� ", r.A N %, �� r N� N � G C �✓ � J �'..Q Op T'r � N C .� N G. o G V � N G '� G G N -:✓ i Op•j � N G- G � G ' 05 uo J Q J G Attachment B List of Findings and Recommendations from the First Follow-up Safety Assessment (January 28, 2000) 1 1 i 1 ' Final Report—June 8, 2001 0 o N 00 at G 7 1 ✓ v 1 a � q O • G U _ U N .0 > 3 G c c1 7 ti) ✓ v C G w L O 7A y C O G J ''✓ J G U G � G O •O •y cC '� N ,O. G G e r J7 '-� n p C ✓, O G O O i N y i y 7 O✓ vt C GA r i 7 G O ro- c' I i fir. G C G ✓ f c rJ t o G p " po N .�. G N 0 N O.'. d v fi t3 QAC F v o U •rpA V- ..+ O y G C ✓ ..- .0 'J C G � I `ll✓ � Off,.'. p v O N v ..-. G ^) ✓ ✓ fS J T .� G C3 GA i % 404G r G C I T G c U ✓ C1� v.' U o> U C 9i v v C bA{. G `'+'� ' : >T U,., C v 'J '� �A GA ' � N G 3 U C a? •r. �' .�; J ✓ r cn •�- Q .�...;' '� G y G •;'✓"' .r,. 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G r r bA ::: 7:0v C cn 3 �. y c Fl G _ _ o r a1 °n G u s y 'c 3 0 " y c > > c L y y u I � .'U �• y C r U G L � C G G O '•• y �, G._ > .0 'n .� T CL 2 ,F, •D :� O _A y U L U = ,� y L C C- C .n y U J U 1 U "�7 C `� O y F ^,C E J. 'O :, .'� > .,� U = a I I iI I — — I C N m w • . O¢ c c v G= ` -5 E G c s c a a „ G a w o o c o G G E c o 3 U E v bn G G uj Q E � U 6a _ c3 N 0 N T tC tCS V} ri O G r 3 ? d u c o F+ a v n. r -C: S a.), C O N N ':: �. .N .• G N r a~? C. N C::; f" C = '� fl G v Q r o rn G .= v s a r c •r. > a� Q V G• U C C C U C "p N y •C .p F. N i G O co s � c e c c p > a c c_ o _ on c cs.._ c = cn v cv o s _ to y C - .Q }� � p � '� � � cz u � C U C G "O G n G 0 a..::.. O •r. y U U G, T L U N "� U U ... SC G C E Z C G N y to G > O = 'C c U C c3 N N . Cl- r G r G p G O T G on C •U r r a,.,. '`�• G O G T rT""' J > T G '):. G E G i c'S Al y i. U C G •G - E" G G-'s=: E :.v " t>... G eGi 7 c " C as C >) O O Oj > 0 > E a > Q 3 G _ V g C1 s.. IA G E U E b a , Q v o n E a> a> n G w W ar>' c a c c f r , C G G C) r r G W �.... _ G ^ '� E r riG-. cn' �.^.. W G . E G G �; �', �, C C :n U G J .- G G O i -•' >+ J U 1 W n U r VI 0 N C > y C G C: n N ^ N G Q ccz r. U CC-:, n O rr, 'C X r :n G G O v, c 0 cn G [-•+ r E"' E ' E E c� a p �•, 'n .S 3 G U ,G •G � �•G O Q > r ° E o a � c ~ a c = v c ti cc _ rl y E on c p y Cs p G c f Y U p . U c]- U U •r, i. G rS O C �.. v .� O ej ¢. .52 •r. r '. a _ G y ..... G.= p E G ,•, dt C C �.. v s C ^ CG ?? p- 3 ^r. G E "O •-p N C cs C1 ") n 87 -V 0LTJ :C1 4"'. 0 h4 'G J . .... fl- s � q M r• Tr I 1' o _ — ! be C C O c G I N C U:: C E ° °? oG cv Z F- m E .1 our rZG y y c y N 1= C O T 0. O O C 3 cU r = y i y cz .� •r, = y w, L rJ• r- `) r• C L C'7 •Tj •b _ Si .C C, G L to N L < L, y ++... C, y ,C C i C. y L ,� 0. vi U to._ > L >_ J C C. r O = =n 0. y _ y `~ CIA •r. GJ C J O = C ice., 0. ^ J C M-- :0 ::: pn ^ �' O .0 C to N O E - ^_ _ y 'C ... L L C F- i L r QJ ;J 'tel � •C C '? C t: •— ^ i= to 'r to r ,� r C� O = f C O C 0. '.� U C. > U •> ci y 3 G U ' 01' to v y...:: C 0.'C _ ^ •i U U C L y U C y y y:Qn to _ y C o >_ _ = _ C � r � cv 7 C C C 3 C C :r � r C C .,, C C •C U CC ^ :� U O — 's U O L' CJ •r. 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T— 'C y U •r. 3 .O �, C' C- .n N - J r - j bA.= y T:-'J` G 'i y n J _ y _ 1 y ^ J O J U 7 .. ,� ,O bA•- _, C C a - C y G. 5f G. = G y y L O v; c. j C o ° c c - C a o > a s ° y 3 ° c o CJ L J y u Ci y u G J L 7D r- I � V U _ Cj LL s x ccs .� — G CZ �c v u' U U — y c N 7-- 5 C.)` c c J C I - V I ' I I I 1 ' Attachment C Glossary of Terms 1 1 1 Final Report—June 8, 2001 ' Glossary ' Accident An undesired event that results in harm to people, damage to property or the environment, or loss to rocess. Action item A formal term used to describe the measures developed in hazard 1 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 1 defensible conclusions. Bidding system Term used by represented labor to describe the way in which a person may gain promotion by "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 programs. 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 u dating 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 employees 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 ' steps needed to shut down the unit if the excursion cannot be rectified. C-1 Final Report—June 8, 2001 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. Emergencv 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 partici ate in the facility's safety management prograrns. , 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 systems. 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 ' ownspecific 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. i 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, j 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 procedures. ! 