haz mat iso attachment E 2005 - Contra Costa County

ISO Annual Performance Review and Evaluation Report — November 15, 2005 1 of 48

ATTACHMENT E

Annual Performance Review and Evaluation of Individual Facilities

INDUSTRIAL SAFETY

ORDINANCE



ATTACHMENT E

156

Annual Performance Review and Evaluation SubmittalJune 15, 2005

*Attach additional pages as necessary

1) Name and address of Stationary Source: Air Products

Tract 1, Tesoro Refi nery (Golden Eagle - Avon), Solano Way, Martinez, CA 94553

2) Contact name and telephone number (should CCHS have questions): Michael Cabral, (925) 372-9302

3) Summarize the status of the Stationary Source’s Safety Plan and Program (450-8.030(B)(2)(i)): The Stationary

Source’s Safety Plan is complete per CCHS requirements and submitted to CCHS for review. The Program has

been implemented, as required.

4) Summarize Safety Plan updates (i.e., brief explanation of update and corresponding date) (450-8.030(B)(2)(ii)):

Date: 10 June 2005

Summary: Annual Performance Review and Evaluation Submittal

Update: Complete update and resubmission of Safety Plan and Human Factors Program to include Annual

Accident History Update.

5) List of locations where Safety Plans are/will be available for review, including contact telephone numbers if the

source will provide individuals with copies of the document (450-8.030(B)(2)(ii)): CCHS Offi ce, 4333 Pacheco

Boulevard, Martinez; Bay Point Library (library closest to the stationary source); Air Products - See contact in

#2, above.

6) Provide any additions to the annual accident history reports (i.e. updates) submitted pursuant to Section 450-

8.016(E)(2) of County Ordinance 98-48 (450-8.030(B)(2)(iii)) (i.e., provide information identifi ed in Section

450-8.016(E)(1) for all major chemical accidents or releases occurring between the last accident history report

submittal (January 15) and the annual performance review and evaluation submittal (June 30)): None

7) Summary of each Root Cause Analysis (Section 450-8.016(C)) including the status of the analysis and the

status of implementation of recommendations formulated during the analysis (450-8.030(B)(2)(iv)): No events

triggered this requirement

8) Summary of the status of implementation of recommendations formulated during audits, inspections, Root

Cause Analyses, or Incident Investigations conducted by the Department (450-8.030(B)(2)(v)): APCI submitted

proposed remedies to the audit fi ndings to Contra Costa County before 16 August 2004. All outstanding actions

of this audit will be completed by 16 August 2005.

9) Summary of inherently safer systems implemented by the source including but not limited to inventory

reduction (i.e., intensifi cation) and substitution (450-8.030(B)(2)(vi)):


(1) Plant uses aqueous ammonia rather than anhydrous ammonia in its emission control system. This helps reduce

the off-site consequence of an ammonia release.

(2) Plant is designed without a liquid hydrogen backup system. This reduces the inventory of hazardous chemicals

on-site.

10) Summarize the enforcement actions (including Notice of Defi ciencies, Audit Reports, and any actions turned

over to the Contra Costa County District Attorney’s Offi ce) taken with the Stationary Source pursuant to

Section 450-8.028 of County Ordinance 98-48 (450-8.030(B)(2)(vii)): No enforcement actions were taken during

this time period.

11) Summarize total penalties assessed as a result of enforcement of this Chapter (450-8.030(3)): No penalities have

been assessed against any facility.

12) Summarize the total fees, service charges, and other assessments collected specifi cally for the support of the

ISO (450-8.030(B)(4)): CalARP Program fees for these eight facilities are - $314,013, the Risk Management

Chapter of the Industrial Safety Ordinance fees are - $319,669.

13) Summarize total personnel and personnel years utilized by the jurisdiction to directly implement or administer

this Chapter (450-8.030(B)(5)): 4000 hours were used to audit/inspect and issue reports on the Risk

Management Chapter of the Industrial Safety Ordinance.

14) Copies of any comments received by the source (that may not have been received by the Department) regarding

the effectiveness of the local program that raise public safety issues(450-8.030(B)(6)): None

15) Summarize how this Chapter improves industrial safety at your stationary source (450-8.030(B)(7)): Air

Products is committed to the safe operation of our facilities and has implemented most of the requirements

outlined in the ISO, as well as the CalARP regulation. The Human Factors program is implemented, and should

have a positive impact on the safety of the facility. This Chapter has helped reinforce the need to maintain and

follow a structured safety program to help ensure the safety of our employees and the communities in which we

operate.

16) List examples of changes made at your stationary source due to implementation of the Industrial Safety

Ordinance (e.g., recommendations from PHA’s, Compliance Audits, and Incident Investigations in units

not subject to CalARP regulations; recommendations from RCA’s) that signifi cantly decrease the severity or

likelihood of accidental releases Air Products has developed and implemented a Human Factors Program as

required by the Industrial Safety Ordinance.

17) Summarize the emergency response activities conducted at the source (e.g., CWS or CAN activation) in

response to major chemical accidents or releases: There were no emergency response activities to this site.




1) Name and address of Stationary Source: Air Products

Shell Martinez Refi nery, 110 Waterfront Road, Martinez, CA 94553

2) Contact name and telephone number (should CCHS have questions): Michael Cabral, (925) 372-9302

3) Summarize the status of the Stationary Source’s Safety Plan and Program (450-8.030(B)(2)(i)): The Stationary

Source’s Safety Plan is complete per CCHS requirements and submitted to CCHS for review. The Program has

been implemented, as required.

4) Summarize Safety Plan updates (i.e., brief explanation of update and corresponding date) (450-8.030(B)(2)(ii)):

Date: 10 June 2005

Summary: Annual Performance Review and Evaluation Submittal

Update: Complete update and resubmission of Safety Plan and Human Factors Program to include Annual

Accident History Update.

