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HomeMy WebLinkAboutMINUTES - 06082004 - D6 Executive Summary The Executive Summary provides a brief overview of the follow-up safety evaluation as well a a summary of the actions that have been taken by General Chemical-Richmond Works(GCRW) to address the major findings and recommendations from the initial safety evaluation.The reader is encouraged to review the entire report to,gain a better understanding of the progress GCRW has made in addressing all of the findings and recommendations.; Background An initial safety evaluation was conducted at the GCRW facility in Richmond,California, from October 7-11, 2002,at the request of the Contra Crista Health Services(CCHS) and the City of Richmond: _ The objectives of the Safety Evaluation were to complete a thorough evaluation of the current management practices and safety culture at the GCRW facility.The focus of the evaluation was on the safety management systems, human factors, and safety culture. The scope of work for this assignment was developed by an ad hoc safety evaluation committee, with representatives from CCHS,the City of richmond,General Chemical,the General Chemical employee union, the Hazardous Materials Commission,and the public. The evaluation was not intended as a compliance audit, and as such, the initial safety evaluation report was not meant to imply legal'certification of compliance or noncompliance with safety regulations. Rather,the evaluation was intended to evaluate the GCRW safety management systems in relation to industry practices and to identify potential deficiencies. The safety evaluation identified 54 findings. For each finding,recommendations were developed to address the deficiency. All of the recommendations were intended to provide a way to achieve safety performance improvement.The recommendations were prioritized based on the degree of risk associated with the finding.Marine>Research Specialists(NIRS)presented the report."Safety Evaluation of the General Chemical Richmond Works Facility"to the Contra Costa County Board of Supervisors and the Richmond City Council on January 14, 2003, Scope and Approach to the Follow-up Safety Evaluation The scope of the follow-up safety evaluation included four major tasks. - Review and Comment on the General Chemical Action Plan Review the Implementation of the Action Plan • Fallow-up Evaluation Public Participation The first two tasks were conducted during the months of February through October 2003.During this period the MRS team reviewed and commented on the GCRW Action Plan as well as three quarterly reports that were prepared by GCRW documenting the progress on various action items. GCRW Follow-up Safety Evatuation- Finui Report ES-1 January 2004 ..............-..... .............. ........... ............. .............. .................... .............. The follow-up safety evaluation involved two parts.The first was to conduct a safety climate survey using the same survey form from the initial evaluation.The survey was conducted in October 2003.The second part of the evaluation was the onsite work that was conducted at the General Chemical Richmond Works facility in Richmond,California from November 10-14, 2003. The objectives of the follow-up evaluation were to: Review the actions GCRW has taken in addressing the findings and recommendations from the initial safety evaluation. • Determine if these actions were adequate to address the findings and recommendations from the initial safety evaluation. Suggest further actions GCRW could take to enhance the effectiveness of their Action Plan. Conduct a follow-up safety evaluation that is trusted and considered credible by the public and other key stakeholders. The follow-up evaluation was designed and implemented in a manner intended to be impartial and objective. The onsite evaluation was conducted using a team of safety professionals working at the GCRW over a period of one-week beginning November 10, 2003.During the onsite evaluation,the team conducted more than 30 interviews with individuals and groups,and reviewed over 100 documents that had been generated or modified as a result of GCRWs Action Plan. in addition, the evaluation team received a number of presentations from the GCRW facility staff an the status of various safety related projects being undertaken by the facility. These included topics such as training, security, the distributed control system,mechanical integrity, etc. Our review of the actions taken by GCRW was based on evidence gathered during the follow-up evaluation. This evidence was obtained from interviews with key people involved in the development and implementation of the respective action items,review of documents, and limited physical observations. A four-step approach was used to assess the progress GCRW has made in addressing the recommendations. 1. Based on the interviews, document reviews, and inspection, a summary was developed that described the actions taken by GCRW to address each of the recommendations. 2. The evaluation team then determined if the actions taken by GCRW met the intent of the recommendation, and if the action items had been implemented. 3. The implementation status was determined for each recommendation. GCRW Follow-up Safety Evaluation- ES-2 Final Report January 2004 ----------............ 4. Recommended further actions were developed as needed. In addition,suggestions were made for C CRW to consider as steps for continuous improvement. - Since cultural ehange,is an ongoing aspect of continuous improvement,the actions taken by GCR,W in response to many of the safety evaluation findings are never truly"complete," so it is inappropriate to conclude that an action item is"closed"or not.GCRW's approach has been to use the terra"implemented"to indicate that a critical milestone has been met in the implementation effort.In the follow-up evaluation,we evaluated the process used to implement each action item., and we made an assessment of how effective the implemented action item appears�to be based on the results of our interviews and review of documents.' A Draft Follow-up Evaluation Report was issued for a 30-day public comment period.The - public comment period ran from Monday,December 15,2003,through January 14,2004. Appendix E contains a copy of all of the comments received on the Public Draft Report. Conclusions There have been many impressive accomplishments and improvements to the'GCRW safety programs during the last year. GCfiW has addressed all 54 findings from the initial safety evaluation,and they have made excellent progress in working towards a more positive safety culture. In many wags, GCRW's commitment to this process has been exemplary. In particular, there has been a very positive change in safety culture. The change was very evident from the onsite interviews andfromthe various program documents that were shared with the evaluation team. Some of the initiatives that have contributed to this change are as follows: * A safety visioning process which involved a wide cross section of employees. • A revamped near miss reporting program. • A.new safety suggestion program. • A new employee safety rewards program. • A new employee recognition program. • Improvements to way in which the Health and Safety Council meetings are used to communicate safety issues to the employees. +� Visits offsite that allow workers to share experiences with other workers in the local area and at other General Chemical locations. • A training summit to review all training needs and training delivery alternatives, • Pilot testing of the full versions of the Maximo maintenance management system, and the appointment of a new maintenance planner. • The ongoing process to design and install a new Distributed Control System(DCS)at the plant. In these initiatives, the common themes have been an open invitation to all employees to participate in the development process, to consider workers' opinions, and to emphasize collaboration between hourly and salaried employees. GCRW Follow-up Safety Evaluation- ES- Final Report January 2004 There are still a number of challenges facing GCRW before the values expressed in their own Safety Vision are met. Some of these challenges are summarized below: « Where is an imperative need to "win over" all employees to the new Safety Vision and to have a higher level of participation in the GCRW safety initiatives. Some workersstill have resistance to this change and are reluctant to get involved.This reluctance is not uncommon when a major change like this is instituted at a facility,and it takes time for all staff