HomeMy WebLinkAboutMINUTES - 03182003 - D2 111.111,...I................................................................................
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Contra
Costa
TO: BOARD OF SUPERVISORS
County
FROM: William Walker, D., H alth Servic ire for
DATE: March 18, 2003
SUBJECT: Industrial Safety Ordinance Follow-up ReDort
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
RECOMMENDATIONS:
i. Accept the Report submitted by Health Services on the Industrial Safety Ordinance, Unannounced
Inspection Program, and Public Participation.
I Direct proposed changes listed on page 2 on the Industrial Safety Ordinance to the Hazardous Materials
Commission for review and public input.
3. Direct Health Services to develop a new position for public outreach for the Hazardous Materials
Programs, including the Industrial Safety Ordinance.
FISCAL IMPACT:
No fiscal impact
CONTINUED ON ATTACHMENT: F] YES Ej NO SIGNATURE
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S):
ACTION OF BOARD ONnQM 18,2003 APPROVED AS RECOMMENDED X OTHER X
SEE ATLACHM AUDOMM
VOTE OF SUPERVISORS
I HEREBY CERTIFY THAT THIS IS A TRUE AND
X UNANIMOUS(ABSENT NM CORRECT COPY OF AN ACTION TAKEN AND
AYES: NOES: ENTERED ON THE MINUTES OF THE BOARD
ASSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN.
D=ICT ITI: SUT MMI
Contact: Randy Sawyer ((925)646-2879) ATTESTED MMM 18,2003
cc: Randy Sawyer, Health Services Department JOHN SWEETEN, CLERK OF THE
Lewis G. Pascalli, Jr. Health Services Department BOARD OF SUPERVISORS AND
Michael Kent, Health Services DepartmentCOUNTY ADMINISTRATOR
BY2,, '/ DEPUTY
RLS
K:/industrial Safety Ordinance/Board of Supervisors/Board Order 031803
A-L"DI)ENDUM TO ITEM D.2
Mare.. 18, 2003
On this day, the Board of Supervisors considered the attached Board Order on the Industrial
Safety Ordinance, the Unannounced Inspection Program, and Public Participation.
Lewis Pascalli, Jr.,Director of Hazardous Materials Program,Michael Kent,Hazardous
Materials Ombudsman, and Randall Sawyer,presented the Health Services Department report
and recommendations.
There were no speakers from the public.
Following Board discussion, Supervisor Uilkema moved approval of the staff recommendations,
including indicating that the Board is favorable inclined towards creating a permanent position
for public outreach, and,
REQUESTED Health Services Department staff to work with County Counsel to develop
language for proposed amendments to the Industrial Safety Ordinance and associated guidelines
based on Health Services Department recommendations; and,
REQUESTED the Hazardous Materials Commission and PEHAB to review the proposed
amendments and other recommendations of the Health Services Department, and REQUESTED
the Health Services Department to report back to the Board in three months.
Supervisor Gioia seconded the motion. The vote on the motion was as follows:
AYES: Supervisors Gioia,Uilkema, Glover and DeSaulnier
NOES: None
ABSTAIN: None
ABSENT: None
DISTRICT III Seat Vacant
The motion passed.
Industrial Safety Ordinance Follow-up Report
March IS,2003
BAgKGROUNDIREASONS FOR RECOMMENDATIONS:
Health Services gave the annual report on the Industrial Safety Ordinance to the Board of
Supervisors on January 28,2003.The Board requested additional information and for Health
Services to report back to the Board on the following items:
• How could the Industrial Safety Ordinance consider near miss reporting
• A review of the number of Major Chemical Accidents and Releases(MCAR's)and the
severity of the MCAR's
• Any amendments that Health Services is recommending that could be made to the
Industrial Safety Ordinance that would strengthen the ordinance
• A report of the Unannounced Inspection Program,including a review of the number of
inspectors for this program
• A report on the recommendations on improving the public participation process for the
Industrial Safety Ordinance
The attached report addresses the above items. Listed below is a summary of Health
Services proposed changes to the Industrial Safety Ordinance:
• Expand the Human Factors section of the Industrial Safety Ordinance to include the
following:
• Maintenance procedures
o Field evaluation for latent conditions of all covered processes
o Management of Organizational Changes
• Maintenance personnel
• A job description for each position in operations, maintenance, and
Health and Safety
• Include temporary changes in the Management of Organizational
Change
• A requirement that the stationary sources perform a Security and Vulnerability
Analysis and test the effectiveness of the changes made as a result of the Security and
Vulnerability Analysis
• Require that the United Kingdom Health and Executive Safety Climate Survey be
executed for the Industrial Safety Ordinance stationary sources
Industrial Safety Ordinance Follow-up Report to the
Board of Supervisors, March 18, 2403
Health Services gave the annual report on the Industrial Safety Ordinance to the Board of
Supervisors on January 28, 2003. The Board requested additional information and for
Health Services to report back to the Board on the following items:
• How could the Industrial Safety Ordinance consider near miss reporting
• A review of the number of Major Chemical Accidents and Releases (MCAR's)
and the severity of the MCAR's
• Any amendments that Health Services is recommending that could be made to the
Industrial Safety Ordinance that would strengthen the ordinance
A report of the Unannounced Inspection Program, including a review of the
number of inspectors for this program
• A report on the recommendations on improving the public participation process
for the Industrial Safety Ordinance
The report on the Unannounced Inspection Program is included in Attachment A and the
report on public participation is included in Attachment B. The remaining items are
discussed below.
Near Mess Reporting
Health Services gave a report to the Board on April 4, 2000 that included the reporting of
Near Misses. Attachment C is a copy of the portion of the report that included near miss
reporting. The conclusions of the report are:
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 create a culture
in', which near miss reporting is done without fear of reprisal. The first Ievel 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.
Industrial Safety Ordinance Follow-up Report to the Board of Supervisors March 18,2003
The report also discusses how external reporting on near misses may have a negative
influence on the overall reporting of near misses due to concern of how this information
may be interpreted and used. The "Triangle �,,f Prevention" program that is being
administered a the Chevron Richmond Refinery is an incident investigation program,
including near misses. The program is administered by the represented employees at the
refinery and has been a successful program, because of the ownership by the employees,
and the cooperation between management and the represented employees. This type of
program needs the cooperation of the employees and management to be successful.
Near Miss reporting, including the investigations of near misses is a strong indicator of
the overall safety culture of a facility. Since the report on Near Miss was issued in April
2000, the United Kingdom's Health and Safety Executive has developed a Safety Climate
Survey. This survey has been used by companies on a voluntary basis to determine the
overall safety culture at their facilities. This Safety Climate Survey was used by MRS
Environmental during the recent safety evaluation of the General Chemical Richmond
Works Plant.
Health Services is proposing that a Safety Climate Survey be performed at all of the
Industrial Safety Ordinance stationary sources. This survey can be implemented on a
triennially basis to assist in an overall assessment of the safety culture and changes in the
safety culture at the different sites, including the near misses reporting program. The
survey in itself only gives a partial indication of the overall safety culture and "Work
Environment" at the different stationary sources. Health Services will use the
information learned from the Safety Climate Surveys to assist in performing the Safety
Program Audits,including how near misses are reported and investigated.
Major Chemical Accidents and Releases
Health Services has analyzed the Major Chemical Accidents and Releases (MCAR) that
have occurred since the implementation of the industrial Safety Ordinance. The analysis
includes the number of MCAR's and the severity of the MCAR's. Three different levels
of severity were assigned:
• Major — A fatality, serious injuries, or major onsite and/or offsite damage
occurred
• Medium — An impact to the community occurred, or if the situation was slightly
different the accident may have been considered major, or there is a recurring type
of incident at that facility
• Minor -- A release where there was no or minor injuries, the release had no or
slight impact to the community,or there was no or minor onsite damage
Below is a chart showing the number of MCAR's from January 1999 through December
2002 for the ISO stationary sources and a chart that shows all stationary sources in
Contra Costa CountyMCAR's for the same period. The charts also show the number of
major, medium, and minor MCAR's for this period.
Page 2 of 7
Industrial Safety Ordinance Follow-up Report to the Board of Supervisors March 18,2003
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The data does not show any trends on the total number of MCAR's that have occurred in
Contra Costa County or at Industrial Safety Ordinance stationary sources. Looking at the
size and the impact of the MCAR's that have occurred there has been no major MCAR's
that have occurred since 2000 and the minor MCAR's have become a larger percentage
of the overall MCAR's. The data in1999 shows only a few MCAR's (three), but two of
these MCAR's were major. Also 1999 was the first year of reporting MCAR's and the
reporting for the minor or medium MCAR's probably was not as good as the reporting is
now. Only one major MCAR has occurred, in 1999, at an Industrial Safety Ordinance
stationary source.