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 y 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 , i 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 jproduction loss. i i C-2 Final Report—June 8, 2001 ! ' Nuisance alarms Alarms defined as being irrelevant to the situation at hand and which could not be shut off easily. Operator 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/or job-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 operator qualification packages. 1 Organizational chancre 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 way 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 p 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, crenerated 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 Prog**ram 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. 1 C-3 Final Report—June 8, 2001 i PSM system description The term used by Tosco.SFAR to describe the written management system ' for a PSM prog=ram 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, j medium or high. j Risk Mana-ement Program The combination of management prourams designed to prevent accidents, to (RMP) evaluate the potential consequences of accidents that may occur, and the rograms 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 jvalues, 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 treasurable targets for safety performance. Safety incentive program A formal program that may be developed and instituted to provide positive j 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 froth 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". j 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. j 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. C-4 Final Report—June 8,2001 ' Unsafe work Any work activity that, in the judgement of an employee or contractor, could lead to a release of a hazardous substance, an injury,orequipment damage. Upset An unpredictable event that results in a process parameter deviating from its ' normal range for safe operation. Verification The measures taken by management to ensure that programs,policies and procedures are being implemented as intended. 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C� CD CZ � 1 E o � a� CD 1 > r LM E c: N C. cZ CD cZ cZ c� I E CZ 1 .cn cz C E a� � Lam '— -� E 1 �� C;) ;� cz cz C: cz c� ' O CZ U) 0 . CE� i� 1 co f a3 C.� CC3 cu 0 0 � o s 1 cv as lotv N s w 0 1 . 6� r W W `* i Q woo 1 7 0 � o soop tcS t� `�' o • .� i0oot� 1 U. 1 N C� C: N � 4, LU — = cz > cz 0 -f 75 cn .N O CD CZ O 1 c� > •u� cn �o 1 $ � cz o CDE cz cm C: o -C: cz 0 C: 1 0) cz C: CZ -c E (D E �- C: cz cn 0 E %+C-Z cr_ 3: 1 0 z cz o U) Ed (1) � � d 1 s W a� z � 0 ) F— .� • • • 1 � i ED VINING 4819 JOHN MUIR RD MARTINEZ CA 94553 925-228-8792 E-mail ed.vining@juno.com May 29, 2001 Randy Sawyer By E-mail: rsawyer@hsd.co.contra-costa.ca.us I have reviewed the Draft report,Follow-up Safety Assessment of the Ultramar Golden Eagle Refinery, and have a few comments. General comments and those associated with pages are of generally decreasing significance to me. General: n I did not participate in the review of previous assessments, so I did not have any idea how this one would be structured. Lack of a Scope of Work item for recommendations was disappointing. !� Although near misses are described in the Glossary I saw no mention of them in the body of the report. I think near miss investigations are a most valuable too] in the safety process. Although I realize that the assessment is intended to be qualitative, in some little indication is given of the degree to which improvement has been made. An example is item 13 on Page 13. One has no idea if this item needs further attention. Page 14 One finding from the May, 1999 assessment was that, "when an upset occurs managers are slow to respond, or does (sic) not respond, to requests for extra people to deal with the situation." I do not find any reference to this statement in Appendix B, nor where it might be addressed in the Safety Culture Observations column. i Page 11 Item 7 discusses valve location. 28 valves have problems that will not be implemented until the next turnaround. Nothing is said about what will be done to see that these valves do not constitute a hazard to operations. Also, the numbers cited don't add up. Page B-8 Item 20 discusses the training coordinator position. Although it is given a high priority, I find no . mention of it in this report. Page 10 Item 6 discusses team investigation of"serious incidents" but doesn't define them, or any other class of incidents. Page ES-3 The phrase in quotes in the third from last paragraph surely did not come from the mouths of the rank and file employees. TM Page ES-2 The numbers in the next to the last paragraph don't agree with the numbers attributed to the same