to become aligned with the new initiative.' « For some workers,there is a lingering distrust of management.This perspective is understandable, given the style of management and the inconsistent leadership in the past. « Even though workers are being given opportunities to share their ideas on safety(e.g., safety suggestion program and communications meetings),there is a perception among some workers that management does not listen to them. Some are unwilling to risk being' blamed(e.g.,for near misses), some doubt that management will really act on their safety suggestions if the solutions are expected to be complex or costly, and some lack confidence that their ideas are worthy of consideration. « Some workers still perceive that disciplinary action is not always based on actual events. They sense that managers do not listen to their positions,and disciplinary actions are not always based on fact.There is some uncertainty with workers about the steps in the disciplinary process, and the time steps involved for follow-up. • In Operations, there are some limited personality conflicts that continue to adversely affect the morale of the group and the ability of Operations to function well as one team. + Some workers argue that the Maintenance Department is understaffed to complete the high volume of work orders that is currently being generated. « Even though there is help available, some Operators with minimal experience expressed a lack of confidence when working at night on non-routine tasks.They understand that working safely is the priority, but they are also aware of the need to complete their tasks in a timely manner. The challenges listed above are not unexpected after one year of working to improve safety culture at the plant. It can take a number of years to get all the employees aligned with the safety vision and to achieve the desired safety culture. GCRW has made tremendous progress at the plant over the past year. If they continue with this degree of diligence,there is a very high likelihood they will achieve the goals of their safety vision and create a positive safety culture throughout the organization. The results section of this report includes a number of suggestions for further improvement.If implemented, these suggestions will likely help to address the issues discussed above. It should be noted, however,that MRS considers that GCRW has met their commitments in addressing the findings of the initial Safety Evaluation(January, 2003), so the suggestions for further improvement are for GCRW's consideration only. They are not required to be implemented as part of this fallow-up evaluation. GCRW Follow-up Safety Evaluatlon- Final Report SSS January 2004 . « « „v Whether or not the suggestions for further improvement are implemented,there will be a need for GCRW to demonstrate an on-going commitment to their safety initiatives to sustain the positive advances in safety culture that they have achieved over the past year.The ultimate success of this effort will be reflected in the extent to which the safety culture continues to improve over time and the extent to which GCRW can achieve their goal "to prevent all injuries, accidents, and incidents and to generate a positive impact in the community„ GCRW Follow-up Safety Evaluation- Final Report ES-5 January 2004 !. Introduction This section of the report discusses the objectives of the follow-up safety evaluation,presents some background information on the initial safety evaluation,and provides the reader with an - overview on the format of the report. A. Background Because of incidents that have occurred at the General Chemical-Richmond Works(GCRW) - facility, the communities surrounding the facility, the Richmond City Council, the Contra Costa County Board of Supervisors,and the Contra Costa.Health Services(CCHS)are concerned about safety at the facility. In response to these incidents, the Richmond City Council and CCHS arranged for a third party safety evaluation to be performed on this facility. A SafetyEvaluation'Oversight Committee was formed that included representatives from CCHS, the City of Richmond,General Chemical, the General'Chemical employee union,Hazardous Materials Commission,and the public. This committee solicited bids from a number of consulting firms to conduct the third party safety evaluation.The committee selected MRS to conduct the evaluation. The initial Marine Research Specialists(MRS)safety evaluation was conducted at the GCRW facility in Richmond,.California from October 7--11,2002. The final safety evaluation report was issued on January 6, 2043. The objectives of the Safety Evaluation were to complete a thorough evaluation of the current management practices and safety culture at the GCRW facility.The focus of the evaluation was on the safety management systems, human factors, and safety culture. - The scope of work for this assignment was developed by the Safety Evaluation Oversight' Committee. The evaluation was not intended as a compliance audit,and as such,the initial safety evaluation report was not meant to imply legal certification of compliance or noncompliance with safety regulations.Rather, the evaluation was intended to evaluate the GCRW safety management systems in relation to industry practices and to identify potential deficiencies. The safety evaluation identified 54 findings. For each Ending,recommendations were developed to address the deficiency.The recommendations were intended to provide a wary to achieve safety performance improvement.The recommendations were prioritized based on the degree of risk associated with the finding. MRS presented the report "Safety Evaluation of the General Chemical Richmond Works Facility"to the Contra Costa County Board of Supervisors and the Richmond City Council on January 14, 2003. At both the Board of Supervisors.and City Council meetings covering the initial safety evaluation, the issue of an onsite follow-up evaluation was discussed. It was GCRW Fallow-up Safety Evaluation- Final Report January 2004 A--....... . .... ................ ...........-...... decided that the Oversite Committee would meet to determine the type and extent of any follow- up evaluation. The Oversite Committee determined that a follow-up evaluation should be performed by MRS, and that the objectives would be as follows. I. To assess the actions that are being taken by GCRW to determine if they are addressing the findings and recommendations from the Safety Evaluation Report dated January 6, 2003. 2. To determine the changes in the overall Safety Culture at the GCRW facility and if any trends in the Safety Culture can be determined. The Oversite Committee developed a scope of work for the follow-up safety evaluation that would meet the objectives listed above. A copy of the scope of work developed by the Over-site Committee is included as Appendix A. As part of the onsite follow-up evaluation,MRS has reviewed and commented on the GCRW Action Plan. In addition,MRS has been reviewing and commenting on the quarterly progress reports prepared by GCRW. Appendix B contains copies of the MRS comment letters on the GCRW Action Plan and quarterly progress reports reviewed to date. B. Objectives This report summarizes the results of the follow-up safety evaluation conducted by MRS at the GCRW facility in Richmond,California,at the request of Contra Costa Health Services and the City of Richmond. The objectives of the follow-up evaluation were to: Review the actions GCRW has taken in addressing the findings and recommendations from the initial safety evaluation. Determine if these actions were adequate to address the findings and recommendations from the initial safety evaluation.. • Suggest further actions GCRW could take to enhance the effectiveness of their Action Plan. • Conduct a follow-up safety evaluation that is trusted and considered credible by the public and other key stakeholders. The initial and follow-up safety evaluations were not intended as a compliance audit, and as such, this report isnot meant to imply legal certification of compliance or noncompliance with safety regulations.The intent of the follow-up safety evaluation was to review the actions that GCRW has taken to implement the initial safety evaluation recommendations. GCRW Follow-up Safety Evaluation- 2 Final Report January 2004 C. Report Format Section H of the report describes the scope and approach for the follow-up evaluation. Section IH presents the follow-up evaluation'>findings.The findings are presented in a text table,which provides the text of each finding from the initial safety evaluation, a description of the actions taken by GCRW to address the finding, the implementation status,and a set of comments and suggested follow-up actions. Section IV presents the overall conclusions from the follow-up evaluation. - The report contains'a number of Appendices that include the following: A. The aversite Committee Scope of Work for the Follow-up Evaluation. B. The MRS comment letters on the General ChemicalAction Plan and Quarterly Reports. C. A listing of the initial safety evaluation findings and recommendations. D. The initial safety study scope of work. E. Copies of the comment letters received on the Public Draft Report. GCRW Follow-up Safety Evaluation- Final Report January 2€04 .......... .............