5) List of locations where Safety Plans are/will be available for review, including contact telephone numbers if the


Boulevard, Martinez; Martinez Library (library closest to the stationary source); Air Products - See contact in

#2, above.

6) Provide any additions to the annual accident history reports (i.e. updates) submitted pursuant to Section 450-



submittal (January 15) and the annual performance review and evaluation submittal (June 30)): None

7) Summary of each Root Cause Analysis (Section 450-8.016(C)) including the status of the analysis and the

status of implementation of recommendations formulated during the analysis (450-8.030(B)(2)(iv)): No events

triggered this requirement this year

8) Summary of the status of implementation of recommendations formulated during audits, inspections, Root

Cause Analyses, or Incident Investigations conducted by the Department (450-8.030(B)(2)(v)): APCI submitted

proposed remedies to the audit fi ndings to Contra Costa County before 16 August 2004. All outstanding actions

of this audit will be completed by 16 August 2005.

9) Summary of inherently safer systems implemented by the source including but not limited to inventory


1) Plant uses aqueous ammonia rather than anhydrous ammonia in its emission control system. This helps

reduce the off-site consequence of an ammonia release.


2) Plant is designed without a liquid hydrogen backup system. This reduces the inventory of hazardous

chemicals on-site.

3) Plant switched from 99% monoethanolamine to 85% monoethanolamine in order to eliminate the need for

insulation around the water treatment tanks. This reduces the potential for a fi re.

10) Summarize the enforcement actions (including Notice of Defi ciencies, Audit Reports, and any actions turned



this time period.

11) Summarize total penalties assessed as a result of enforcement of this Chapter (450-8.030(3)): No penalities

have been assessed against any facility.

12) Summarize the total fees, service charges, and other assessments collected specifi cally for the support of the



13) Summarize total personnel and personnel years utilized by the jurisdiction to directly implement or administer



14) Copies of any comments received by the source (that may not have been received by the Department) regarding

the effectiveness of the local program that raise public safety issues(450-8.030(B)(6)): None

15) Summarize how this Chapter improves industrial safety at your stationary source (450-8.030(B)(7)): Air

Products is committed to the safe operation of our facilities and has implemented most of the requirements

outlined in the ISO, as well as the CalARP regulation. The Human Factors program is implemented, and should

have a positive impact on the safety of the facility. This Chapter has helped reinforce the need to maintain and

follow a structured safety program to help ensure the safety of our employees and the communities in which we

operate.

16) List examples of changes made at your stationary source due to implementation of the Industrial Safety



likelihood of accidental releases Air Products has developed and implemented a Human Factors Program as

required by the Industrial Safety Ordinance. The site clarifi ed issues associated with the Management of Change

for Organizational Changes at the site.

17) Summarize the emergency response activities conducted at the source (e.g., CWS or CAN activation) in

response to major chemical accidents or releases: There were no emergency response activities to this site.




1. Name and address of Stationary Source: ConocoPhillips

Rodeo Refi nery, 1380 San Pablo Avenue, Rodeo, CA 94572

2. Contact name and telephone number (should CCHS have questions): John Driscoll at 510-245-4466 or Chris

Bowman at 510-245-4669

3. Summarize the status of the Stationary Source’s Safety Plan and Program (450-8.030(B)(2)(i)): The original

Safety plan and updates have been submitted (see item #4). All safety programs required by the ISO have been

implemented. CCHS has completed a review of the RMP. Public meetings for our plans were held on June 22,

2004 in Rodeo and July 8, 2004 in Crockett.

4. Summarize Safety Plan updates (i.e., brief explanation of update and corresponding date) (450-8.030(B)(2)(ii)):

The original Safety Plan for this facility was fi led with Contra Costa Health Services on January 14, 2000. A

revised plan was fi led on April 7, 2000 with the updated recommendations requested by CCHS. A Human

Factors Amendment was submitted on January 15, 2001. In conjunction with CCHSs required 2nd public

meeting on our plan and audit fi ndings, we submitted a complete revision of the plan to refl ect the change in

ownership of our facility and to update where needed. We took this opportunity to include Human Factors

within the plan instead of having it as an amendment. On August 9, 2002 the plan was resubmitted. The Plan is

scheduled for a full update this year.

5. List of locations where Safety Plans are/will be available for review, including contact telephone numbers if the


Blvd., Martinez, CA. and the Crocket & Rodeo libraries.

6. Provide any additions to the annual accident history reports (i.e. updates) submitted pursuant to Section 450-



submittal (January 15) and the annual performance review and evaluation submittal (June 30)): October 31,

2004 “Odor Incident”

Process gas was inadvertenly released from a piping system in Plant 19 (Refi nery Flare and Blowdown system).

The gas contained odorous compounds that migrated off site. This resulted in a Community Warning System

Level 3 response, which asks the community to shelter in place. The accidential opening occurred during

preparation for maintenance work when the wrong pipe fl ange was opened to install a pipe blind.

There were no injuries reported. The 72 hour and 30 day reports were submitted. A investigation team completed a

root cause analysis and corrective actions have been implelmented.

7. Summary of each Root Cause Analysis (Section 450-8.016(C)) including the status of the analysis and the status

of implementation of recommendations formulated during the analysis (450-8.030(B)(2)(iv)): October 31, 2004

“Odor Incident”


A root cause analysis was performed using the Reason RC Software. Two root causes were identifi ed:

• COP policies did not require the fl ange, where a blind is to be installed, to be tagged specifi cally as a blind

installation location. The current Policy allowed the blind locations to be shown to the mechanics as part of the

jobwalk.