tasks on pages 5 and 6. Page 7 The word "recommend" in the third paragraph should be "recommended." Thank you for the opportunity to comment. If I can be of any assistance, please let me know Regards Ed Vining u n \Nii.l.inna Q. WALKER. M. D. HAZARDOUS MATERIALS PROGRAMS HEALTH SERVICEs DIRECTOR --- LFw,Is G. Pnscni.ti,Jr,..E`o; 4333 Pacheco Boulevard z, California DIRECTOR Martine ��;> ,�„`_ o 94553-2295 CONTRA COSTA Ph (925) 646-2286 HEALTH SERVICES Fax (925) 646-2073 June 8, 2001 Mr. Ed Vining 4819 John Muir Road Martinez, CA 94553 Dear Mr. Vining: SU-BJECT: ARTHU-R D. LITTLE, INC. FOLLOW-TiP ASSESSMENT OF THE ULTRAMAR GOLDEN EAGLE REFINERY Thank you for your comments on the "Follow-up Safety Assessment of the Ultramar Golden Eagle Refinery in Martinez, CA" report written by Arthur D. Little, Inc. I have asked for John Peirson from Arthur D. Little, Inc. to address your comments. The enclosed table is his responses to your comments. I have also enclosed copies of the original safety evaluation report, the first follow-up evaluation, and the final report on the "Follow-up Safety Assessment of the Ultramar Golden Eagle Refinery. in Martinez, CA". Please contact Randy Sawyer at (925) 646- 2286 if you have any questions. CSincerely, �is G. Pa✓✓✓scalli, Jr. Director Hazardous Materials Programs Enclosures (4) cc: Randall Sawyer CCHS John Peirson, Jr. Arthur D. Little • Contra Costa Community Substance Abuse Services • Contra Costa Emergency Medical Services • Contra Cesta Environmental 4=-alth Contra Costa Health Plan Contra Costa Hazardous fvlater:afs Programs •Contra Costa Mental 4ealth • Contra Costa Puhfic Health • Contra Costa Regional Medical Center • Contra Costa Health Centers -�Y General A Many of the safety recommendations developed by Arthur D. Little (ADL) in the initial Safety Evaluation(May 1999) were designed to encourage the refinery to integrate safety systems into their routine process. A well-run refinery should not require an outside team of specialists to come onsite routinely to evaluate their processes (unless requested or required by regulation) If the initial ADL recommendations were implemented in the spirit they were intended, the desire for continuous improvement would move the refinery to develop their own systems for - identifying potential weaknesses and solving problems. At this time, we are sensitive to the fact that developing new recommendations on top of the old recommendations could be counter- productive at a time when the refinery is recreating its safety vision and cultural identity. The first element of this assessment was to review progress made against previous recommendations. The overriding conclusion from the assessment was that the refinery is actively addressing the recommendations and scheduling additional work as necessary. For the second element—the assessment of safety culture—the ADL team concluded the refinery has made great progress in the last two years, and processes are being set in place to allow for continued improvement. Internal review processes, such as audits and assessments, should be adequate to sustain the safety performance improvement without additional recommendations from this assessment. General B We agree that near miss investigations are a valid tool in the safety process. Near misses were discussed extensively during the Safety Evaluation (May 1999) and in the first Follow-up Safety Assessment(Dec, 1999). The Golden Eagle Refinery Incident Investigation Program includes near misses with definitions,reporting requirements, and investigation procedures: (Refer to Item 438, Recommendation A-14.c on pacre B-13, and Item#67, Recommendation C-0 Lc on page B-22 for background on this issue.) Following the first Follow-up Safety Assessment, the ADL team determined that near misses were being reported and investigated, and Tosco had implemented a reward program for the best near miss reports. Since there were no further recommendations concerning near misses at that time, there was no specific requirement to explore them further as part of this assessment. General C The assessment team did not rate the change in Safety Culture for each individual finding. However, the tone of this report compared with the previous two ADL reports should give a clear indication of the improvement that has occurred over the two years. The overall change is best - described in the conclusions section of the Executive Summary. As for the example cited, the issue was whether or not the previous recommendation was completed or not, rather than whether there had been improvement in this area. Page 14 This finding was included in the May 1999 Safety Evaluation report(See Attachment A on page A-12). The recommendation to address this