-.......... ...................... ..............-..... If. Scope and Approach This section presents the scope and approach for the follow-up safety evaluation. A. Scope The scope of work for the follow-up evaluation is composed of four separate tasks.Each of the tasks is described below. Review and Comment on General Chemical Action Plan—MRS reviewed and commented on the GCRW Action Plan developed to address the recommendations and findings from the initial safety evaluation. Appendix B contains a copy of the MRS comments on the Action Plan. Review the Implementation of the Action Plan—MRS reviewed and commented on GCRW's quarterly progress reports that provided a detailed status on the implementation of the action items. Appendix B contains a copy of the MRS comments on the first three quarterly progress reports. Follow-up Evaluation—MRS conducted a follow-up evaluation to determine how GCRW was addressing the findings and recommendations from the initial safety evaluation and to evaluate if the actions taken by GCRW were addressing the findings and recommendations.The follow-up evaluation was conducted in two parts.The first part was to conduct a safety culture survey, which took place in October 2003.The second part was the onsite evaluation, which took place in November 2003.The onsite portion of the follow-up evaluation involved reviewing documents, conducting interviews, and limited site inspections. Public Participation—Public participation is a key element of the follow-up safety evaluation scope. The public participation steps include: • The issuance of a draft work plan for the follow-up evaluation for public comment, which occurred in October 2003. • The issuance of a draft follow-up evaluation report for a 30-day public comment period. The public comment period ran from Monday,December 15, 2003, through January 14, 2004. Appendix E contains a copy of all of the comments received on-the Public Draft Report. • Meetings with the Contra Costa County Board of Supervisors and the Richmond City Council to present the final follow-up evaluation report.This hearing should occur in February 2003. GCRW Follow-up Safety Evaluation- Final Report January 2004 .................... B. Approach There were two main steps to the follow-up evaluation,which are discussed below. Safety Climate Survey MRS conducted a Safety Climate Survey prior to the onsite follow-up evaluation.The survey was distributed to all employees at the GCRW facility,to selected contractors,and to those managers at the corporate level with responsibilities for safety at the GCRW facility.The survey was used to obtain an initial perspective of people's views and perceptions on key aspects of health and safety in the GCRW organization as it exists today. It included questions based on the Health and Safety Climate Survey Tool developed by the UK HSE Assessment Tool. The survey was the same as was used as part of the initial safety evaluation. The survey was administered in away that protects the anonymity of the respondents and the confidentiality of the information provided. MRS provided>a stamped,addressed envelope with each form distributed to allow the completed forum to be sent directly to MRS(an independent consultant)in a seated envelope.All the individual results from the survey were keep in confidence and net shared with any party outside of MRS The Safety Climate Survey offered several advantages for the onsite follow-up safety evaluation; which included: • Allowing MRS to determine how the perceptions of the safety culture may have changed since the first survey, which was conducted prior to the initial safety evaluation in September 2002. • Providing a convenient way of soliciting input from a wider range of people(onsite and offsite) than could be achieved with interviews and focus groups alone. +� Providing anonymity. With the small number of employees at this facility, workers may be concerned about the evaluation team's ability to preserve anonymity with the interview process.This anonymity may help to alleviate this concern during the initial phase of the follow-up evaluation: - Providing the evaluation team with an opportunity to review safety concerns and perceptions identified in the survey prior to their onsite work. This review helped the team to plan more effectively, and target key issues. Onsite Follow-up Evaluation One of the main purposes of the onsite follow-up evaluation was to determine how GCRW was addressing the findings and recommendations from the initial evaluation and to report on the - progress that was being made in addressing these findings and recommendations. Reviews of the actions taken by GCRW were based on evidence gathered during the onsite follow-up safety evaluation.This evidence was be obtained from interviews with key people involved in the development and implementation of the respective action items,review of documents,and limited physical observations. A four-step approach was used to assess the progress GCRW had made in addressing the findings and recommendations. GCRW Follow-up Safety Evaluation- Final Report $ January 2004 1. Based on the interviews, document reviews, and inspection, a summary was developed that described the actions taken by GCRW to address each of the findings/recommendations. 2. The evaluation team then determined if the actions taken by GCRW met the intent of the finding/recommendation,and if the action items had been implemented. 3. The implementation status was then determined for each findings/recommendation. 4. Recommended further actions were developed as needed. The approach taken by GCRW to address the MRS recommendations was to develop a series of Action.Items intended to address the recommendations and the underlying findings. Since cultural change is an ongoing aspect of continuous improvement,the actions taken by GCRW in response to the safety culture findings are never truly "complete, so it is inappropriate to conclude that an action item is"closed"or not.GCRW's approach has been to use the term "implemented" to indicate that a critical_milestone has been met in the implementation effort. In the follow-up evaluation, we evaluated the process used to implement each action item,and we made an assessment of how effective the implemented action item appears to be based on the results of our interviews and review of documents. We consider this to be an appropriate way of designating sufficient progress. Our determination of the critical milestone is based on the issue of whether the program is sustainable from that point.For example, in terms of the near miss reporting program, we agree that a critical milestone has been reached when the program has been developed, employees have been trained, near misses are being reported, and management is acting on the information.The real benefit of this program is achieved later when all employees are participating in the process,but after the program is rolled-out,it is reasonable to conclude that the critical milestone has been met. The ether purpose of the onsite follow-up evaluation was to assess the overall culture at GCRW and determine if any trends in the safety culture can be identified. To address this issue;the evaluation conducted an extensive series of employee interviews, using the results of the safety climate survey to focus in on key issues. Information obtained from these interviews was used together with a review of applicable documents provided by GCRW to make an assessment of the present culture compared with that observed a year ago, GCRW Follow-up Safety Evaluation- 6 Final Report January 2004 111. Follow-up Suety Evaluation Findings The findings in this section are presented separately for safety management systems,human . factors,and safety culture,consistent with the initial safety evaluation.The findings provide a discussion of the actions GCRW has taken to address each of the recommendations from the initial