• The mechanics did not follow the Company Lock Tag Try Policy for executing maintenance for all the work.

The mechanics followed the Lock Tag Try Policy for the fi rst four fl anges they worked on. However, they did

not follow the Policy when they inadverently worked on the incorrect system and opened the fl ange on a system

that was in service.The mechanics should have double checked the isolations points before attempting to open

the last fl ange.

Recommendations/Preventive Measures

• Work Stand Down meetings were held to review the preliminary fi ndings of the incident and to reinforce that

the Lock Tay Try Policy principals must be followed. COMPLETED 10/31/04

• Counseled the Maintenance Supervosors and mechanics involved to always follow the Lock Tag Try Policy and

to double check the insolation to ensure that they are working on the correct system. COMPLETED 11/1/04

• Modify practices and procedures to require blind installation locations be marked with a distinctive tag to reduce

the chances of worker’s opening the incorrect system. Practices changed to require that each fl ange be tagged

prior to blinding COMPLETED 10/31/04. Formal change of policy for fl ange tagging before blinding -

COMPLETED 2/01/05

8. Summary of the status of implementation of recommendations formulated during audits, inspections, Root

Cause Analyses, or Incident Investigations conducted by the Department (450-8.030(B)(2)(v)): See Question 7

above for implementation of the root cause analysis for the October 31, 2004 incident. Two action items from

the ISO/ CalARP remain open and have established target completion dates.

9. Summary of inherently safer systems implemented by the source including but not limited to inventory

reduction (i.e., intensifi cation) and substitution (450-8.030(B)(2)(vi)): A number of inherently safer systems have

been implemented since the last submittal. The attached list shows those that meet the criteria for inherent or

passive.

10. Summarize the enforcement actions (including Notice of Defi ciencies, Audit Reports, and any actions turned


Section 450-8.028 of County Ordinance 98-48 (450-8.030(B)(2)(vii)): There have been no enforcement actions

against the facility.

11. Summarize total penalties assessed as a result of enforcement of this Chapter (450-8.030(3)): No penalities have


12. Summarize the total fees, service charges, and other assessments collected specifi cally for the support of the




13. Summarize total personnel and personnel years utilized by the jurisdiction to directly implement or administer



14. Copies of any comments received by the source (that may not have been received by the Department) regarding

the effectiveness of the local program that raise public safety issues(450-8.030(B)(6)): Comments received at the

public meetings were addressed by COP and CCHS. No other written comments have been received.

15. Summarize how this Chapter improves industrial safety at your stationary source (450-8.030(B)(7)): The ISO

improves safety by expanding safety programs to cover all operating units, emphasising human factors, requiring

Root Cause analysis for major chemical accidents and releases, and requiring inherently safer systems as part of

implementing PHA recommendations.

16. List examples of changes made at your stationary source due to implementation of the Industrial Safety



likelihood of accidental releases The project to revamp/reformat the operating procedures continues

on schedule. Alarm system management continues to be addressed. Improvements have been made to the

management of change system. The Lock Tag Try Policy and associated practices have been improved.

17. Summarize the emergency response activities conducted at the source (e.g., CWS or CAN activation) in response

to major chemical accidents or releases: October 31, 2004 “ Odor Incident “ A CWS Level 2 condition was

initiated when odors were apparent in the Plant 19 area ( Refi nery Flare and Blowdown System) as a result of

gas inadvertently released from a piping system. When the conditions was identifi ed as an uncontrolled release

of gas from an active fl are line fl ange that could not be quickly mitigated a CWS “Pushbutton” Level 3 was

activated resulting in a Shelter-In -Place. The Facility Responders developed a plan to mitigate the release.

Facility Hazmat Specialists, under the cover of hose lines, fi re-fi ghting foam and in full fi re-fi ghting turnouts

with SCBAs, were able to replace and take-up fl ange bolts, pulling the fl ange pair together and stopping the

release. Monitoring took place both on and off-site by facility safety specialists during the incident. Agencies

were notifi ed and those responding included CCHS, Contra Costa Sheriff, BAAQMD and Rodeo/Hercules Fire

Department.




1. Name and address of Stationary Source: General Chemical Bay Point Works, 501 Nichols Road, Bay Point,

California_94565

2. Contact name and telephone number (should CCHS have questions): Jeff Luengo; (925) 458-7365

3. Summarize the status of the Stationary Source’s Safety Plan and Program (450-8.030(B)(2)(i)): The Safety Plan

was originally completed in November 2000 and was updated in December 2003.


The Safety Plan was most recently updated in December 2003 to refl ect a change in ownership.



Boulevard, Martinez; Bay Point Library (library closest to the stationary source); General Chemical Bay Point

Works - See contact in #2, above.




submittal (January 15) and the annual performance review and evaluation submittal (June 30)): There have been

no major chemical accidents or releases during this time period.


of implementation of recommendations formulated during the analysis (450-8.030(B)(2)(iv)): There were no

RCAs conducted during this time period.


Cause Analyses, or Incident Investigations conducted by the Department (450-8.030(B)(2)(v)): An audit

was conducted by the Department in June 2003 and resulted in 114 fi ndings. To date, 31 fi ndings have been

completed and the remainder of the fi ndings will be closed by August 26, 2005.


reduction (i.e., intensifi cation) and substitution (450-8.030(B)(2)(vi)): Several PHAs have been completed during

this evaluation period. Inherently safer systems were considered during this process and were either already

addressed or will be addressed within one year of conducting the PHA, as required by the ISO.




this time period.











the effectiveness of the local program that raise public safety issues(450-8.030(B)(6)): The facility has not

received any comments regarding the effectiveness of the local program that raises public safety issues.