was B-09.a-g. The finding does not appear in Attachment B, because Attachment B includes only the recommendations from the first Safety Evaluation, and not the findings. Recommendation B-09.a-g(Safety Summit) was developed in response'to this finding because the assessment team considered there were significant communication issues underlying this and other findings which involved management-worker interaction and vertical communication. Tosco did hold two Safety Summits between May 1999 and Sep 2000, and progress was made to improve the communications. However, since Ultramar took over the refinery,the vertical communication has improved considerably. Operators interviewed in this assessment said they " now get the help they need to deal with upset conditions. Text has been added to.the Safety I Culture Observations column to acknowledge this. Page 11 Of the 123 valves originally identified, 70 were addressed and closed, 25 were found not to need repair, and the remaining 28 were deferred to turnaround time (123 total). The comment about what will be done to see that the 28 valves do not constitute a hazard between now and turnaround is well taken. This has been passed to Ultramar for their consideration. Page B-8 See Item 12, page 12 for a discussion of this issue. Page 10 The Golden Eagle Refinery has developed their own definitions for a minor incident, serious incident, and a major incident,as well as a near miss. These are included in the Incident Investigation Procedure. The issue is not whether these definitions are appropriate or not. Rather the issue is whether the refinery is following their own procedure. The comments on page 10 indicate that, at the time of this assessment, the refinery did appear to be following their own procedure for investigating serious incidents. In the initial Safety Evaluation and in the first Follow-up Safety Assessment, ADL did make recommendations for improving the incident investigation process, and these recommendations have been implemented. Ultramar now recognizes there are ways to further improve the investigation procedure, and they are considering how best to achieve these improvements. The text of the report has been changed on page 18 to acknowledge this. Page ES-3 This comment is correct. The language in the paragraph cited has been revised. Page ES-2 The numbers included in the Executive Summary (50 interviews, 60 documents) are the combined numbers for the two-onsite tasks. The numbers on page 5 (30 interviews, 50 documents) refer to the interviews and documents used for this assessment on the outstanding Safety Evaluation recommendations. The number on page 6 (50 interviews) refers to the number of interviews used for the assessment of safety culture. Since some of the people interviews were done jointly for both tasks and some were group interviews, the total number of interviews will not add-up to.what was listed in the executive summary. Page 7 This correction has been made. JUN' 4-2001 -MON ill :13 P14 !'r;�/fri: MA ":� COM'MUNITIES FOR.A June 4,2001 R Contra Costa County 4333 Pacheco Blvd. EW RONI�= Mattinez,CA 94553-2229 Dear NL.Sawyer: Please accept CBE's comments on the AD Little Follow up review of the safety culture of the A von refinery, formerly owned by the Tosco corporation,currently owned by the Ultramar corparation and prc posed to be sold to the Valero corporation,pending approval by state and federal agencies. ' Essentially the AD Little review confirms earlier studies conclusions that a long term oan►m1trn1I t by refinery management is required to reform the saf ty culture at Avon. As well the'safety culture,accord AD Little,"is typically a slow and long term process." Therefore although many positive signs have been not d,there is much that remains to be done to ensure long term change, We strongly agree with AD Little that a number of the serious items"will reou a number of years to fully implement." Therefore CBE strongly recommend that regular safety reviews such as this recently concluded effort continue for a period of ten,years after the Feb 1994 Death Tower incident that took the Iives of four innocent workers and seriously injured another. While there is reason to believe that the efforts of the new owner Ultramar have begun to chang the culture at Avon,it is impor`,=t to note that some workers intervi:w:d continued to be skeptical for a vari, of reasons that are well founded. These reasons include the financial success of cufrcnt gas mL-keting which could be reversed and bring production pressures back to haunt recent safety improvements. The most troubling development is clearly the sale ofthe facility from Ultramar to the Valero c oration. The AD Little report clearly shows that change