safety evaluation.The findings are based on evidence gathered daring the follow--up safety evaluation. This evidence was obtained from interviews with key people involved in the development and implementation of the respective actions,interviews of other people throughout the refinery organization,review of documents,and limited physical observations. In addition GCRW gave a number of presentations to the evaluation team that addressed areas where they had implemented significant programs to address various aspects of safety at the plant.The presentation topics included'the following. * The Safety Vision for the plant • Quarterly Progress Reports • Training • Security Cognitive Task Analysis • Turnaround Planning • Distributed Control System + Mechanical Integrity Program • Initial Safety Evaluation Action Item Supplemental Back-up Data on the Documentation Initial Safety Evaluation Action Items The remainder of this section provides some general discussion on the findings of the follow-up safety evaluation.At the end of the section is a text table that presents the initial safety evaluation fundings, a summary of the actions taken by GCRW to address the findings,the implementation status,as determined by the MRS team,and a set of comments and suggestions for further improvement. A. Safety Management Systema The evaluation of the safety management systems was not intended as a compliance audit,and as such,this report is not meant to imply legal certification of compliance or noncompliance with safety regulations. Rather,the evaluation was intended to evaluate the GCRW facility safety management systems in relation to industry practices and to identify potential deficiencies. The emphasis was to evaluate the safety management systems in place to prevent incidents that could impact workers and the community. Safety management systems are the policies,procedures and practices that a facility uses to ensure that the facility is operated in a safe manner and to ensure that process related incidents are minimized to the maximum extent feasible. During the initial safety evaluation,the GCRW facility was found to have a written set of safety management systems in place.The facility has done a considerable amount of work'on the safety management procedures over the past 3 years.They had updated the majority of the procedures GCRW Fallow-up Safety E'valuation- Final report 7 January 2004 ....... .... ............. .......... including the operating procedures, the incident investigation procedures,portions of the emergency response manual,as well as the management of change(MOC)procedure. The facility had a written process hazards analysis(PHA)procedure, and all of the PHAs had been revalidated.As part of this revalidation process the facility had conducted a human factors and facility siting assessment. GCRW has taken a number of significant actions to address the finding related to safety management systems,which include the following. Incident investigation training was provided to all supervisors at the plant.As part of the training the supervisors learned the Power Analysis method, which is a tool for identifying root causes.A review of a number ofincident investigations shows that root causes were being identified. In addition,the number of incident investigations conducted at the plant has increase substantially. This was due to the large increase in the number of near misses reported. • GCRW has implemented annual emergency response and emergency evacuation drills. Emergency response and emergency evacuation drills were conducted in 2002 and drills are planned for the end of November 2003. GCRW conducted critiques of drills which lead to a number of action items that have been implemented. GCRW has implemented a program to ensure that all policy and procedure changes that affect safety are handled through the MOC process. This includes any changes to the Emergency Response Manual. GCRW is in the process of upgrading and expanding the Maximo system, which is used to track work orders at the facility. When fully implemented,the expanded Maximo system will allow GCRW to better track maintenance activities and will serve as the data base system for the mechanical integrity program. • While mechanical integrity was not part of the initial safety evaluation scope, it is important to note that GCRW has-made significant progress on updating their mechanical integrity program. Significant work has been done in updating and verifying all of the process safety information,inspections and repairs have been completed to all of the electrical systems,and work is ongoing on various elements of the predictive maintenance program such as vibration analysis for rotating equipment. The initial safety evaluation found that the plant had well-documented safety management systems that were, for the most part, being implemented. The follow-up safety evaluation found that GCRW had made improvements to a number of their safety management systems and had developed processes to ensure that these systems were being fully implemented. GCRW Follow-up Safety Evaluation- 8 Final Report January 2004 ........... ................. —------ B Human Factors Human factors engineering is a multidisciplinary practice that seeps to promote safety through more effective design of sociotechnical systems(i.e., systems that are comprised of complex interactions between people and technology). Its primary focus is the effect of human-machine interactions on safe work performance. However,human factors also include related issues such as training,teamwork and team performance, and the effect of fatigue, workload, and stress on worker performance. As part of the initial safety culture evaluation,effort was devoted to examining human factors issues related to safe work practices.The human factor issues identified as part of the initial safety evaluation focused on the design of control room displays and alarm systems, training,and teamwork among the Operators. In the area of design of the control room displays and alarms, GCRW is in the process of - completing the design of a new Distributed Control System(DCS).The current plan is to have the new ICS system in place within the next 12 to 18 months. GCRW's commitment to a DCS is a clear indication of how seriously they are taking the issues associated safety culture. This is -- one of many cases were GCRW went beyond what was the recommendation in the initial safety evaluation to further'improve the safety and operability of the plant.GCRW used a"best management practice"in developing the design of the DCS. They conducted a cognitive task analysis(CTA) that involved extensive input from the Operators to identify need alarms and their priority.The CTA also was used to develop a control room layout as well as preliminary operating screens for the DCS, GCRW has implemented a process to review and update all of the training programs at the plant. As part of the training improvement program, a training summit was held that included both _ salary and hourly staff.The main objectives of the summit were to look at the existing training programs and identify how they could be enhanced and improved:. The summit was used to identify the needed training,programs,the essential elements of the training programs, and a rating of the effectiveness of the existing training programs. Some of the key elements of a training program that were identified as part of the summit,included a method for providing feedback on the training,a means of measuring effectiveness of the training, and assuring that the training programs included bath theory as well as hands-on training elements. A training summit steering committee has been established to track progress on the development of the training programs. A schedule has been developed for completing the updates on the various training program. A number of training program updates have been.completed. GCRW is in the process of evaluating a number of computer based training programs. GCRW is committed to implementing a number of computer based training programs that will be used to supplement the existing training programs.These programs provide both instruction and well as testing of knowledge. As part of the new contract with the Operators union the shift structure was modified so that all of the Operators work with the same team on a 12-hour shift. Based on discussions with the Operators it was clear that this has increased the amount of team work on each of the shifts.For the most part,the change in shift structure has increased the teamwork bonds on the shifts,and GCRW Follow-up Safety