Page 3 of 7
Industrial Safety Ordinance Follow-up Report to the Board of Supervisors March 18,2003
now. Only one major MCAR has occurred, in 1999, at an Industrial Safety Ordinance
stationary source.
Health Services Proposed Change in the Risk Management
Chapter of the Industrial Safety Ordinance
The Board asked Health Services to come back with any recommendations that may
improve the overall effectiveness of the Industrial Safety Ordinance. Below are the
proposed changes to the Industrial Safety Ordinance that if implemented should improve
the safety at the Industrial Safety Ordinance stationary sources.
• Expand the Hunan Factors section of the Industrial safety Ordinance to include
the following:
o Maintenance procedures
o Field evaluation for latent conditions of all covered processes
• Management of Organizational Changes
• Maintenance personnel
• A job task analysis for each of the positions that work in
operations, maintenance, and Health and Safety
• Include temporary changes in the Management of Organizational
Change
• A requirement that the stationary sources perform a Security and Vulnerability
Analysis and test the effectiveness of the changes made as a result of the Security
and Vulnerability Analysis
• Require that the United Kingdom Health and Executive Safety Climate Survey be
executed for the Industrial Safety Ordinance stationary sources
Human Factors
Maintenance Procedures
The maintaining of the covered processes has a direct correlation to the overall safety of a
stationary source. Maintenance includes the procedures for the different requirements to
maintain the equipment. The number of personnel that is required to maintain the
different covered processes may determine how well the equipment in the different
covered processes are being maintained. When the Industrial Safety Ordinance was
written, there were discussions of requiring the consideration of Human Factors for
maintenance procedures and management of organizational change for maintenance
personnel. The ordinance requires many requirements for Human Factors at a stationary
source that is not required by any other regulations. The stationary sources were required
to implement these changes within one year after a guidance document was completed.
Because of this concern over the time constraint, maintenance procedures and the
management of changes requirements to the maintenance organization were not included
in the Industrial Safety Ordinance as adopted by the Board.
Field Analysis for Latent Conditions
Before a source can manage human factors and error, it may be useful to understand
where and how human factors and error initiate. Literature commonly refers to active
failures and latent conditions in describing where human factors and error originate and
Page 4 of 7
Industrial Safety Ordinance Follow-up Report to the Board of Supervisors March 18,2003
decisions made throughout the organization (e.g., marketing personnel, designers,
managers) and outside of the organization (e.g., regulating agencies). Latent conditions
exist in all systems and may lie unrecognized until combining with active failures to
result in an incident. The same latent condition may contribute to a number of different
accidents. An example of active failures and latent conditions is "the design of a
scrubbing system may not be adequate to handle all credible releases. If an active human
error initiates the production of an excessive volume of product the system may allow
toxic materials to be released to the environment."
The stationary sources are looking for latent conditions that exist in the covered processes
in different ways as part of their Process Hazard Analysis, in the operating procedures,
and in doing incident investigations. Health Services has found that the stationary
sources that do a field analysis for latent conditions at each of the covered processes has
done a more thorough and complete analysis for determining where latent conditions may
exist. Health Services is recommending that a field analysis for latent conditions be done
for all covered processes.
Management of Organizational ChanaeS
The Chemical Process Industries, including petroleum refining, have gone through major
changes in the last ten to fifteen years. The changes include "downsizing",
`°reengineering,', "rightsizing,', etc. There also have been many corporate buyouts and
mergers. In Contra Costa County the following companies have been involved with
mergers, corporate buyouts, or spin offs:
• Richmond Refinery-Chevron merged with Texaco to form ChevronTexaco
• Rodeo Refinery - Unocal sold their refineries to Tosco including the Rodeo
refinery. Tosco was then bought out by Phillips who now has merged with
Conoco to form ConocoPhillips
• Martinez Refinery — Shell and Texaco refineries were spun off to form a new
company called Equilon. When Texaco merged with Chevron, Texaco sold their
interest in Equilon back.to Shell.
Avon/Golden Eagle Refinery — Tosco bought the Unocal refineries. Tosco sold
the Avon Refinery to Ultramar Diamond Shamrock. Ultramar Diamond
Shamrock was bought out by Velaro. Velaro were required to sell the Golden
Eagle Refinery, which they did to Tesoro.
• Rhine Poulenc spun off a new company called Rhodia that includes their
Martinez plant
• General Chemical parent company has been granted protection under the
bankruptcy laws
•' Dow Chemical merged with Union Carbide
The changes to these companies have affected the overall operations and management of
the different stationary sources. When changes are made through mergers, buyouts,
"downsizing", or "reengineering", experienced personnel leave their companies. The
loss of this experience and historical knowledge can and does effect the overall
operations and safety of a stationary source.
The Industrial Safety Ordinance requires that the stationary sources manage any changes
in their personnel that work in operations or health and safety. This will help to offset
Page 5 of 7
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Industrial Safety Ordinance Follow-up Report to the Board of Supervisors March 18,2003
loss of this experience and historical knowledge can and does effect the overall
operations and safety of a stationary source.
The Industrial Safety Ordinance requires that the stationary sources manage any changes
in their personnel that work in operations or health and safety. This will help to offset
any potential safety concerns by "downsizing", "reengineering", or the affects from
mergers, buyouts,or spin offs.
Health Services is recommending that the following changes be done to strengthen the
managing of organizational changes. To be able to do an accurate and complete analysis
of the change in personnel, a description of the responsibility of each job working in
operations or health and safety be completed. Health Services is recommending that the
Industrial Safety Ordinance be changed to require the stationary sources to develop and
document a job description for all jobs that are responsible for operations, maintenance,
and health and safety. This includes the following positions:
• Operators
Maintenance personnel
• Maintenance or operating positions that are filled by contract personnel
• Engineers working in operations or health and safety or who are supporting
operations and/or health and safety
• Supervisors and managers who have responsibilities in operations or health and
safety
Health Services is also recommending that as part of the managing the change for
organizational changes that new personnel be educated on the history of the process or
processes that they will be involved with, including the accidents that have occurred in
the different processes.
The ordinance does not require that a management of change for organizational changes
be done for temporary changes. Health Services is recommending that the management
of change for organizational changes include temporary changes.
Security and Vulnerability Analysis
Health Services is recommending that the Industrial Safety Ordinance be changed to
require stationary sources to perform a Security and Vulnerability Analysis. The terrorist
acts that occurred on September 11, 2001 showed the vulnerability of the United States to
terrorist attacks. Chemical plants and petroleum refineries are a potential target for
terrorists, because of the potential effect of a release or fire and explosions that could
occur at these sites. Chemical plants and petroleum refineries are also potential symbolic
and economic targets. The American Chemistry Council has developed security
guidelines for their member companies. Security and Vulnerability Analyses have been
developed by Sandia Labs, the American Institute for Chemical Engineers Center for
Chemical Process Safety, Synthetic and Organic Chemical Manufacturers Association,
and by many companies.
Health Services is recommending that a recognized Security and Vulnerability Analysis
method be performed by the Industrial Safety Ordinance stationary sources and that
Page 6 of 7
Industrial Safety Ordinance Follow-up Report to the Board of Supervisors March 18,2003
Health Services will audit the process that has been developed for the analysis and the
process for implementing the actions that are the result of the analysis.
Safety Climate Survey
As discussed earlier in this report, Health Services is recommending that the Industrial
Safety Ordinance be changed to require the stationary sources to work with Health
Services on performing a Safety Climate Survey that has been developed by the United
Kingdom Health and Executive. It may be appropriate for Health Services to apply the
Safety Climate Survey, instead of having the stationary sources applying the survey.
The l safety culture at a stationary source does have an effect on the overall safety at that
stationary source. This includes management systems, reporting of near misses, and how
people feel about the safety at their work place. The Safety Climate Survey will assist in
determining the overall safety culture at a stationary source. The survey will also assist
Health Services in performing Safety Program audits.
Pubic Input to Proposed Changes
The above proposed changes have not had any input from the public, industries, or other
interested parties. Health Services is asking the Board to refer the proposed changes
listed above for review by the Hazardous Materials Commission. This will allow a forum
for public input in the proposed changes to the Industrial Safety Ordinance. When the
review by the Hazardous Materials Commission is complete, Health Services is asking
them to report to the Board with their recommendations on the proposed changes.