in ownership is a critical factor in safety culture improvej nent. The effect of the change in management is unlmown,bur can not be left to chance on its effect on safety cul -e. Therefore it is in, to ensure that whoever owns the facility will continu:to be evaluated by AD Little f.r enad er eight Years. The other critical effort that must continue is development of"work safety environment indica rs"in order to have a clear method to evaluate each of the safety culture element. AD Little has previously told the ounty and the Board of Supervisors that such indicators could be developed and used to track the performance of Avon. This matter of continuing to track the safety culture at Avon is now extremely critical due to the ending sale of the refinery,since the current report lays most of the credit for progress with Ultramar,who will no ongcr be in charge as early as October,2001, The County must take action now to er��-ts:that the new owners are r1equired to continue safety reviews by AD Little end that the long delayed development of"work safety environmen indicators"be started immediately. We would request a written reply to our:concerns as soon as-possible. Thank you for your coop ration. Sincerely, Denny on CBE 1611 Telegraph;450 Oakland,CA 94612 1611 Telegraph Avenue,Suite 460 •.Oakland,CA 94612 • T (510),302-0430 • F (530)302-0437 In.Southern California:5610 Pacific Blvd., Suite 203 •Huntineton Park, CA. 90255 (323) 526.9771 chlorin®-Free ,00%post-oonsumer WII.I.IAm G. WALKER. M. D. , n, HAZARDOUS MATERIALS PROGRAMS HEALTH SERVIC',S DIRECTOR LFwIs G. PASCAI.I.1.JIt..EscZ 4333 Pacheco Boulevard DIRECTOR � � � •""�� Martinez, California 94553-2295 CONTRA COSTA Ph (925) 646-2286 HEALTH S E R V I C E S Fax (925) 64.6-2073 June 11, 2001 Mr. Denny Larson Communities for a Better Environment 1611 Telegraph #450 Oakland, CA 94612 Dear Mr. Larson: SUBJECT: ULTRA-MAR FOLLOW-UP ON THE SAFETY EVALUATION PERFORMED BY ARTHUR D. LITTLE, INC. Thank you for your comments on the Follow-up Safety Assessment of the Golden Eagle Refinery in Martinez, California report written by Arthur D. Little, Inc. Contra Costa Health Services (CCHS) believes that Ultramar, Inc. has take the appropriate actions to address all of the recommendations from the original safety evaluation of the then Tosco Avon Refinery performed by Arthur D. Little, Inc. plus two recommendations from CCHS root cause analysis of the February 23, 1999 incident. CCHS believes, in most cases, that you are correct in that it takes years to change a culture. CCHS believes that in the case of the Ultramar Golden Eagle Refinery the safety culture changed substantially overnight when the ownership of the refinery changing from Tosco to Ultramar. Safety Culture' — The Safety Culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of 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). The employees feel more positive about their jobs and that Ultramar, Inc. is concerned about their safety and the safety of the refinery. CCHS is the administering agency for the California Accidental Release Prevention (CalARP) 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 CalARP Program regulations. The CalARP Program regulations do not provide a frequency for audits but inspections must be conducted every three years. ' Health &Safety Executive(HSE)ACSNI Study Group on Huinan Factors, Third report: Organising for safety; 1998 Contra Costa Community 5ubstance Abuse S.Ni„s Contra Cosa Emergency Medical Services Contra Costa nvironm?ntal Health Contra Costa Health Plan Contia C,Sio Hazardous Ivatciiali Df0giam5 •Contra„Costa Menial Health hh • Contra Public Health • Contra.05.2 R?OlOnal I✓?OiCal Center • Contra Costa Health Ceme s • 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. 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 CalARP 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 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. CCHS does not believe any additional oversight of the Ultramar, Inc. refinery is appropriate at this time. Ultramar, Inc. has committed to CCHS and the Board of Supervisors to performing an evaluation from an outside company to develop indicators to determine the change in the overall work environment of the Golden Eagle Refinery. This evaluation is expected to occur in the third or fourth quarter 2001. Enclosed you will find a final copy of the Arthur D. Little, Inc. "Follow-up Safety Assessment of the Ultramar Golden Eagle Refinery in Martinez, California" report. Please contact Randy Sawyer if you have any questions at(925)646-2879. Sincerely; 1 -- 1 Le.vYslTascalli;, -- Director Hazardous Materials Programs Enclosure(1) cc: Randall Sawyer CCHS John Peirson,Jr. Arthur D. Little,Inc. I