kv-d ation- Final Report January 2004 has promoted a sense of caring and awareness of other team members' strengths and weaknesses. Operators appear to be more willing to ask for and provide help to other Operators on their shift as well as with other shift teams.The Operators had made significant improvements in their communications particularly relating to shift change, C. Safety Culture "Nothing is more important than safety." GCRW Safety Vision,March 2003 The results of the safety culture evaluation are discussed below. The first section addresses the onsite evaluation of safety culture, and includes some highlights of the improvements made in commitment and communications,employee participation and teamwork, and in competence and training.The second section includes a discussion of the main results from the safety culture survey and how the survey results compared with the onsite evaluation. Onsite Evaluation of Safety Culture Based on the results the follow-up interviews and review of documents,it was clear to the MRS team that there has been a very positive change in safety culture at GCRW during the last year. Some of the initiatives that have contributed to this change are as:follows; * A safety visioning process which involved a wide cross section of employees. • A revamped near miss reporting program. • A new safety suggestion program. • A new employee safety rewards program * A new employee recognition program. « Improvements to way in which Health and Safety Council meetings are used to communicate safety issues. « Visits offsite that allow workers to share experiences with other workers in the local area and at other GC locations'. • A.training summit to review all training needs and training delivery alternatives. * pilot testing of the full version of a computerized maintenance management'system (Maximo), and the appointment of a new maintenance planner. In these initiatives, the common themes have been an open invitation to all employees to participate in the development process, to consider workers' opinions,and to emphasis collaboration between hourly and salaried employees. Other achievements that have played a role in improving the safety culture during the last year include considerable progress with the enhanced mechanical integrity program, acquisition of a cogeneration unit(to be installed by the end of 2003),enhancements to plant security,improvements to the Operations shift structure,a Cognitive Task Analysis of Operations,and planning and design for a new ICS. The following sections provide brief summaries of the culture change initiatives that are ongoing in some of the important safety culture areas.' GCRW Follow-up Safety Evaluation- 10 Final Report January 2004 Commitment and Communications Based on the follow-up interviews and review of GCRW documents,the clear message was that "Safety is#1 in everything we do"(the first guiding principle of the new Safety Vision). Observations that led to this conclusion are as follows: + There is good written and verbal communication from management on business and performance issues,so"there are no rumors any more".The Plant Manager is providing written'"Communications Memos"on a weekly basis. Communications meetings with all employees are also held on a quarterly basis. - • In all communications from management,there is a clear and consistent emphasis on safety. + Everyone is clear about the importanceof safety,even though there is still some reluctance to fully embrace the new Safety Vision. • Expectations of the workers are more clearly defined, and workers are using"one set of rules" This differs'from past experience when workers were given mixed messages about the relative importance of safety and production: + Environmental,health and safety policies have been rewritten to ensure there is consistency in the messages from General Chemical(Corporate)and GCRW.The safety programs at GCRW have been structured tomake them consistent with the Corporate 3P" (People, Practices,Performance) structure. • There is now a written disciplinary policy that spells out the steps that will be taken in the event that a worker fails to comply with a requirement of the job position. • Leading and lagging indicators are being used to measure safety'performance, and the results are being shared with workers. • Management is insistent that time be given to assure safety, when work is being planned and implemented. Employee Participation and Teamwork The following observations were made with respect to teamwork and employee participation in the safety programs + Morale at GCRW appears to be higher'across the beard. + There is more decisive leadership that is setting a clean and consistent direction for employees. + The shift structure in Operations has been changed'in a way that greatly enhances teamwork.Each shift team(three Operators)now works together at all times in 12-hour shifts. + Operators are very willing to ask for help, both from their fellow Operators and from Supervisors, + Many Operators said that their"comfort level"was now much higher because of the support they have(from management and fellow workers). • Workers said that they are now"looking out for each other".It,appears that individual workers are no longer being ostracized by their peers. * The evaluation team found that there was a greater sense of purpose in the Maintenance Department work ethic. GCRW"Follow-up Safety Evaluation- Final Report 1 I January 2004 + Several small groups and committees have been established to work on safety-related initiatives.These work groups provide hourly workers an opportunity to express their opinions and concerns about safety issues.These group activities are helping to increase the level of participation by hourly workers,and they are also helping to build trust between hourly and salaried employees. Competence and Training Several initiatives are in progress;to address the effectiveness of the GCRW training programs and to raise the competence level of the GCRW workforce: • When new hires are recruited,the GCRW employees who will work most closely with the new person are involved in the interview process.This increases the level of employee participation,it provides important input to management,and it helps to increase the level of support for the new person when hired. +� GCRW has started to use drills and simulations to help raise the confidence level of workers during upsets and emergency conditions. +� A new policy has been issued that describes the proposed cross-training program for Operators.This program will be formally implemented during the first quarter of 2004. • As discussed in the Human Factors section above, several new initiatives are being pursued to improve the training programs,both in terms of content and method of delivery. • While there is a mix of apprehension and excitement among Operators about the proposed DCS,GCRW management expects that Operators will receive extensive training on this prior to implementation. • The selection of a new Maintenance Supervisor, a new Maintenance Planner and a new Maintenance Technician supports the goal of continued improvement in the Maintenance Department. Safety Culture Survey The results of the 2003 survey are presented in Figures 1 and 2.The figures show how the responses compare between the hourly workers, supervisors and managers.Figure 1 shows the percentages of favorable responses for each of 11 cultural:factors, and Figure 2 shows percentages of unfavorable responses.Apart from helping to identify the factors where there may be cultural concerns,the two figures highlight the factors where the employee categories differ in their perspectives.Note that the summation of favorable and unfavorable responses in Figures 1 and 2 do not usually add up to 100%because they do not include the neutral responses (not shown). The results from the 2003 survey were compared with the results from an identical survey conducted in 2002. In general, the survey data suggest that for most factors, there have been only minor changes'in safety culture during the last year,and the cultural factors that had the least favorable responses in 2003 were generally the same ones that had the least favorable ratings in 2002.These were"job security"and"some obstacles to safe behavior"(workers,supervisors and managers), "reporting of accidents and near misses" (workers), and"risk taking behavior" (managers). GCRW Follow-up Safety Evaluation- 12 Final ReportJanuary 2004 Figure 1 GCRW Safety Climate Survey, 2003—Favorable Responses C3rg2tnirational Currtr itment and Communication Line M anagement Commitment' SupervisorsRole Personal Role' Workmates'Influence Competence: .. Risk Taking Behavior and Contributory Ej shavlor Some Obstacles to Safe Behavior Permit to ftr.k.