15. Summarize how this Chapter improves industrial safety at your stationary source (450-8.030(B)(7)): This chapter

helps minimize potential risk and exposure to employees, the community and the environment.




likelihood of accidental releases Several PHAs were conducted for processes that are not subject to CalARP

regulations. Many recommendations from these PHAs have been completed or are in the process of being

addressed.


to major chemical accidents or releases: There have been no emergency response activities associated with this

facility during this time period.




1. Name and address of Stationary Source: Shell Oil Products U.S. Martinez Refi nery

3485 Pacheco Blvd., Martinez, CA 94553

2. Contact name and telephone number (should CCHS have questions): Mike Beck; 925-313-3199

3. Summarize the status of the Stationary Source’s Safety Plan and Program (450-8.030(B)(2)(i)): SMR’s Safety Plan

is complete, and the Safety Program has been implemented at SMR. Documentation of the Human Factors

Program is described in this document. SMR’s Human Factors program has been developed and implemented.


SMR’s initial Safety Plan was submitted in January 2000. An update to the Accident History section of the

Safety Plan was submitted on April 12th, 2000 and againin June 2002. A revised Safety Plan describing SMR’s

Human Factors Program was submitted in January 2001. An additional revision was submitted in June 2003.



Boulevard, Martinez; Martinez Public Library (library closest to the stationary source).




submittal and the annual performance review and evaluation submittal (June 30)): The Accident History section

of the Safety Plan describes the MCARs that have occurred at SMR since June 1, 1992. In 2003, the Safety Plan

was updated to include all MCARs that have occurred to that date. SMR has not had any additional MCARs

since the 2003 submittal of the Safety Plan.


of implementation of recommendations formulated during the analysis (450-8.030(B)(2)(iv)): The Accident

History section of the SMR’s Safety Plan includes Root Cause Analysis (RCA) fi ndings where available. The

status for all recommendations resulting from RCAs perfomed on MCARs are included.

8. Summary of the status of implementation of recommendations formulated during audits, inspections,

Root Cause Analyses, or Incident Investigations conducted by the Department (450-8.030(B)(2)(v)): All

recommendations are complete following the CCHS on-site audit of SMR during the fall of 2000. All

recommendations are complete following CCHS’s unannounced inspection that occurred in January 2002.

All recommendations are complete following CCHS’s audit of SMR’s Human Factors and Inherently Safer

Systems. There has been no RCA or Incident Investigations conducted by the Department at SMR. 13 of

43 recommendations remain open from CCHS’s November 2003 RMP/PSM/ISO Audit. The county has

conducted no RCAs or Incident Investigations.



reduction (i.e., intensifi cation) and substitution (450-8.030(B)(2)(vi)): The major implemented ISS items can be

found in Attachment I.



Section 450-8.028 of County Ordinance 98-48 (450-8.030(B)(2)(vii)): None










the effectiveness of the local program that raise public safety issues(450-8.030(B)(6)): None received.

15. Summarize how this Chapter improves industrial safety at your stationary source (450-8.030(B)(7)): Industrial

safety is improved by requiring Process Safety Management application to all processes. In addition, the

potential impact on industrial safety has been improved by the application of MOOC to several organizational

changes in the past year. ISS reviews have also identifi ed opportunities to improve industrial safety. Procedure

PHAs are another area that has contributed to the improvement of industrial safety at our facility.

16. List examples of changes made at your stationary source due to implementation of the Indusrial Safety



likelihood of accidental releases As noted above, the Industrial Safety Ordinance has assured application of

Process Safety Management to all processes at SMR. The application of Human Factors review and Latent

Conditions Checklist has been applied to the development of operating procedures as well as incident

investigation and Process Hazard Analyses. Review for Inherently Safer Systems has also been applied at SMR.


to major chemical accidents or releases: SMR has not experienced an MCAR in this reporting period, and thus

have not had any CWS Level 3 activations of the siren system, nor the CAN system. SMR continues to use the

CWS system for communication of all events classifi ed with a Level under the warning system, and has reported

several Level 0 and Level 1 events this reporting period.


Attachment I - Major Implemented ISS Items

Name ISS Type Basis Description

Flexsorb Unit Inherent New Process Substitution: The Stretford Unit, which

used a solution containing vanadium,

was replaced with the Flexsorb unit

that uses an inherently safer amine

solution.

Vents To DCU Passive Existing Process Simplifi cation: During project design,

ISS review drove towards an inher-

ently safer design that required only piping

versus some of the other options that includ

ed higher operating pressures and additional

mechanical equipment. This project was

Name ISS Type Basis Description


implemented in 2005.



1. Name and address of Stationary Source:

Tesoro Golden Eagle Refi nery

150 Solano Way

Martinez, CA 94553

2. Contact name and telephone number (should CCHS have questions):

Rich Leland at (925) 370-3264 or Sabiha Gokcen at (925) 370-3620.

3. Summarize the status of the Stationary Source’s Safety Plan and Program (450-8.030(B)(2)(i)):

The original Safety Plan and two Safety Plan updates have been submitted (see below). Contra Costa Health

Services has completed four audits of the safety programs. The fi rst audit was in September, 2000 on the safety

programs. The second audit was in December, 2001 and focused on Inherently Safer Systems and Human Factors.

An unannounced inspection occurred in March, 2003. The fi nal audit was in August, 2003. All safety program

elements required by the ISO have been developed and are being implemented.


The original Safety Plan for this facility was fi led with Contra Costa Health Services on January 14, 2000. An

amended plan, updated to refl ect CCHS recommendations and ownership change, was fi led on November 30, 2000.