Page 7 of 7
ATTACHMENT A
CONTRA COSTA COUNTY
HEALTH S'ERVICEs DEPARTMENT
HAZAR ous MATERIALS PROGRAMS
18 MAR 03
TO Beard of Supervisors
FROM : Lewis G. Pascalli,Jr.,
Director Hazardous Ma rograms
SUBJ : UNANNOUNCED INSPECTIC7N PROGRAM(UIP) STATUS REPORT
Reference is made to the 28 JAN 03 Board Order and the 20 JUN 00 Report to the Board of
Supervisors with the Order directing the Hazardous Materials Programs to implement
Recommended Item 2 A.: the Unannounced Inspection Program. This is a status report of the
Unannounced Inspection Program.
This program was developed after significant industrial events caused the death of workers. The
County needed to assure that facilities, operating in Contra Costa County and handling large
volumes of acutely hazardous materials,were operating safely. While the County's regulatory
oversight in the Certified Unified Program Agency (CUPA)programs address the requirements
of State law and Regulations,the Board determined that additional oversight and an innovative
Unannounced Inspection Program was needed.
Upon direction and approval of the Board, the Hazardous Materials Programs began recruitment
for the positions needed to staff the UIP. We also began development of the training and the
protocols required for such a program.
The job specifications for the positions California Accidental Release Prevention Specialist
(Cal/ARP)and the Hazardous Materials Specialist I (HMS)were reviewed. Recruitment and
testing for the positions were authorized with the Cal/ARP position being filed by AUG 00 and
the HMS position by MAR 01.
By NOV 00,the training program was developed. The training involved two sessions. The first
was held for two (2)days in DEC 00 and was titled"Safe Work Practices". The second for three
(3)days in JAN 01 was titled"Process Safety Auditing". Consultants, with noted expertise in
these fields,were hired to provide the training. Since the UIP training involved the total staff, the
training was coordinated with the work schedules of all staff.
The (29)page UIP protocol policy and procedure was completed and approved in MAR 01. This
document provides twelve(12)aspects of the UIP from Purpose and Objeetives to Revisions.
Under the UIP, facilities may be evaluated with any or all of the following inspection elements:
the Cal/ARP Program;the Industrial Safety Ordinance; Safe Work Practices; the Hazardous
Materials Release Response Plans and Inventory Program; the Underground Storage of
Page 1 of 3
CONTRA COSTA COUNTY
HEALTH SERVICES DEPARTMENT
HAZARDOUS MATERIALS PROGRAMS
HazardousSubstances Program;the Hazardous Waste Management Program; and the
Aboveground Storage of Petroleum Program.
The personnel involved in each UIP includes, at a minimum, one(1)Cal/ARP Specialist and one
(1)Hazardous Materials Specialist. Upon Direction of the Board, a Trades Craftsperson with
experience'and familiarity with the larger facilities has been included on the inspection team for
these facilities. At each facility where there is an organized work force, a worker representative
of the facility is also involved with the inspection.
The order of inspection scheduling is accomplished by prioritizing a number of factors,
including,but not limited to,the hazard risk of the activities occurring at the facility, past
incidents at the facility,past inspection results,reports from other agencies; and information
received from the community or employees.
Preparation for each UIP begins with the selection of the facility. Once the site has been selected,
schedules are checked to see who will be on the Unannounced Inspection Team(UI Team). A
Team header is designated to coordinate the Ul. Selected staff are notified and the dates of the
UIP are set. The facility's past program inspections and audits that are subject to the UIP, are
reviewed and a Work Plan developed. The Work Plan is reviewed for QA/QC by staff not
participating in the inspection. Comments and suggestions are discussed among the reviewers
and the assigned inspection staff. The Work Plan is finalized,reviewed and approved by the
Director.
Early on the day of the Unannounced Inspection(UI), staff assemble at a predesignated location.
The facility',is notified by phone with a Notice of the UI being faxed to the facility along with the
Work Plan, stating that the UI Team will arrive within (30)minutes. The UI Team makes final
preparations, checks their safety equipment and departs for the facility to conduct the UI. If any
problems were to occur,the Ul Team leader contacts the Director.No problems have occurred to
date, which required the Director notification.
Upon arrival at the facility, an Opening Meeting is held with the appropriate facility key staff to
review the Work Plan and the schedule. At the Opening Meeting,the number of days the UI
Team expects to be on site is revealed. It is also noted that the UI time frame may be expanded
by the UI Team based upon circumstances discovered during the UI.
The UI Team lists the documents to be reviewed; requests information on the maintenance,
turnaround and new construction activities occurring on the facility that may be of interest; and
the number of employees, contractors and management staff to be interviewed. Any required
safety training for the UI Team is accomplished.A tour of the facility is taken to evaluate the
maintenance,turnaround and new construction activities that occurring on site.
Page 2 of 3
CONTRA COSTA COUNTY
HEATH SERVICES DEPARTMENT
HAZARDOUS MATERIALS PROGRAMS
Various facility documents and action items generated from them are reviewed. A review of the
Safe WorkPractices in conformance with the Cal/ARP guidance document is accomplished.
The employee, contractor and management interviews are conducted. The interviews are held
with complete confidentiality to the interviewee. The number of interviews conducted at each
facility is related to the size of the facility, the work force on site,the type and size of the process
units, and whether contractors are at the facility during the Ul.
After the UI is completed,the UI Team conducts a closing meeting to review the findings made
during the Ul. A copy of the inspection forms are left with the facility with a Final Determination
submitted within seven(7)days.
All Uls completed to date have found items requiring follow up action by the facility (see
attached copies of the Final Determinations for the first 15 facilities inspected in Appendix 1).
The facility is given a schedule for the action item updates they must report. The submitted
reports are reviewed and additional contact made if the progress on implementation is not
meeting our Final Determination requirements.
Appendix II lists the(28)facilities subject to the UIP. The UIP has completed(16)inspections to
date. The UIP began inspections on 26 FEB 01 with the last inspection completed on 14 MAR
03. The preparation for each Ul requires at least 40 hours of staff time. The average time at a
facility is approximately 2.5 clays. Follow up takes significant additional time depending upon
the number'of and the degree of complicated action items required.
As of this time, no imminent life or safety non-compliance items that could present danger to the
worker(s)or to the environment have been found during the UIs. If such conditions had been
found,the UI Policy requires that the UI Team immediately bring this to the attention of the
Environmental, Health and Safety Manager,his or her designee or equivalent to stop the work.
The staffing for the UIP is adequate at this time. Recent staff retirements and medical leaves
have delayed some of the inspections. We have requested approval to announce an examination
for the vacant positions. An eligible list of candidates should be forthcoming after the exam is
held.
A number of the staff involved in the Uls will be at the Board meeting and will be available to
answer any questions.
Page 3 of 3
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FINAL DETERMINATION
OF
UNNANNOUNCED INSPECTION
Pittsburg Water Treatment Plant
300 Olympia Drive
Pittsburg, CA 94565
March 15, 2001
- CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAMS
I
Final Determination
Contra Costa Health Services (CCHS)conducted an announced inspection of the City of
Pittsburg Water Treatment Plant located at 300 Olympia Drive, Pittsburg, from February 26
throughFebruary 28,2001. CCHS is required to conduct this inspection of the facility as
authorized by Order of the Contra Costa County Board of Supervisors adopted on June 20, 2000,
and titled"Unannounced Inspection Policy of the Hazardous Materials Programs". CCHS
conducted the inspection in accordance with the Inspection Plan for Unannounced Inspection at
Pittsburg Water Treatment Plant. This plan describes pre-inspection, inspection, and
post-inspection activities and is included in Attachment I.
The completed questionnaires(e.g., "IA—PSM Program Review), including the basis for each
action items, are included as Attachment II.
CCHS generated 33 action items to correct potential deficiencies in existing programs. Many of
these action items resolve deficiencies primarily in implementing the CaIARP Program
prevention elements and documentation(e.g.,conduct revalidation of PHA as soon as possible,
establish written procedures to maintain the mechanical integrity of the process equipment).
Approximately seventeen of the action items address potential deficiencies in the CaIARP
Program.
CCHS also generated 2 action items to improve upon programs that comply with the
requirements of the CalARP Program Regulations. 'These action items begin with"Consider"
and are optional for Pittsburg Water Treatment Plant to incorporate(e.g.,consider establishing a
compliance audit policy/procedure). A list of the action items is included in Attachment III.
NOTE: The corresponding"Question ID#"for each recommended action is included in
Attachment III. The"Question ID#"includes the questionnaire and question number from
which each action item that was generated. For example, IA-6 represents the sixth question in
the IA: PSM Program Review questionnaire.