< ...::: . ................. Reporting of Accidents and Near M lases .............. Job Satisfaction(Q4) :;: .. Job Security(Q52) 0 20 40 60 80 100 120 percent ■Workers ■Supervisors p hUnagers Figure 2 GCRW Safety Climate Survey, 2€03—Unfavorable Responses Organizational Commitment and Communication Line Management Commitment - Supervisors'Role Personal Role Workmates'Influence Competence Risk Taking Behavior and Contributory Behavior Some Obstacles to Safe Behavior Permit to Work Reporting of Accidents and Near M Issas Job Satisfaction(04) Job Security() 0 10 20 30 40 percent ■Workers ■;Supervisors.0 Nkinagers GCRWFollow-up Safety Evaluation- 13 Final Report January 2004 As stated above,it was clear from the onsite follow-up evaluation and the content of the quarterly progress reports reviewed by MRS that there has been a positive change in safety - culture at GCRW during the last year. However, the improvements were not generally reflected in the results of the most recent safety culture survey. Given the considerable effort that has been devoted to improvement efforts during the last year,it is surprising that the survey results did not reflect more favorable responses.This is especially true for the hourly workers,where the survey responses;show no clear improvement in any of the safety culture factors. In general, there may not yet have been sufficient time for the improvements to be reflected in the survey results.The survey results may be influenced by a relatively small percentage of workers who may still not fully accept management's commitment to the new emphasis on safety. For this relatively small group,past practices at the plant may still be influencing the way they rate the safety culture statements.Also,the expectations for safety performance were raised during 2003,so in the most recent survey the employees may have been rating the statements against a higher standard. Another factor that may influence some of the results for the Supervisors' group is that there has been a relatively high turnover within this small group(two out of six)during the last year. For example,this may explain why there was an increase in the ratings for Job Security in this group, but not for the other two groups. Apart from Job Security, the one other safety culture factor that is rated less favorably by all three groups is"obstacles to safe behavior." The statements which are rated in this category are: Some jobs here are difficult to do safely. • Some health and safety procedureshnstructions/rules are not really practical. • Some health and safety procedures/instructions/rules do not reflect how the job is now done. • Some health and safety procedures/instructions/rules are difficult to follow. +. Some health and safety procedures/instructions/rules are only there to protect management's back. + People can always get the equipment which is needed to work to the health and safety procedures/instructions/rules. • There are always enough people available to get the job done according to the health and safety procedures/instructions/rules. Sometimes physical conditions at the workplace restrict people's ability to work safely. • Sometimes it is necessary to take risks to get the job done. It is interesting to note that managers' rating for this factor decreased from 95% to 71% (favorable responses). This may indicate a better appreciation by management of the issues which workers consider to be"obstacles to safe behavior". GCRW Follow-up Safety Evaluation- 14 JanuaryCi04 Final Report The factors where the survey results suggest there have been changes in perspectives of the safety culture(better or worse)are highlighted below,together with a discussion of the underlying issues that may have influenced the survey scores: • Reporting of accidents and near misses.Favorable responses from managers increased from 50%to 90%.Favorable responses from supervisors,however,decreased from 2% to 79%during the last year. Based on the onsite component of the evaluation,it seems reasonable to conclude that the response by managers is reflective of the success of the revamped near miss reporting program that was launched at the beginning of the year. Supervisors' responses on the other hand may suggest that there are near misses that are still not being reported. • Line management supervision.Favorable responses from supervisors increased from 79% to 100%.This is likely to be in response to the clear safety message that is being delivered from the plant manager.The team-building and leadership training provided to all supervisors may also have contributed to this particular increase. • Competence.Favorable responses from managers increased from 80%to 92%.This increase may be attributable to the improved teamwork and collaboration among the Operators and Maintenance workers discussed above.Workers were also provided additional training on hazards recognition. • Job security.Favorable responses for workers and managers both decreased by more than 20%.It is possible that these decreases are attributable to the GCRW Chapter 11 bankruptcy proceedings, and/or the absence of a long-term contract to supply acid to a large regional customer. A small percentage of workers still expressed concern about job security because of the potential for termination from disciplinary action.. (Mote that in November 2003,GCRW announced that they have emerged from the Chapter 11 bankruptcy.) • Job satisfaction for supervisors.Favorable responses decreased from 100%to 71%m. The decrease in job satisfaction may be a result of the increased workload placed on Supervisors daring the course of this year, implementing the new programs and safety improvements, and maintaining operations. « Obstacles to safe behavior.Favorable responses decreased from 60%v to 49%for workers and from 95% to 7l% for managers. (Refer to the discussion of Current Challenges below.) • Work permits.Favorable responses for Supervisors decreased from 100%to 76%.This may be attributable to an increased awareness of the level of detail needed in the permits, and the ability of supervisors to recognize deficiencies. • Supervisors'role.Favorable responses for workers decreased from 74% to 65%. In summary,it is disappointing that the survey results did not reflect the positive changes that were observed'during the onsite follow-up evaluation.There are several possible explanations for this,but it is apparent that further work is needed by GCRW management to establish unanimous support for the new Safety Vision and all it represents,and to address the perceived obstacles to safe behavior. GCRW Follow—up Safety Evaluation- Final Report 15 January 2004 The use of the HSE Safety Culture Survey for this evaluation has been helpful in singling out cultural factors that may have been contributing to poor safetyperformance in the past.However, the evaluation process has shown how the survey is limited in its ability to measure changes in culture in an environment where considerable change is occurring in a relatively short time period.To gain a thorough<appreciation`of culture during these times,it is probably necessary to combine the survey with onsite interviews and observations. GCRW Fallow-up Safety Evaluation- 6 Final.Report1 anuary 2004 ........... :... .. :..<:. ::,,. ti It ad w tele . J Ila LL T ti. J caAia� � � © Via, acs p ` v2 Ul as 14 0 16, o 44 r� •y �'v 3 cgi w A ew > ., °3 ct w o cv awesb4 � 0 � A < N ^V �� hi cy � J j, r" s uvi 4; w c �,yy 978 98 ' � a. _ : ' R � � s� .� � � > ,�?, �. rr eq� � �» '� N ��,,, ° bA.� � � �Y '� •L" aJ raj ' � � � � •� c C4 CA ,.. 