A Human Factors Amendment was submitted on January 15, 2001. A Power Disruption Plan was submitted, per

Board of Supervisor request, on June 1, 2001. An amended Safety Plan, updated to refl ect ownership change was

submitted on June 17, 2002.

The Safety Plan for this facility will be updated whenever changes at the facility warrant an update or every three

years from June 17, 2002. An updated Safety Plan will be submitted this year along with an updated RMP. In

addition, the accident history along with other information is updated every year on June 30. This submittal serves

as the 2005 update.



Boulevard, Martinez; local library closest to the stationary source.

Provide any additions to the annual accident history reports (i.e. updates) submitted pursuant to Section 450-

8.016(E)(2) of County Ordinance 98-48 (450-8.030(B)(2)(iii)) (i.e., provide information identifi ed in Section 450-

8.016(E)(1) for all major chemical accidents or releases occurring between the last accident history report submittal

(January 15) and the annual performance review and evaluation submittal (June 30)):

The accident history was updated in the 2004 update. Since that update, there have been fi ve incidents that meet the

Major Chemical Accident or Release criteria in the last year.


July 4, 2004

On Sunday, July 4, 2004, at approximately 1:42 PM, the #5 Boiler developed an internal water leak suffi cient to

compromise good boiler water level control. Per refi nery safety procedures, Coker fl ue gas was then diverted

directly to the stack, and #5 Boiler was shutdown. To reduce stack emissions water sprays were activated, and

Coker rate was brought to a minimum. Crude rate was also cutback. IH performed monitoring. OS&E monitored

for odors in the community on July 4th and 5th and did not detect any offsite odors. The Ground Level Monitors

(GLM) did not detect any Hydrogen Sulfi de nor Sulfur Dioxide during the event. The following agencies were

immediately notifi ed: Contra Costa Health Services (CCHS) via the CWS, the Bay Area Air Quality Management

District (BAAQMD), and the Contra Costa County Offi ce of Emergency Services. Agencies responding with

personnel to the site include the Contra Costa County Sheriff and the BAAQMD. Refi nery personnel immediately

responded to the situation by shutting down the boiler and activating water sprays to minimize the amount of coke

dust leaving the stack. Actions were also taken to transfer the material leaving the stack to #6 Boiler. In addition, the

Coker rate was reduced and crude rate was cutback. Materials released include Petroleum Coke fi nes and fl ue gas. It

is estimated that approximately 1200 pounds of coke was released during the incident. An estimated 1600 pounds

of Hydrogen Sulfi de was released during the incident as well. The weather was overcast with the wind coming out

of the Northwest. The average wind speed was approximately 7-13 MPH. The temperature was 80 degrees. There

were no injuries reported on or offsite.

Root Cause # 1: Sodium Sulfate deposits contributed to external corrosion of the #5 Boiler furnace tubes.

Root Cause # 2: The Sodium Sulfate originates from treated spent caustic that is eventually used as makeup

water for some units.

Root Cause #3: The combustion of the CO Gas/Coke fi nes from the Coker in the #5 Boiler furnace causes

Vanadium to deposit on the exterior furnace tubes, which contributes to external corrosion

of the tubes.

Root Cause #4: The line to transfer fl ue gas between #5 and #6 Boiler is not kept hot.

Root Cause #5: There is external corrosion on the furnace tubes.

Corrective Actions for July 4, 2004 Anticipated Date of Completion1 Zeolite water will be used to quench the elutriator

at the Coker unit (addresses Root Cause #1 and #2). Complete

2 Evaluate alternative methods for spent caustic neutralization

(addresses Root Cause #1 and #2). (Spent caustic is now

being sent offsite.) Complete

3 Optimize dosage of and continue to add anti-vanadium

deposit chemical Baker KI-85 to the #5 Boiler furnace

(addresses Root Cause #3). Complete

4 Conduct an engineering review to determine the feasibility of

keeping the line between #5 and #6 Boiler hot (addresses Root Cause #4). 7/1/06

5 Install new tubes in furnace. (addresses Root Cause #5). 12/31/04

September 16, 2004


On Wednesday September 15, 2004, at approximately 23:59:48, there was an explosion and fi re at Tank 745. (Note:

based on analysis of process data, a new estimate of the time of the explosion and fi re has been determined. The

original incident time was reported as Thursday, September 16, 2004, at about 12:03 A.M.) The tank involved in

the incident contained spent sulfuric acid. Emergency response personnel immediately responded to the area. The

Sulfuric Acid Recycling Unit was shut down by Operations personnel. A CWS level 1 notifi cation was made at 12:11

A.M. The CWS level was raised to a Level 2 at 12:22 A.M. The specifi c circumstances of this fi re precluded the use

of water or fi refi ghting foam to extinguish it. A plan was developed and implemented to apply carbon dioxide as

the extinguishing agent. Odor Science and Engineering (OS&E) was dispatched to monitor for odors off site. They

detected no odors offsite during their patrol of North Concord, Clyde and Bay Point. Refi nery personnel were also

dispatched to monitor the community for odors and conduct industrial hygiene (IH) sampling. The IH sampling

detected no chemicals of concern offsite. There was no activity detected by the Ground Level Monitors (GLMs).

There were no injuries associated with this incident. The all clear was declared at 8:25 on September 16th. The

following agencies were immediately notifi ed: Contra Costa Health Services (CCHS) via the CWS, the Bay Area Air

Quality Management District (BAAQMD), and the Contra Costa County Offi ce of Emergency Services. Agencies

responding with personnel to the site included CCHS, Contra Costa County Sheriff, Contra Costa Fire Protection

District, and the BAAQMD. Tesoro emergency response personnel were notifi ed and responded immediately.