Pittsburg Water Treatment Plant has 14 days to respond with a confirmation of the proposed
schedule on how Pittsburg Water Treatment Plant plans to address CCHS's action items and to
dispute any inspection findings. The response should also identify all technical and factual
inaccuracies or justification for any discussion with CCHS's action items. The response shall
also identify which action items, if any, will be rejected in whole or in part and alternate
solutions that addresses CCHS's action items. For those action items rejected, Pittsburg Water
Treatment Plant shall explain the basis for the rejection and provide substitute revisions.
PRELIMINARY FINAL DETERMINATION
OF
UNNANNOUNCED INSPECTION
Tosco San Francisco Refinery
1380 San Pablo Avenue
Rodeo,CA 94573
March 16, 2001
>kcl
CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAMS
........................................
Preliminary Final Determination
Contra Costa Health Services (CCHS)unannounced inspection team(UIT)conducted an
unannounced inspection of Tosco San Francisco Refinery located at 1380 San Pablo
Avenue in Rodeo from March 6 through March 9, 2001. CCHS is required to conduct
periodic unannounced inspections of the CalARP regulated facility as authorized by
Order of the Contra Costa County Board of Supervisors adopted on June 20, 2000,which
adopted the"Unannounced Inspection Policy of the Hazardous Materials Programs".
The UIT conducted the inspection in accordance with the Unannounced Inspection Plan
for Tosco San Francisco Refinery(see Attachment 1). This plan describes the inspection
purpose and scope, and inspection and post-inspection activities. The completed
questionnaires(e.g.,"IB: HF Program Overview), including the basis for each action
items, are included as Attachment 11.
The UIT followed the unannounced inspection plan and examined Human Factors (HF)
Program Overview(see questionnaire IB: HF Program Overview), inherently Safer
System and Incident Investigation(I 1)(see questionnaire IC: Inherently Safer Systems&
11) and follow-up to previous audit findings including Hot Work Permit(see
questionnaire ID: Audit Follow-up). A UIT member also worked with facility personnel
regarding the stationary source incident notification system.
The UIT noted Tosco considerable efforts in improving the hot work permit system and
commends the management's commitment to safety issues by proactively updating and
improving existing safe work practices. During the unannounced inspection, the UIT
found that the organization of operating procedure training records had much improved
since the last CalARP audit in June 2000. In addition, Tosco should be commended for
the organization of the operations training program documentation and Central Training
Records Room.
A primary focus of the unannounced inspection was conducting field audits. Tosco
should be commended for planning maintenance activities to eliminate hot work
activities in process areas(e.g. by working on the parts in a weld bay or at the machine
shop). The UIT was able to locate only 3 hot work activities during the inspection
period. The UIT inspected 3 different maintenance work sites, Tank 298, Tank 292 and
welding of a safety cage in the sulfur plant. Members of the UIT observed the permitting
process for Tank 298 and Tank 292 and revisited these locations after work had
commenced. In general, contractors and Tosco employees were open and answered UIT
member questions. Both the contractors and Tosco employees recognized the
requirements of a very thorough permitting process. Specific findings and general
observations regarding these field activities are located in Attachment 11, questionnaire
ID: Audit Follow-up.
CCHS generated 8 action items to correct potential deficiencies in existing programs.
These action items resolve deficiencies in Safe Work Practices(e.g. confined space
procedure, presence of fire watch during hot work, proper hot work permit,etc.), in
determining the adequacy of operating procedures, and in the documentation of
competency of refresher training,etc.
CCHS also generated 3 action items to improve upon programs that are in compliance
with the scope of this inspection. These action items begin with"Consider"and are
optional for Tosco to incorporate(e.g., consider using a latent conditions checklist with
the Root Cause Methodology).
A summarized list of all action items is included in Attachment III. NOTE: The
corresponding"Question ID#"for each corrective action is included in Attachment III.
The"Question ID#" includes the questionnaire and question number from which each
action item was generated. For example, IB-3 represents the third question in the IB: HF
Program Overview questionnaire and A13-10 in the ID: Audit Follow-up questionnaire
refers back to the Audit question number 10 of A 13: Operating Procedure that was
completed in June 2000.
Tosco has 14 calendar days to respond with written comments on how Tosco plans to
address UIT's action items in the proposed deadline and to dispute any inspection
findings. The response should also identify all technical and factual inaccuracies. The
response shall also identify which action items, if any, that will be rejected in whole or in
part, or alternate solutions that address UIT's action items. For those action items
rejected, Tosco shall explain the basis for the rejection and provide substitute revisions..
FINAL DETERMINATION
OF
UNNANNOUNCED'INSPECTION
Chevron Products Company
841 Chevron Way
Richmond, California 94802
June 29, 2001
>klc�l
CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAMS
:............................. .
Final Determination
Contra Costa Health Services(CCHS)unannounced inspection team(UIT)conducted an
unannounced inspection of the Chevron Refinery located at 841 Chevron Way in
Richmond from June 18 through June 20, 2001. CCHS is required to conduct periodic
unannounced inspections of the CalARP regulated facility as authorized by Order of the
Contra Costa County Board of Supervisors adopted on June 20, 2000,which adopted the
"Unannounced Inspection Policy of the Hazardous Materials Programs". The UIT
conducted the inspection in accordance with the Unannounced Inspection Plan,for
Chevron Products Company(see Attachment I). This plan describes the inspection
purpose and scope, and inspection and post-inspection activities. The completed
questionnaires(e.g.,"Safe Work Practices), including the basis for each action item, are
included as Attachment II.
The UIT followed the unannounced inspection plan and examined Safe Work Practices
(see questionnaire: "Ib—Safe Work Practices Review") and Emergency Response
Notification Follow-up(see questionnaire 17—Emergency Response Notification"). As
specified in the unannounced inspection plan, only portions of the four Safe Work
Practice questionnaires(i.e., SI ---Hot Work Permit,S2 —Opening Lines and Equipment,
S3 Lockout/Tagout, and S4—Confined Space)would be completed. The portions
completed were summarized in questionnaire 16-Safe Work Practices Review".
Questionnaire"l7—Emergency Response Notification"was developed at the conclusion
of the audit to summarize the audit findings associated with this issue.
The primary focus of the unannounced inspection was conducting field audits. The UIT
audited eight job sites in the field for the following areas: Furnace 500 at TKC,Brine
Tank V4803 at the Reverse Osmosis Plant,Pump P-5 at Blending and Shipping, crude
Tank 3143,Pump P-1 751A in Plant 17 ofRLOP,Pump P-1440 at North Isomax, Tank
1899 east of wharf, and LPG Sphere T-1828. At these locations,the UIT was able to
view 3 pump isolations, I general entry confined space, and I active hot work permit
activities during the inspection period. CCHS appreciates the cooperativeness of
Chevron employees and contractors in answering UIT member questions. Specific
findings and general observations regarding these field activities are located in
Attachment II,questionnaire ID: 16—Safe Work Practices Review.
Members of the UIT also met with Chevron personnel to discuss the facility's emergency
notification policy and relative increase in the number of notifications to CCHS this year
compared to previous years. CCHS appreciates the level of detail in the information
provided during this meeting. A summary of this meeting is located in Attachment II,
questionnaire ID: 17—Emergency Response Notification.
CCHS generated 4 action items to correct potential deficiencies in existing programs.
These action items resolve deficiencies in Safe Work Practices(i.e., retest for LEL after
2-hours of hot work inactivity,maintain field copies of completed hot work permits,
ensure safety precautions are followed during hot work, and locking and tagging block
UI Final Determination Chevron.doc Page 2 June 29,2001
valves).
CCHS generated 5 action items to improve upon programs that are in compliance with
the scope of this inspection. These action items begin with"Consider"and are optional
for Chevron to incorporate(e.g., consider recording the LEL reading on the hot work
permit,consider issuing plant radios to fire and hole watchers).
A summarized list of all action items is included in Attachment III. NOTE: The
corresponding"ID#" for each corrective action is included in Attachment III. The"ID#"
includes the questionnaire and question number from which each action item was
generated. For example,the ID#16-02(S 1-2)"represents the second question in the 16
—Safe Work Practices Review questionnaire. The"(S 1-2)"portion of the ID#refers
back:to the previous CalARP Audit question S 1-2 (audit question number 2 of the hot
work permit questionnaire S I)that was completed. in March 2001.
Chevron has until July 19, 2001 to respond with written comments on how Chevron plans
to address UIT's action items in the proposed deadline and/or to dispute any inspection
findings. The response should also identify all technical and factual inaccuracies. The
response shall also identify which action items, if any, that will be rejected in whole or in
part, or alternate solutions that address UIT's action items. For those action items
rejected, Chevron shall explain the basis for the rejection and provide substitute
revisions.