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GCRW has addressed all 54 findings from the initial safety evaluation, and they have made excellent progress in working towards a more positive safety culture. In many ways, GCRW's commitment to this process has been exemplary. Some of the more significant achievements and actions taken by GCRW are listed below. A. Safety Management Systems * The number of incident investigations conducted at the plant has increased substantially, largely due to the increased effort on reporting near misses, « GCRW is in the process of upgrading and expanding the Maximo system, which is used to track work orders at the facility.When Fully implemented,the expanded Maximo system will allow GCRW to better track maintenance activities and will serve as the data base system for the mechanical integrity program.' • While mechanical integrity was not part of the initial safety evaluation scope,it is important to note that GCRW has made significant progress on updating their mechanical integrity program. B. Haman factors * GCRW is in the process of completing the design of a new DCS.They conducted a CTA that involved extensive input from the Operators to identify needed alarms and their priority.The CTA also was used to develop a control room:layout as well as preliminary operating screens for the DCS. * As part of the training improvement program, a training summit was held that included both salary and hourly staff The summit was used to identify the needed training programs,the essential elements of the training programs, and a rating of the effectiveness of the existing training programs. * GCRW is in the process of evaluating a number of computer based training programs and they are committed to implementing a number of computer based training programs within the near future. * The Operators' shift structure was modified so that all of the Operators work with the same team on a I2-hour shift.This has improved the level of team work on each of the shifts. Operators appear to be more willing to ask for and provide help to other Operators on their shift as well as with other shift teams. GCRW.Follow-up Safety Evaluation- Final Report 45 January 2004 C. Safety Culture There has been a very positive change in safety culture.The change was very evident from the onsite interviews and from the various program documents that were shared with the evaluation team. Some of the initiatives that have contributed to this change>are as follows: • A safety visioning process which involved a gide cross section of employees. A revamped near miss reporting program: • A new safety suggestion program., • A new employee safety rewards program. • A new employee recognition program. Improvements to way in which Health>and Safety Council meetings are used to communicate safety issues. • Visits offsite that allow workers to share experiences with other workers in the local area and at other General Chen-deal locations. A training summit to review all training needs and training:delivery alternatives. • pilot testing of the complete version of the Maximo maintenance management system, and the appointment of a new maintenance planner. In these initiatives, the common themes have been an open invitation to all employees to participate in the development process, to consider workers' opinions,and to emphasize collaboration between hourly and salaried employees. D. Summary There are still a number of challenges facing GCRW before the values'expressed in their own Safety Vision are met. Some of these challenges are summarized below: • There is an imperative need.to"win over" all employees to the new Safety Vision,and to have a higher level of participation in the GCRW safety initiatives. Some workers still have resistance to this change, and are reluctant to get involved.This reluctance is not uncommon when a major change like this is instituted at afacility, and it takes time for all staff to became aligned;with the new initiative: For some workers, there is'a lingering distrust of management. This perspective is understandable, given the style of management and the inconsistent leadership in the past. Even though workers are being given opportunities to share their ideas on safety(e.g., safety suggestion program and communications meetings), there is a perception among some workers that management does not listen to them. Some are unwilling to risk being blamed(e.g.,for near misses), some doubt that management will really act on their safety suggestions if'the solutions are expected to be complex or costly,and some lack confidence that their ideas are worthy of consideration. GCRW Follow-up Safety Evaluation- Final Report 46 January 2€04 • Some workers still perceive that disciplinary action is not always``based on actual events. They sense that managers do not listen to their positions,and disciplinary actions are not always based on fast. There is some uncertainty with workers about the steps in the disciplinary process,and the time steps involved for follow-up, In Operations, there are some limited personality conflicts that continue to adversely affect the morale of the group and the ability of Operations to function well as one team. * Some workers argue that the Maintenance Department is understaffed to complete the high volume of work orders that is currently being generated. • Even though there is help available,some Operators with minimal experience expressed a lack of confidence when working at night on non-routine tasks. They understand that working safely is the priority, but they are also aware of the need to complete their tasks in a timely manner. While these issues reflect some resistance to the cultural change that is taking place, this is not unexpected.For many years the workers at GCRW were subject to indecisive and unsupportive management.Justifiably,this has resulted in skepticism and a lack of trust for management.It is natural to expect that this will influence workers' opinions until they develop more confidence in the new operating philosophy and an acceptance that their contributions are truly valued. The results section of this report includes a number of suggestions for further improvement.If implemented, these suggestions will likely help to address the issues discussed above. (The suggestions are summarized in Table 2.)It should be noted,however, that MRS considers that GCRW has met their commitments in addressing the findings of the initial Safety Evaluation (January, 2003),so the suggestions for further improvement are for GCRW s consideration only. They are not required to be implemented as part of this follow-up evaluation. Whether or not the suggestions for further improvement are implemented.,there will be a need for GCRW to demonstrate an on- oiug comm tment'to their safety initiatives to sustain the _ positive advances in safety culture.The ultimate success of this effort will be reflected in the extent to which the safety culture continues to,improve over time, and the extent to which GCRW can achieve their goal "to prevent all injuries, accidents and incidents and to generate a positive impact in the community". GCRW Follow-up Safety Evaluation- Final Report 47 January 2004 Table 2 Summary of Suggestions for Further Improvement 1. Consider modifying the PITA procedure to include that incidents be identifiedin the specific deviation lime items that address the incident. 2. Consider modifying'Section IX.F of the Injury and Illness Prevention Program to include a requirement that the incident investigation team leader be trained in incident investigation techniques and haw to identify root causes. 3. Consider a more formal use of the Power Analysis Linear Problem Solving Technique, which is the incident investigation technique that the Supervisors have received training on.The more formal approach would involve the use of the Power Analysis Investigation Report'forms as a means of documenting the incident investigation analysis. An alternative technique based on a simplified checklist may be more suitable for minor incidents and near misses. 4. Consider conducting a field trip with the Operators to a facility that has a DCS so that Operators can see what a ICS looks like.This type of field visit would also provide an opportunity for the General Chemical Operators to discuss_the benefits of a DCS with.the Operators at the other facility. 5. Consider having the Safety Vision Team reconvene at regular intervals(perhaps quarterly)to help employees stay focused on the values expressed in the Safety Vision statement. 6. Consider implementing a mechanism that would require all workers to become involved in the group meetings and committees working on safety-related initiatives.The mechanism should provide a way to consider the merits of teams consisting of hourly workers,teams of salaried employees, and teams with both.The ad hoe approach to forming teams—voluntary participation—has worked well through the initial stages of the change process.However, the change process will move faster if others are encouraged to participate. 7. The hourly workers who have participated in the Safety Vision process have expressed a willingness to meet with their fellow workers to explore their reluctance to being more involved in the safety activities. Management should support and encourage these individuals and provide any help that may be needed. 8. Consider requiring all employees to join a team to explore ways for improving the pace at which the Safety Vision guiding principles are being accepted by theGCRW workers. 