Contra Costa County Fire Protection District also responded to the site. The Sulfuric Acid recycling unit was

shutdown by operations personnel. The specifi c circumstances of this fi re precluded the use of fi refi ghting foam

to extinguish it. A plan was developed and implemented to apply Carbon Dioxide as the extinguishing agent. The

plan was formulated after discussions with Contra Costa Fire and Williams Fire and Hazard Control. The burning

material was gasoline range hydrocarbon. Smoke from the fi re is a material released by this type of incident. Sulfur

Dioxide (SO2) is also a potential emission for this type of incident. No SO2 was detected by the GLM monitors

or by IH monitoring performed offsite. An estimated 115,000 pounds of hydrocarbon material was consumed by

the fi re. The weather was clear on 9/16/04, with wind direction varying from 180 to 280 degrees. The wind speed

varied from 3 to 8 MPH. The temperature at the time of the incident was about 65 to 70 degrees F. No injuries

were reported on or offsite.

Root causes #1-6 relate primarily to the duration of the event and not to its occurrence, while root causes #7-12 are

more directly related to the probable cause of the incident.

Root Cause #1: Refi nery emergency response studies did not identify the need for specialized fi refi ghting

equipment at spent sulfuric acid Tanks 745 and 746.

Root Cause #2: Acid Plant PHA did not identify fi re as a consequence for low pressure in the spent acid Tanks

745 and 746.

Root Cause #3: The spent acid Tank 714 at the LHP unit does not have a permanent, engineered skim system for

alkylate removal.

Root Cause #4: There is no real time acid/alkylate interface indication on Tank 714 at the LHP unit.

Root Cause #5: The level bridle and associated instrumentation on Tank 745 for detecting the acid/alkylate

interface was out of service as it was diffi cult to keep maintained.

Root Cause #6: The design for the alternate alkylate draw from Tank 745 did not meet operations needs for

removing alkylate from the spent sulfuric acid tank during a single tank operation.


Root Cause #7: There are no means to verify online operability and historical performance of the pressure

regulators on spent acid Tanks 745 and 746 to confi rm control within desired limits.

Root Cause #8: The capacity of the gas blanketing system for spent acid Tanks 745 and 746 was inadequate to

meet the maximum tank draw down rate during use of railcar transfer pump (may have allowed

for air entry into tank).

Root Cause #9: The pressure regulators may have been set to maintain a negative pressure (may have allowed for

routine air leakage into tank).

Root Cause #10: The fl ame arrestor on the vent lines from spent acid Tanks 745 and 746 may not have been

specifi ed for the range of gas compositions possible in these two tanks (may have allowed passage

of fl ame through fl ame arrestor due to presence of hydrogen).

Root Cause #11: The fl ame arrestor system for the vent lines from spent acid Tanks 745 and 746 has no means to

detect the presence of a sustained burn (may allow passage of fl ame through fl ame arrestor).

Root Cause #12: The thermal check valve of the fl ame arrestor system from the vent lines of spent acid Tanks

745 and 746 did not seat properly, which may have allowed a sustained burn at the fl ame arrestor.

The valve may have malfunctioned during the incident, which prevented seating and there are no

means to verify the integrity of this valve prior to the incident due to lack of maintenance and

inspection records.

Additional Finding #1: The implication of the lead pill melting in the thermal check valve in the past (indicating

that there was a fl ammable mixture in the vent from spent acid Tanks 745 and 746 to the

stack) was not recognized/understood by plant personnel.

Additional Finding #2: The MSDS for spent sulfuric acid did not contain information about the fl ammable

properties of the alkylate entrained in the spent sulfuric acid.

Additional Finding #3: Operating procedures do not exist for some tasks involving spent acid at the chemical

plant.

Additional Finding #4: There was incomplete design information available for spent sulfuric acid tanks 745 and

746.

Additional Finding #5: Nitrogen, an inert gas, is the preferred blanketing gas for current design of spent sulfuric

acid tanks.

Corrective Actions for September 16, 2004 Anticipated Date of Completion

1 Evaluate spent acid and spent caustic storage

(chemicals that react negatively with water and

fi refi ghting foam) to determine if specialized

fi refi ghting equipment is required. (addresses

root cause #1) 3/31/05

2 Review PHAs that include hydrocarbon gas

blanketed tanks to determine if scenarios


involving fl ammable mixtures due to oxygen

ingress are adequately addressed in

the PHA. (addresses root cause #2) 4/1/05

3 Review design of spent acid tank 714 at

the LHP unit for conformance with best

practice and design with respect to

instrumentation, control, skimming operations,

safety systems, etc. (addresses root causes #3 and #4) 1/1/06

4 Review design of spent acid tanks 745 and

746 at the Acid Plant for conformance with

best practice and design with respect to

instrumentation, control, skimming operations,

safety systems, etc. (addresses root causes #5, #6 and #9) 1/1/06

5 1) Review all gas blanketing regulators for

chemical storage tanks in fl ammable service to

ensure that all tank blanketing regulators are

assigned equipment ID numbers, have appropriate

documentation and that their maintenance is tracked.

(addresses root cause #7)

2) Ensure the standard tank turnaround work-list

for gas blanketed storage tanks in fl ammable service

requires a verifi cation that all tank blanketing regulators

have assigned equipment ID numbers, have appropriate

documentation and that their maintenance is tracked.

(addresses root cause #7) 1/1/06

6 Consider installation of remote and local pressure

indication with alarms on spent acid Tanks 745 and 746.