Ul Final Determination Chevron.doc Page 3 Jane 29,2€101
FINAL DETERMINATION
OF
UNANNOUNCED INSPECTION
Antioch Water Treatment Plant
401 Putnam Street
P.O. Box 5007
Antioch, CA 94531-5007
August 10, 2001
>kr"
CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAM'S
Find Determination
Contra Costa Health Services(CCHS)conducted an unannounced inspection of the City of
Antioch Water Treatment Plant located at 441 Putnam Street, Antioch, from July 30 through July
31, 2001. CCHS is required to conduct this inspection of the facility as authorized by Order of
the Contra Costa County Beard of Supervisors adopted on June 20,2000,and titled
"Unannounced Inspection Policy of the Hazardous Materials Programs". CCHS conducted the
inspection in accordance with the unannounced Inspection Plan at Antioch Water Treatment
Plant. This plan describes pre-inspection,inspection, and post-inspection activities and is
included in Attachment I.
The completed questionnaires(e.g.,"IA—CalARP Program Review), including the basis for
each action items,are included as Attachment II. The completed inspection reports for
Hazardous Waste Generator Inspection, Hazardous Materials Release Response&Inventory
Program,and Underground Storage Tank Inspection are also included with Attachment Il.
CCHS generated 26 action items to correct potential deficiencies in existing programs. Many of
these action items resolve deficiencies primarily in implementing the CalARP Program
prevention elements and documentation(e.g., ensure that the original Process Hazard Analysis
(PHA)and PHA revalidation documents are available on-site at all times, conduct a CalARP
Program compliance audit as soon as possible).
CCHS also generated 2 action items to improve upon programs that comply with the
requirements of the CalARP Program Regulations. These action items begin with"Consider"
and are optional for Antioch Water Treatment Plant to incorporate(e.g., consider establishing a
compliance audit policy/procedure). A list of all the action items is included in Attachment III.
NOTE: The corresponding"Question ID#"for each recommended action is included.in
Attachment III. The"Question ID#"includes the questionnaire and question number from
which each action item that was generated. For example,IA-6 represents the sixth question in
the IA: CalARP Program Review questionnaire.
Antioch Water Treatment Plant has 14 days to respond with a confirmation of the proposed
schedule on how Antioch Water Treatment Plant plans to address CCHS's action items and to
dispute any inspection findings. The response should also identify all technical and factual
inaccuracies or justification for any discussion with CCHS's action items. The response shall
also identify which action items, if any, will be rejected in whole or in part and alternate
solutions that addresses CCHS's action. items. For those action items rejected, Antioch Water
Treatment Plant shall explain the basis for the rejection and provide substitute revisions.
FINAL DETERMINATION
OF
IINNANNOUNCED INSPECTION
General Chemical Corporation-Bay Point Works
501 Nichols Road
Pittsburg, CA 94565-1098
September 10, 2001
>k461
CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAMS
Final Determination
Contra Costa Health Services(CCHS)unannounced inspection team(UIT) conducted an
unannounced inspection of General Chemical-Bay Point Works (BPW) located at 501
Nichols Road in Pittsburg, from August 29 through August 31, 2001. CCH" is required
to conduct periodic unannounced inspections of RMP and CalARP regulated facilities as
authorized by Order of the Contra Costa County Board of Supervisors adopted on June
20, 2000,which adopted the"Unannounced Inspection Policy of the Hazardous Materials
Programs". The UIT conducted the inspection in accordance with the Unannounced
Inspection Plan for General Chemical Corporation-Bay Point Works(see Attachment I)
. This plan describes the inspection purpose and scope, and inspection and
post-inspection activities. The completed questionnaires (e.g., "I1: CalARP Audit
Follow-up), including the basis for each action item and inspection reports, are included
as Attachment II.
The UIT followed:the unannounced inspection plan and examined completed action
items from the CaIARP audit findings(completed in August 2400), Hazardous Waste
Generator Inspection Report, Hazardous Materials Release Response and Inventory
Program Business Plan Validation and Site Inspection Report and observed a line
breaking procedure during a maintenance activity. UIT also selected 10 PHA asction
items that was completed in the monthly status report for field verification. All ten items
were verified to be complete and satisfactory. A list of the action items reviewed in
included in Attachment III. A safe work questionnaire was not completed for this field
observation. A linebreaking permit was issued following BPW°s environmental health
and safety(EHS)policy,lock out/tag out procedure was followed and personnel
(including back-up personnel)donned required personal protection equipment before
commencing work. CCHS did not identify any non-compliant issues and no
recommended action was generated from this field observation.
The UIT noted BPW's considerable efforts in capital improvements in construction and
upgrades of secondary containments throughout the facility. During the unannounced
inspection,the UIT also found much improvement in EHS training since the last CalARP
audit in August 2000.
There were no violations found from the Hazardous Waste Generator Inspection and the
Hazardous Materials Business Plan Inspection report. These reports are included in
Attachment IV.
CCHS generated 3 action items to correct potential deficiencies in existing programs.
These action items resolve potential deficiencies in incident investigation and PHA
procedures.
A summarized list of all action items is included in Attachment V. NOTE: The
corresponding identification"No."for each corrective action is included in Attachment
IV.', The identification"No."includes the questionnaire and question number from
.........._...
................................................................................................
..........................................................................
............................I...........................
.......................
which each action item was generated. For example, 1(A11-2)in the 11: CalARP Audit
Follow-up questionnaire is the first question in this unannounced inspection and refers
back to the Audit question number 2 of A 11: PHA that was completed in August 2000.
General Chemical-BPW has 14 calendar days to respond with written comments on how
BPW plans to address UIT's action items in the proposed deadline and to dispute any
inspection findings. The response should also identify all technical and factual
inaccuracies. The response shall also identify which action items, if any, that will be
rejected in whole or in part, or provide alternate solutions that address UIT's action
items. For those action items rejected, BPW shall explain the basis for the rejection and
provide substitute revisions.
................................................................................
..........................................
PRELIMINARY FINAL DETERMINATION
OF
UNNANNOUNCED INSPECTION
CONDUCTED ON SEPTEMBER 25 AND 269, 2001
AT
GWF Power Systems
1600 Loveridge Road
Pittsburg, CA
And
GWF Power Systems
985 East Third Street
Pittsburg, CA
October 29, 2001
>k6,
- CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAMS
..............
. .............................................................................................................__..
...........................................................
Preliminary Final Determination
Contra Costa Health Services(CCHS)unannounced inspection team(UIT)conducted an
unannounced inspection of GWF Power Systems sites located at 1600 Loveridge Road
and 895 East Third Street in Pittsburg, Ca. The inspection was conducted on September
25 and 26, 2001. CCHS is required to conduct periodic unannounced inspections of
CalARP regulated facilities by Order of the Contra Costa County Board of Supervisors,
which adopted the"Unannounced Inspection Policy of the Hazardous Materials
Programs"on June 20, 2000. The UIT conducted the inspection in accordance with the
Unannounced Inspection.Plan for GWF Power Systems (Attachment I.)
GWF Power Systems has five petroleum coke fired power plants operating in Contra
Costa County. The five sites utilize ammonia to control oxides of nitrogen formed in the
combustion process. GWF is converting the nitrogen oxide control system at each site
from anhydrous ammonia to aqueous ammonia. The conversion is scheduled for
completion at all sites by November 2001. The UIT focused its efforts on the Loveridge
Road site because it uses aqueous ammonia, as will all GWF sites by November 2001.
The UIT also visited the East Third Street site, which was using anhydrous ammonia at
the time of the inspection.
The UIT followed the unannounced inspection plan, assessing compliance with the
CaIARP Program, the Emergency Response Program, and the Hazardous Waste
Management Program. The UIT noted that conversion of the nitrogen oxide control
process from anhydrous to aqueous ammonia will reduce the risk of ammonia exposure to
GWF employees and the community, and commends GWF for undertaking this
conversion.
Attachment II, Completed Questionnaires, is a listing of each CalARP item reviewed
during the inspection,presenting a question, a clarification, the UIT findings,the answer
(to the question), and an action. A"Y" (yes)answer indicates compliance, a"P"
indicates partial compliance, an "N" indicates the site is not in compliance, and"NA"
indicates the question is not applicable. A copy of the Hazardous Waste Generator
Inspection document is also included in Attachment 11.