9. Consider an annual review of the safety suggestion program to ensure that the method of implementation and the feedback it generates are optimized to meet the objectives of the program.Issues to consider include. (l)how to encourage employees to write down their Suggestions;(2)how to reward employees that take action through Werk Orders(rather than safety suggestions); (3)who the suggestions are assigned to,and the potential for "conflict of interest";and(4)to assess resources and GCRW's ability to address the suggestions in a timely manner. GCRW Follow--up Safety Evaluation- Final Report 48 January 2404 v :..: Table 2 Summary of Suggestions for Further improvement(continued) 10. Consider an annual review of the near miss program that includes a formal review the types of near misses being reported,the quality of the root causes that are being generated,and the value of the program in reducing risk and in building a positive safety culture.Consider implementing the proposed Job Observation program to help differentiate unsafe conditions and behaviors from near misses. 11. Consider an annual review of the safety incentive program to make sure rewards are serving to align behavior with the guiding principles of the Safety Vision, and to make the program as equitable as possible to all employees. 12. Consider the potential benefits of providing team-building and motivational training to certain Operators and/or maintenance workers. Management may wish to offer or require this training when behaviors are identified that are counter productive to teamwork and trust. 13. Management should consider providing structured feedback throughout the follow-up period for workers who have been disciplined.This type of follow-up will help to demonstrate management's intent to achieve a positive outcome for both parties. 14. Consider the potential advantages of instituting an annual performance review for hourly employees.If this is considered to have merit,the format and objectives of the reviews should be discussed with Union representatives. 15. To help address the"obstacles to safe behavior",consider using a qualified independent third party(such as an Industrial Hygienist)to conduct a review of Personal Protective Equipment,and consider making radios available to those working alone in the plant. 16. Consider the potential advantage of preparing Operator aids such as packet-books, "rip- and-run"binders, or posted photographs to help Operators work safely when prompt actions are required.For example,for a tank fill operation, the rip-and-run binder could include a photograph of the equipment highlighting the valves to be opened and closed for the specific tank-:ill operation.These types of aids could be especially helpful to Operators who may be required to complete these tasks when they are alone at night or in the period immediately following their qualification. GcRW To -up Safety Evaluation- Final Report 49 January 2004 ...................................................................................................................................1.11... ............................................................................................................ .............................................. Appendix A Scope of Work for Follow-up Safety Evaluation(prepared by Contra Costa County Health Care Services and the Oversite Committee GCRW Follow-up Safety EValuadon- Final Report January 2004 ................................................ ........................................ .m; General Chemical w Richmond Warks Follow-up Evaluation to the Management Systems and Safety Evaluation Statement of Scope Objective The objectives of the follow-up evaluation are to: 1. Determine the actions that are being taken by General Chemical Richmond Works are addressing the findings and recommendations from the Safety Evaluation Report,dated January 6, 2003. 2. Determine the changes in the overallSafety Culture at the Richmond Works plant and if any trends in the Safety Culture can be determined. Background Because of incidents that have occurred at the General Chemical -Richmond Works plant, communities adjacent to the plant,the Richmond City Council,the Contra Costa County Board of Supervisors, and Health Services are concerned about the safe operation of the plant. Among these incidents are a July 26, 1993 release of oleum,May 1, 2001 release of sulfur dioxide,and a .November 29, 2001 release of sulfur trioxide and sulfur dioxide. In response to the two 2001 incidents,the Richmond City Council together with Contra Crista Health Services arranged for a third-party evaluation to be performed on this plant. This evaluation was not an investigation of the incidents, but an overall review of the;Management Systems that were in place at the plant for process safety and a Safety Evaluation of the plant. A third-party Safety Evaluation was completed and the final report for this evaluation was issued on January 7, 2003. Ural reports by the third-party consultants were given to the Centra Costa County Board of Supervisors and the Richmond City Council on January 14, 2003.. Scope of Work The evaluation will be conducted at the General Chemical -Richmond Works plant. 1. Evaluate the action plan that was developed by General Chemical to address the findings and recommendations from the third party safety evaluation and quarterly reports. a. Review and give comments on the action plan that was developed to address the findings and recommendations of the third-party safety evaluation (See Safety Evaluation fl,f the General-Richmond Works Facility,dated January 6, 2003, by MRS) b. Review quarterly reports to the Richmond City Council on the progress of addressing the findings and recommendations from the safety evaluation and how the progress compares`to the action plan to address dime items. Quarterly reports are tentatively GCRW Follow-up Safety Evaluation- Final Report �-� January 2004 scheduled on April 15, July> 15, and October: 14. The reports will be written and presented by General Chemical. 2. Follow-up Evaluation a. A Safety Climate (Culture) Survey from the United Kingdom Health & Safety Executive will reapplied to the employees and selected contractors that work for or who have managerial responsibilities for the General Chemical Richmond Works plant b. Perform an onsite evaluation; of the General Chemical Richmond Works Plant to determine that the action plan is being implemented and that the findings and recommendations are being addressed from the third party safety evaluation ; C. Public Participation — the evaluation will include time for public comments on the draft report and presentations to the Centra Costa County Board of Supervisors and the Richmond City Council. The contractor will prepare a plan for evaluation and will submit this plan to the Project Manager from Contra Costa Health Services for review. GCRW Follow--up Safety Evaluation- Final Report A- January 20(4 _...<.. ,. ............. n Appendix B MRS Comment Letters on GeneralChemical Action Plan and Quarterly Progress Reports CCRW Fallow-up Safety Evaluadon- Final Report January 2004 a� po 0 e o o f- 3 o ty u> tr7 r. A i � CNi 0 00 N * a0 't � :q w' xi LO o csi ari i� -M as 0 �M"s Ce � "7 c7i r� 4a ° oo 000 Nu7 ttx r. ca 040 r- u7 r,. lotGCi w o ai �- tti da rn C) M c tai u woi w 69a 44 c � C! v11*1� CC'S o r— Co o N ZO N 641`h n 14 CO m �' r 1.OD A v w 8 g mv)C to al d N Y-� vtCVOo °rr. o o C, inam u' E OD to o ai a�ri ori , of tyi a) w. ear;xo �- rL U) C-5 ' tiCPo � 0 rrs N a . 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C"y CO) C L k 7 co OD qyl °Cy r C O r 69 r E C C14 M► LQ E ia r LLf � Ca OCLC�33s CO r 1 m_ +." rte- e>^ ti7 v- Q P M M CO) � N CO ! T- r r M CV 89 In C4 C C7 C4 400. EH tv v a U. c LL t7 4► a .y Z c C to ti 00 Q e o► t1 c°3 a s -� z fi r o vi � ¢¢+ ¢ U. „ z m rt3 iJ m uy G7 <t AC w N C*4 C t t°- cL w 56 /i 4'k�.3➢Fi Sia�i aF.,^2K}y Real Estate Economics Regional Economics Public Finance Land Use Policy APPENDIX C HISTORICAL DATA v CO a Q C4 c r r cv to to > C3 a eo rn Foy 00 0 to .- v e4 r cn w m Csi ui coC tn c� uo A 2 = `+dm cn cv py o 03 wtoCOW C� cc cv r i rr o 04 cl;Rrvrii ti CD too 04 Ncn L C21 W �W m >� - Q acs ri z cli o 4r) um w t� to sn N ra s N p v r- a Ica w W " cClt 0. > � rar ° L o W a u`�ic3 " a Ogo acttizp ut ? " mem ea ` c ru o e Iva C = yp ly m }�ar tai cl afp tt' rrJ ` 4? `t w C6 tip S .J amu. tJ o h ►- {�j o0 i p i.. tlWl 0 n c w v 9 U w 57 k z zzz 4Ai ZI n 16 as a ops g n y r ti co m m y� 1. 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