7 Confi rm that the capacity of the new natural gas

blanketing system for Tank 746 is suffi cient to meet

the maximum expected tank draw down rate

(addresses root cause #8) Complete

Corrective Actions for September 16, 2004(con’t) Anticipated Date of Completion

8 Consider specifying positive tank pressure control

set point (at all times) for Tanks 745 and 746 to

prevent air from entering the tank. (addresses root

cause #9) 12/1/04


9 Revise operating procedures for Tanks 745 and 746

to include gas blanket system check for positive

pressure control. (addresses root cause #9) 1/31/05

10 Review design of spent acid vent line safety systems

for Tanks 745 and 746. (addresses root causes #10,

#11 and #12) 1/1/06

11 Develop inspection and maintenance procedures

that include the frequency of task performance for

the fl ame arrestor system at Tanks 745 and 746.

Develop a system for maintaining documentation

of the inspection. Train all personnel on new

procedures and document retention. (addresses root

cause #12) 9/1/05

12 Train Chemical Plant maintenance personnel on

consequences of fl ammable mixtures in vent gas

from Tanks 745 and 746 and how to recognize

its occurrence and communicate its occurrence to

operations. (addresses additional fi nding #1) 9/1/05

13 Revise MSDS for spent sulfuric acid to contain

information regarding fl ammability. (addresses

additional fi nding #2) Complete

14 Develop operating procedures for operation of a

single spent acid tank and for any other spent acid

tank related tasks at the Chemical Plant. (addresses

additional fi nding #3) 1/31/05

15 1) Ensure tank 746 design information is complete

after rebuild. 4/1/05

2) Develop tank 745 design information if tank is

replaced. (addresses additional fi nding #4) 1/1/06

16 Review blanketing gas alternatives including the use

of nitrogen (an inert gas) for spent acid Tanks 745

and 746. (addresses additional fi nding #5) 1/1/06

October 14, 2004

On Thursday, October 14, 2004, at about 2:45 A.M. there was a fi re at the naphtha transfer pump (P-0234).

Emergency response personnel immediately responded to the area. A CWS level 1 notifi cation was made at 2:54

A.M. The CWS level was raised to a Level 2 at 3:39 A.M due to the visibility of smoke offsite. The Petrochemical

Mutual Aid Organization (PMAO) was also activated and several PMAO member companies responded. Water

and fi refi ghting foam were used to fi ght the fi re. Fire response personnel were able to isolate the tank from the

pump and the fi re was extinguished. Odor Science and Engineering (OS&E) was dispatched to monitor for odors

off site. They detected no odors offsite during their odor patrols. Refi nery personnel were also dispatched to

monitor the community for odors and conduct industrial hygiene sampling. There was no activity detected by the

Ground Level Monitors (GLMs). The following agencies were immediately notifi ed: Contra Costa Health Services

(CCHS) via the CWS, the Bay Area Air Quality Management District (BAAQMD), the Contra Costa County

Fire Protection District (CCCFPD), and the Contra Costa County Offi ce of Emergency Services (CCC OES).

Agencies responding with personnel to the site included CCHS, Contra Costa County Sheriff, and CCCFPD. Tesoro


emergency response personnel were notifi ed and responded immediately to the fi re. CCCFPD also responded to

the facility. The Petrochemical Mutual Aid Organization (PMAO) was also activated and several PMAO member

companies responded. Water and fi refi ghting foam were used to fi ght the fi re. Fire response personnel were able to

isolate the tank from the pump and the fi re was extinguished. The burning material was gasoline range hydrocarbon

and wooden walkways. Smoke from the fi re is a material released by this type of incident. The weather was clear

on 10/14/04, with wind direction varying from 150 to 200 degrees. The wind speed varied from 3 to 8 MPH. The

temperature at the time of the incident was about 58 degrees F. No injuries were reported on or offsite.

Root Cause #1: The pump had a gear coupling with a spacer design that allowed coupling hub travel.

Root Cause #2: Maintenance programs did not ensure gear couplings received lubrication per required frequency.

Root Cause #3: Although the naphtha pump sat “idle” for several years, no maintenance was conducted on the

pump to check for suitability for operation.

Root Cause #4: Small bore threaded piping sheared causing two naphtha leaks through ¾” holes.

Corrective Actions for October 14, 2004 Anticipated Date of Completion

1 Conduct refi nery audit to identify any other pump

with gear couplings. (addresses root cause #1) Complete

2 Initiate and complete coupling upgrade program to With spacers: 9/1/05

eliminate gear couplings. Pumps with spacer gear

coupling should be top priority. (addresses root cause #1) Without spacers:12/31/06

3 Consider creating a SAP Preventative Maintenance

plan for gear coupling which triggers lubrication at

recommended frequencies. (addresses root cause #2) 6/1/05

4 Consider installation of high vibration auto shutdown

on remote hydrocarbon systems. (addresses root causes

#1 and #2) 1/1/06

5 Develop refi nery wide procedure to startup idle pumps.


6 Evaluate whether pump is really needed and should

be replaced. Review system and manifolds for opportunity

to simplify and eliminate equipment. (addresses root

cause #3) 1/1/06

7 Consider upgrading small bore threaded fi ttings in

hydrocarbon service to welded pipe. (addresses root

cause #4) 1/1/06

These corrective actions refer to availability of additional fuel for the fi re or for improvement of emergency

response.