A summarized list of all items requiring a response(action)is included in Attachment III,
Action Items. CCHS generated 18 action items to correct deficiencies in existing
programs. CCHS also generated 2 action items to improve upon programs that are
technically in compliance. These action items begin with "Consider" and are
recommendations which GWF may choose to implement.
GWF has 14 calendar days to respond with written comments on how it plans to address
the UIT's action items by the proposed deadline and to dispute any inspection findings.
The response should also identify all technical and factual inaccuracies. The response
shall' also identify which action items, if any, that will be rejected in whole or in part, or
alternate solutions that address UIT's action items. For those action items rejected, GWF
shall''explain the basis for the rejection and provide a written alternate plan.
.................................................................................................................................
........................................................................................
...............................
FINAL DETERMINATION
OF
UNNANNOUNCED INSPECTION
Martinez Refining Company
Equilon Enterprises LLC
Martinez, CA 94553-0071
February 5, 2002
>k4c.l
- CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAMS
Final Determination
Contra Costa Health Services(CCHS)unannounced inspection team(UIT)conducted an
unannounced inspection of the Martinez Refining Company's Equilon Refinery(MRC)located in
Martinez,California from January 22 through January 25,2002.CCHS is required to conduct
periodic unannounced inspections of CalARP regulated facilities by Order of the Contra Costa
County Board of Supervisors adoption of the"Unannounced Inspection Policy of the Hazardous
Materials Programs"on June 20,2000. The UIT conducted the inspection in accordance with the
Unannounced Inspection Plan for Martinez Refining Company(see Attachment I). This plan
describes the inspection purpose and scope,and inspection and post-inspection activities. The
completed questionnaires(e.g.,"UI Safe Work Practices"), including the basis for each action
item,are included as Attachment 11.
The UIT followed the unannounced inspection plan by reviewing the Hazardous Waste Generator
Inspection&Cover Sheet,Hazardous Materials Business Plan,Underground Storage Tank
Inspection,and Tiered Permitting Program. Copies of the Hazardous Waste Generator,Business
Plan,Underground Storage Tank and Tiered Permitting inspection forms were given to MRC on
January 25,2002,and additional copies are included in Attachment 111. As identified on the
inspection forms,several items were addressed while CCHS was onsite with no further action
required. Four items were identified as possible violations(regarding waste antifreeze,
motorcycle battery,oily trash,and storage within the Bin Storage Area),and a follow-up report
was requested within 30 days(by February 25,2002). In addition,three items were identified
within the Business Plan that will need to be revised for the next Business Plan submittal.
The UIT also examined Safe Work Practices in progress at the facility. As specified in the
unannounced inspection plan,only portions of the four Safe Work Practice questionnaires(i.e.,
S 1 -Hot Work Permit, S2—Opening Lines and Equipment, S3—Lockout/Tagout,and S4—
Confined Space)were completed. The portions completed are summarized in the questionnaire
"UI Safe Work Practices",and are included as Attachment 11.
The UIT audited job sites in the field for safe work practices for the following areas: Cogen Unit
turnaround,Flexicoker Column 178,Crude Unit NHT guard bed,Fire Water Line to wharf repair,
Lubricant Blending Area pump line,Flexicoker MCR,and Catalytic Cracking F67 Duct platform.
At these locations,the UIT was able to view two active hot work permits,one general entry
confined space, and a variety of lockout/tagout activities. CCHS appreciates the cooperativeness
of MRC employees and contractors in answering UIT member questions. Specific findings and
general observations regarding these field activities are located in Attachment 11,the Ul Safe
Work Practices questionnaire.
CCHS generated five action items to correct partial deficiencies in existing Safe Work Practice
programs: 1)training of fire watches; 2)specifying the process used to ensure bleeder valves are
clear when double block and bleed is used during confined space entry; 3)maintaining sufficient
information on isolation tags; 4)identifying methods to remove tags left inadvertently; and 5)to
documenting periodic confined space atmospheric testing.
CCHS generated three action items to improve upon Safe Work Practice programs that are in
compliance with the scope of this inspection.These action items begin with "Consider"and are
optional for MRC to incorporate(e.g., consider clarifying the maximum acceptable%LEL value
allowed for hot work,consider locking in addition to tagging out all valves used for isolation).
Ul Final Determination MRC.doc Page 2 February 5,2002
A summarized list of all action items for Safe Work Practices is included in Attachment III.
NOTE: The corresponding"ID#"for each corrective action listed on the"Summary of Ul Action
Items"questionnaire includes the questionnaire and question number from which each action
item was generated. For example,the ID#"UI-04(S1-5)"represents the fourth question in the
"UI Safe Work Practice"questionnaire. The"(S 1-5)"portion of the ID#refers back to the
previous CaIARP Audit question S1-5(audit question 5 of the hot work permit questionnaire S1)
that was provided in the Unannounced Inspection Audit Plan identified in Attachment I.
Except as noted above, MRC has until February 25, 2002 to respond with written comments on
how'MRC plans to address UIT's action items and the proposed deadline and/or to dispute any
inspection findings. The response should also identify all technical and factual inaccuracies. The
response shall also identify which action items, if any, will be rejected in whole or in part, or
alternate solutions that address UIT's action items. For those action items rejected, MRC shall
explain the basis for the rejection and provide substitute revisions.
til Final Determination MRC.doc Page 3 February 5,2€02
FINAL DETERMINATION
OF
UNANNOUNCED INSPECTION
The Dow Chemical Company
P.O. Box 1398
901 Loveridge Road
Pittsburg,California 94565
July 26, 2002
CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAMS
......................
............................ ..........................................................................................
........................................
Final Determination
The Contra Costa Health Services(CCHS)unannounced inspection team(UIT)conducted an
unannounced inspection of the Dow Chemical Company(Dow)located in Pittsburg,California
from July 9 through 11,2002. CCHS is required to conduct periodic unannounced inspections of
CaIARP regulated facilities by Order of the Contra Costa County Board of Supervisors adoption
of the"Unannounced Inspection Policy of the Hazardous Materials Programs"on June 20,2000.
The UIT conducted the inspection in accordance with the Unannounced Inspection Plan for Dow
ChemicalCompany(see Attachment 1). This plan describes the inspection purpose and scope,
inspection,and post-inspection activities. The completed questionnaires(e.g.,"UI Safe Work
Practices'), including the basis for each action item, are included as Attachment 11.
The UIT followed the unannounced inspection plan by reviewing the Hazardous Waste Generator
Inspection,Hazardous Materials Release Response and Inventory Program(Business Plan),
Underground Storage Tank Inspection,and Tiered Permitting Program. Copies of the completed
Hazardous Waste Generator,Business Plan,Underground Storage Tank and Tiered Permitting
inspection forms were given to Dow on July 11,2002,and additional copies are included in
Attachment 11.
Two items were identified as possible violations, and follow-up reports were requested within 30
and 60 days respectively(by August 11,and September 12,2002). One recommendation was for
performing and documentation of secondary containment testing for underground storage tanks
(by December 31,2002). In addition,two items were identified within the Business Plan that can
improve the next Business Plan submittal. These action items begin with"Consider"and are
optional for Dow to incorporate(e.g.,consider combining Like-chemicals on one inventory sheet
and when possible).
The UIT also examined Safe Work Practices in progress at the facility. As specified in the
unannounced inspection plan,only portions of the four Safe Work Practice questionnaires(i.e.,
S I —Hot Work Permit,S2—Opening Lines and Equipment S3—Lockout/Tagout,and S4—
Confined Space)were completed. The portions completed are summarized in the questionnaire
"UI Safe Work Practices",and are included as Attachment 11.
The UIT audited job sites in the field for safe work practices for the following areas: 660 Block
Process and Associated Operations. At these locations,the UIT was able to view one general
entry confined space,which included line and equipment closure and opening and a variety of
lockout/tagout activities. CCHS appreciates the cooperativeness of Dow employees and
contractors in answering UIT member questions. Specific findings and general observations
regarding these field activities are located in Attachment 11,the UI Safe Work Practices
questionnaire.
CCHS generated three action items to correct partial deficiencies in existing Safe Work Practice
programs: 1)develop a facility variance to the Global Standard to indicate a limit of 24 hours or
less for the permit to remain valid for a given hot work activity;2)develop a facility variance to
the Global Standard to indicate that no less than 50 lbs cable tie or wire strength is required for
securing the red tags; 3)document a list of all workplaces that are determined to be permit
required confined spaces for the site.
Ul Final Determination Dow 072602 Page 2 July 26,2002
............-
...............................................................................................................................
............. ...............................
...............................
A summarized list of all action items for this inspection is included in Attachment 111. NOTE:
The corresponding"IM"for selected corrective actions listed on the"Summary of UI Action
Items"questionnaire includes the questionnaire and question number from which the action item
was generated. For example,the ID#"UI-02(S 1-2)"represents the second question in the"UI
Safe Work Practice"questionnaire. The"(51-2)"portion of the ID#refers back to the previous
CaIARP Audit question 51-2 that was provided in the Unannounced Inspection Audit Plan
identified in Attachment I.
Dow has 14 days to respond with written comments on how Dow plans to address UIT's action
items and confirmation of the proposed deadlines and/or to dispute any inspection findings. The
response should also identify all technical and factual inaccuracies. The response shall also
identify which action items, if any,will be rejected in whole or in part, or alternate solutions that
address UIT's action items. For those action items rejected, Dow shall explain the basis for the
rejection and provide substitute revisions.
Ul Final Determination Dow 072602 Page 3 July 26,2002
.11,11.1............................................................. ...........................................................................................................................
........................................................................................................
. ......... ...
FINAL DETERMINATION
OF
UNANNOUNCED INSPECTION
Shell Martinez Catalyst Plant
10 Mococo Road
P.O. Box 7070
Martinez, CA 94553
August 15, 2002
>14rwl
- CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAMS
.....................
Final Determination
Centra Costa Health Services(CCHS)conducted an unannounced inspection of the Shell
Martinez Catalyst Plant located at 10 Mococo Road,Martinez, from July 30 through August 1
2002. A'closing meeting was held:on August 7, 2002. CCHS is required to conduct this
inspection of the facility as authorized by Order of the Contra Costa County Board of
Supervisors adopted on June 20, 2000,and titled"Unannounced Inspection Policy of the
Hazardous Materials Programs". 'CCHS conducted the inspection in accordance with the
Unannounced Inspection flan at Shell Martinez Catalyst Plant. This plan describes
pre-inspection,inspection,and post-inspection activities and is included in Attachment I.
The completed questionnaires(e.g.,"I1—CalARP Audit follow-up),including the basis for each
action items,are included as Attachment II. The completed inspection reports for Hazardous
Waste Generator and Hazardous Materials Release Response& Inventory Program are also
included with Attachment 11.
CCHS generated 2 action items to correct potential deficiencies in existing CalARP programs.
CCHS also generated 3 action items to improve upon programs that comply with the
requirements of the CalARP Program Regulations. These action items begin with"Consider"
and are optional for Shell Martinez Catalyst Plant. A summary of all the action items is
included in Attachment 111.
Shell Martinez Catalyst Plant has 14 days to respond with a confirmation of the proposed
schedule on how Shell Martinez Catalyst Plant plans to address CCHS's action items and to
dispute any inspection findings. The response should also identify all technical and factual
inaccuracies or justification for any discussion with CCHS's action items. The response shall
also identify which action items, if any, will be rejected in whole or in part and alternate
solutions that addresses CCHS's action items. For those action items rejected, Shell Martinez
Catalyst Plant shall explain the basis for the rejection and provide substitute revisions.
......................
...................................................................................................................................................
..............................................................................................
..............................
FINAL DETERMINATION
OF
UNANNOUNCED INSPECTION
Rhodia, Inc.
100 Mococo Road
Martinez, CA 94553
August 26, 2002
>k4rwl
--0000t=b��
CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAMS
.........................
I--............... .........................................................................................................................
..........11..............................................................
Final Determination
The Contra Costa Health Services(CCHS)unannounced inspection team(UIT)conducted an
unannounced inspection of Rhodia's Martinez facility on August 21,2002. CCHS is required to
conduct periodic unannounced inspections of CalARP regulated facilities by Order of the Contra
Costa County Board of Supervisors' adoption of the"Unannounced Inspection Policy of the
Hazardous Materials Programs"(June 20,2000). The UIT conducted the inspection in
accordance with the Unannounced Inspection Plan for Rhodia, Inc.(see Attachment 1). This plan
describes the inspection purpose and scope,inspection results, and the post-inspection activities.
The completed questionnaire(i.e., "I1 —Inspect Previous Actions'), including the basis for each
action item, is included as Attachment 11.
As outlined in the Unannounced Inspection Plan,the UIT performed Hazardous Waste Generator,
Hazardous Materials Release Response and Inventory(Business Plan),and Tiered Permitting
program inspections. Copies of the completed Hazardous Waste Generator,Business Plan,and
Tiered Permitting inspection forms were given to Rhodia on August 21, 2002. Additional copies
of the inspection forms,along with copies of Rhodia's Hazardous Waste Disposal Summary and
Permit By Rule block flow diagram are included in Attachment 11.
During the inspection,a violation of California Code of Regulations Title 22, Section 66265.173
was observed. Several roll-off bins containing hazardous waste—off spec zinc fertilizer—were
not covered. This violation was rectified the same day.
The following recommendations were made as a result of the Hazardous Waste Generator
inspection: 1)Eye wash cups should be covered unless in use;2)Buckets in route to the satellite
storage area should be labeled as satellite storage;3)The waste analysis plan for the Permit By
Rule unit was minimal and required sampling only when the feed changed. Rhodia identified
there was no easy way to sample the feed. CCHS recommends examining the system to see if
influent sampling access could be improved.
The UIT also followed up on the progress the facility has made on addressing previous action
items identified from the CaIARP audit. The UIT found that Rhodia has made significant
progress in completing these action items and found no deficiencies. The UIT did identify two
optional items that may improve the programs at Rhodia. The completed questionnaires are
included as Attachment 11. NOTE: The corresponding"ID#"on the questionnaire includes the
unannounced inspection question number, and within parentheses,the original question number
from the CalARP audit. For example,the ID# "UI-01 (A2-20)"represents the first question in
the unannounced questionnaire, where"(A2-20)"refers back to the previous CalARP Audit
question A2-20 identified in Attachment I of the Unannounced Inspection Audit Plan.
Rhodia has until September 13, 2002to respond with written comments on how Rhodia plans to
address the UIT's action items and confirm the proposed deadlines, or dispute any inspection
findings. The written response should also identify all technical and factual inaccuracies, if any.
Rhodia's response shall also indicate which action items, if any, will be rejected in whole or in
part, and identify alternate solutions that address the UIT's action items. Since the only action
items associated with the CalARP audit follow-up review were optional (i.e., consider items),
Rhodia must provide comment on these items, but is not required to implement them.
U1 Final Determination Rhodia 082602.doc Page 2 August 26,2442
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FINAL D►ETERMINA'TION
OF
UNANNOUNCED INSPECTION
USS POSCO INDUSTRIES (UPI)
900 LOVERIDGE ROAD
P.O. BOX 471
PITTSBURG, CA 94565
September 6, 2002
CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAMS
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Final Determination
Contra Costa Health Services Hazardous Materials (CCHSHM)conducted an unannounced
inspection of USS POSCO INDUSTRIES,in the City of Pittsburg on August 26,2002 and
August 29, 2002. CCHSHM is required to conduct this inspection of the facility as authorized
by Order of the Contra Costa County Board of Supervisors adopted on June 20, 2000, and titled
"Unannounced Inspection Policy of the Hazardous Materials Programs". CCHSHM conducted
the inspection in accordance with the Unannounced Inspection Plan at USS POSCO
INDUSTRIES. This plan describes pre-inspection,inspection, and post-inspection activities and
is included in Attachment L
The completed questionnaires(e.g., "I l—CalARP Audit follow-up), including the basis for each
action items, are included as Attachment Il. The completed inspection report for the Hazardous
Materials Release Response& Inventory Program is also included with Attachment IL
CCHSHM generated 6 action items to correct potential deficiencies in the existing CalARP
program.
CCHSHM also generated action items to improve upon programs that comply with the
requirements of the CalARP Program Regulations. These action items begin with"Consider"
and are optional for UPI. A summary of all the action items is included in Attachment 111.
UPI has 14 days to respond with a confirmation of the proposed schedule on how UPI plans to
address CCHSHM's action items and to dispute any inspection findings. The response should
also identify all technical and/or factual inaccuracies with justification for any discussion with
CCHSHM's action items. The response should also identify which action items that will be
rejected in whole or in part and alternate solutions that will address CCHSHM's action items.
For those action items rejected, UPI must explain the basis for the rejection and provide
substitute revisions.
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FINAL DETERMINATION
OF
UNNANNOUNCED INSPECTION
Air Products and Chemicals, Inc.
110 Waterfront Road
Gate 75 - Shell Refinery
Martinez, CA 94553
Air Products and Chemicals, Inc.
Tract 1, Solano Way, 3rd IF' Street
#2 Hydrogen Plant-Tesoro Refinery
Martinez, CA 94553
October 4, 2002
>k6l
- CONTRA COSTA
HEALTH SERVICES
HAZARDOUS MATERIALS PROGRAMS
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Final Determination
Contra Costa Health Services(CCHS)unannounced inspection team(UIT)conducted an
unannounced inspection of Air Products and Chemicals,Inc.(Air Products)plants located within
the Shell and Tesoro Refineries in Martinez, California from>September 25-26,2002. CCHS is
required to conduct periodic unannounced inspections of CalARP regulated facilities by Order of
the Contra Costa County Board of Supervisors adoption of the"Unannounced Inspection Policy
of the Hazardous Materials Programs"on June 20,2000. The UIT conducted the inspection in
accordance with the Unannounced Inspection Plan for Air Products(see Attachment 1). This
plan describes the inspection purpose and scope,and inspection and post-inspection activities.
The completed questionnaires(e.g.,"17-Seismic Assessment"), including the basis for each action
item, are included as Attachment 11.
The UIT followed the unannounced inspection plan by reviewing the Hazardous Waste Generator
Inspection&Cover Sheet and Hazardous Materials Business Plan. Copies of the Hazardous
Waste Generator and Business Plan inspection forms were given to Air Products on September
26,2002,and additional copies are included in Attachment 11. One violation was noted at the
Shell site,which consisted of a waste oil label was partially unreadable,including the site name
and the accumulation start date.
The UIT also examined the seismic assessments that have been completed to date at both sites.
The seismic questionnaire,17,was completed and is included as Attachment H. CCHS generated
four action items on the seismic assessments for the following: 1)to enhance the level of detail
presented within future seismic reports on the potential magnitude of nearby faults and
interactions between equipment;and 2)obtain clarification from the seismic engineer of ground
acceleration impacts at the stationary source and pipe racks seismic adequacy.
CCHS generated one action item to improve upon the seismic assessment. This action item began
with"Consider"and is optional for Air Products to incorporate(e.g.,consider discussing all of
the major types of seismic hazards in future assessments and identify which are applicable).
Air Products has until October 21, 2002 to respond with written comments on how they plan to
address the UIT's action items and the proposed deadlines and/or to dispute any inspection
findings. The response should also identify all technical and factual inaccuracies. The response
shall also identify which action items, if any, will be rejected in whole or in part, or alternate
solutions that address the UIT's action items. For those action items rejected, Air Products shall
explain the basis for the rejection and provide substitute revisions.
U1 Final Determination Air Products 100402,doe Page 2 October 4,2002
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ATTACHMENT
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Public Outreach for the Industrial Safety Ordinance 3/7/03
On January 28, 2003,staff of the Hazardous Materials Programs and the Hazardous
Material Ombudsman gave an annual report on the status of the Industrial Safety
Ordinance to the Board of Supervisors. The Board of Supervisors requested the
Hazardous Materials Ombudsman and the staff of the Hazardous Materials Programs to
work together to analyze the public outreach>and participation aspect of implementing the
Industrial Safety Ordinance, and report back with any recommendations they might have
concerning public outreach and participation.
Public outreach and participation has always been an important component of the
ordinance. Several sections of the ordinance stress the importance of public participation
and outreach, and the Hazardous Materials Ombudsman position was created to help
insure meaningful public participation. Even before the Industrial Safety Ordinance was
adopted,seven public meetings were held to allow the public to learn about the proposed
ordinance and provide their input.
Since the ordinance was adopted,public outreach and participation has taken several
forms. Public meetings have been held after specific incidents to allow the public to learn
about the cause of the incident, and the Hazardous Materials Programs response and
follow-up activities.Two comprehensive evaluations of individual facility's safety
culture have taken place with extensive public involvement in the design and review of
the studies.Interested individuals have been mailed specific incident investigation and
root cause reports.Finally, over the past year, the Hazardous Materials Commission and
the Public and Environmental Health Advisory extensively reviewed proposed
amendments to the ordinance and undertook a comprehensive review of the whole
ordinance. Several of the recommendations that came out of that review included
improvements to the public involvement process.
Currently, an extensive outreach program is being conducted to inform people about their
opportunity to comment on the Safety Plans and Safety Programs of the facilities covered
by the ordnance. This outreach effort also provides people with assistance,if they so
desire,to review specific plans and prepare written and oral comments.This effort will
culminate in three public meetings to provide the public with the opportunity to comment
on the Safety Plans and Safety Programs. Also, a comprehensive database is being
developed for Internet access to the safety plans,the results of root cause investigations
and other information
We used a draft model checklist that is being prepared for implementing the County's
Environmental Justice policy to determine the future public outreach and participation
needs for the Industrial Safety Ordnance. This checklist describes the essential elements
of a good public participation strategy.
The first element we examined looked at the gap between when an issue arises and when
the public can get involved and take action. We feel we will be able to address this issue
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adequately through several mechanisms. We will be able to use the Intemet site being
developed and our interested parties list to quickly alert people to specific issues. We will
be able to use the Hazardous Materials Commission and the Public and Environmental
Health Advisory Board to address emerging policy considerations. Also,we will continue
to be able to quickly hold public meetings after incidents or when specific issues arise to
inform the general public and receive community input.
The next element we examined was the range of approaches we use when we interface
with the community includes formal, cooperative,informal, reactive and proactive
modes. Again, we feel the type of public outreach and participation we have conducted
cover this broad spectrum and will continue to do so in the future. The meetings held to
review w Safety Plans and Safety Programs are formal, thus ensuring written responses to
questions and comments raised by the public. Outreach efforts have been done
cooperatively,such as the pilot outreach effort conducted by PACE, and the effort to
work with an ad hoc advisory committee and the Hazardous Materials Commission to
develop the format of the Safety Culture study of the Tosco Avon Refinery. Informally,
we have worked with the two Public Health projects, the Partnership for the Public's
Health and the Healthy Neighborhoods program, to bring issues to various communities
and to get input from those communities. We have worked reactively to deal with issues
such as developing the Laotian database for the telephone ring-down system.Finally,we
will continue to work with the Hazardous Materials Commission and the Public and
Environmental Health Advisory Board to proactively consider emerging issues.
The third element we addressed examined general concerns about the meaningfulness of
the program,>that is, does it really give the community a real role in decision-making,
does it really foster open communication and most importantly,is it sustainable over the
long-term. While we came to the conclusion that our program does provide the
framework for open communication and input into decision making, it lacks the
necessary resources to make people aware of the opportunities to participate in the long-
term.Therefore, we recommend that the type of position currently conducting outreach
on involvement opportunities for the Industrial Safety Ordinance be continued. This
position can continue outreach on additional safety plans and safety programs when
public involvement opportunity arise, and inform the public about other Hazardous
Materials Programs activities and their public involvement opportunities.
ATTACHMENT MENT C
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NEAR MISS INTERNAL INVESTIGATION AT OIL REFINERIES
AND CHEMICAL PROCESS FACILITIES
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 Cal/OSHA'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.
• 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 are reporting near misses important?
• Is it good or bad to have many near misses reported?
DEFINITIONS
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 actual negative
consequence.'
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Near miss is defined as an incident that could, but actually did not, result in
negative consequences.I
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.)
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
• 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).'
WHY ARE REPORTING NEAR MISSES IMPORTANT?
Near misses are usually far more frequent than actual accidents, and they provide an early
warning of underlying problems that eventually will lead to an accident.3 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.4 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.4
What is not reported cannot be
investigated.
What is not investigated cannot be
changed
FaW
Injuries
Serious Injuries
Minor Injuries
Near Miss Events
Unsafe Behavior anfir At
ErrorslDeviations
Figure A
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). As shown on this
triangle, near misses are in the middle with anomalies below the near misses.
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.'
Fa
Applying lessons learned from
Injuries near misses investigations acts
to eliminate this group of
incidents
Serious Injuries
Minor Injuries
Near Miss Events
Uasfe Behavior and#or Acts
Errors[Deviations
Figure B
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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 processindustry. 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 control3 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
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'Hisses. Lipper 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 tapper 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
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incidents to learn how to prevent events that are more serious. 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 claims4
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
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.
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
''I'll...........................................................................................
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may not be able to implement a near miss internal reporting program without
management's visible support.
1 Guidelines for Investigating Chemical Process Incidents,American Institute for Chemical Engineers
Center for Chemical Process Safety(CCPS)
2 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)
4 Successful Health and Safety Management,Health&Safety Executive
5 Guidelines for Process Safety Documentation,American Institute for Chemical Engineers Center for
Chemical Process Safety(CCPS)