8 Consider establishing a maintenance standard for future

repairs of wooden walkways that provides fi re resistant

walkways rather than repair “like-and-kind.” Complete

9 Consider initiating a project to upgrade isolation

access points for existing tank systems. 1/1/06

10 Consider developing a refi nery policy defi ning the

acceptable locations and uses of wooden walkways

& platforms. 1/1/06


11 Consider conducting an emergency response

critique that includes most responders from

the incident. 4/1/05

October 30, 2004

On Saturday, October 30, 2004, at about 12:44 hours, there were visible emissions coming from the No. 5 Boiler

stack. The associated Coker Unit had an upset that resulted in visible emissions from the stack and, ultimately, a

shutdown of the No. 5 Boiler. During the incident, coke dust and steam were emitted from the stack, resulting

in a visible plume. When the boiler was shutdown, water sprays were activated and the Coker rate was reduced to

minimize the amount of coke dust leaving the stack. Odor Science and Engineering (OS&E) was dispatched to

monitor for odors off site. They detected no odors offsite during their patrol of North Concord, Clyde and Bay

Point. Refi nery personnel were also dispatched to monitor the community for odors and conduct industrial hygiene

(IH) sampling. The IH sampling detected no chemicals of concern offsite. There was no activity detected by the

Ground Level Monitors (GLMs). The following agencies were immediately notifi ed: Contra Costa Health Services

(CCHS) via the CWS, the Bay Area Air Quality Management District (BAAQMD) via the CWS, Contra Costa

Fire Protection District, and the Contra Costa County Offi ce of Emergency Services. Agencies responding with

personnel to the site include CCHS and BAAQMD. Operations personnel shut down the boiler and activated water

sprays to minimize the amount of coke dust leaving the stack. The boiler was restarted as quickly as possible to

stop the visible emissions from the stack. An estimated 2.2 tons of petroleum coke was released during this event.

The weather was partly cloudy on 10/30/04, with wind direction varying from 150 to 300 degrees. The wind speed

varied from 2 to 10 MPH. The temperature varied between 50 and 65 degrees F. No injuries were reported on or

offsite.

Root Cause # 1: There was a large increase of solids carried over into the cyclones.

Root Cause # 2: The cyclone effi ciency may not have been adequate.

Corrective Actions for October 30, 2004 Anticipated Date of Completion

1 Consider modifying the Coker start up procedure

to reduce the steam fl ow to the Cold Coke Riser

and Angle Bend to the minimum required to

fl uidize the coke during the coke loading, until

it is needed to establish the coke circulation from

the Reactor to the Burner. Evaluate if additional

steam connections to the Cold Coke Riser are

required to start the circulation from the Reactor

to the Burner. (addresses Root Cause #1). 12/31/05

Corrective Actions for October 30, 2004(con’t) Anticipated Date of Completion

2 Consider modifying the Coker start-up procedure to

initially load coke into the Reactor by back-fl owing

the coke through the cold coke riser, angle bend and

slide valve as was done in the 2004 start-up. Evaluate

if additional steam connections to the Cold Coke


Riser or angle bend are required to move the coke in

this direction. (addresses Root Cause #1) 12/31/05

3 Consider modifi cation to the Burner cyclone outlet

plenum to reduce the likelihood of accumulating

coke particles during the low velocity start up periods.

(addresses Root Cause #1). 12/31/05

4 Consider whether to operate at minimum air/steam

rates to the Burner during coke loading to minimize

coke carry over through the Burner cyclones, or to

operate at higher air/steam fl ows to minimize the

settling out of particles in the Burner overhead system.

Modify the Coker start up procedure to refl ect these

changes as necessary. (addresses Root Cause #2). 12/31/05

5 Retain outside engineering consultants to review the

four recommendations listed above and provide

additional recommendations to prevent recurrence

of coke carryover to the No. 5 boiler during a Coker

start-up. (addresses Root Causes #1 and #2). 12/31/05

January 12, 2005

On Wednesday, January 12, 2005, at about 14:09 hours, there were visible emissions coming from the #5 Boiler

stack. The #5 Boiler experienced a tube failure that resulted in visible emissions from the stack and the shutdown

of the #5 Boiler. During the incident, coke dust and steam were emitted from the stack, resulting in a visible

plume. When the boiler was shutdown, water sprays were activated and the Coker rate was reduced to minimize the

amount of coke dust leaving the stack. Odor patrols during the incident indicated that there were no odors in the

surrounding communities (Concord, Vine Hill, Benicia Bridge, and Martinez areas). Refi nery personnel were also

dispatched to monitor the community (Martinez and Pacheco areas) for odors and conduct industrial hygiene (IH)

sampling. The IH sampling detected no chemicals of concern offsite. There was no signifi cant activity detected

by the Ground Level Monitors (GLMs). The following agencies were immediately notifi ed: Contra Costa Health

Services (CCHS) via the CWS, the Bay Area Air Quality Management District (BAAQMD) via the CWS, Contra

Costa County Fire Protection District, and the Contra Costa County Offi ce of Emergency Services. Agencies

responding with personnel to the site included CCHS, BAAQMD and the Contra Costa Sheriff. Operations

personnel shut down the boiler and activated water sprays to minimize the amount of coke dust leaving the stack.

Materials released include Petroleum Coke fi nes and fl ue gas. It is estimated that approximately 4000 pounds of

coke was released during the incident. An estimated 1400 pounds of Hydrogen Sulfi de was released during the

incident as well. The weather was partly cloudy on 1/12/05, with wind direction varying from about 30 to 80

degrees. The wind speed varied from 4 to 9 MPH. The temperature was about 52 degrees F. No injuries were

reported on or offsite.

Root Cause # 1: #6 Boiler was not ready to process the CO gas from #5 Boiler (addresses coke dust plume).

Root Cause # 2: The boiler tube restriction may have come from contaminated attemperating water (addresses

tube failure).


Root Cause # 3: An Inappropriate Source Of Water Was Used For Attemperating Water (addresses tube failure).

Root Cause # 4: Attemperating water piping is made of carbon steel (addresses tube failure).

Root Cause # 5: High superheater temperatures on the boiler tubes were not understood or communicated

(addresses tube failure).

Root Cause # 6: The boiler tubes may have exceeded maximum operating temperature due to high fl ue gas

temperature associated with instrument error (addresses tube failure). [Note: the investigation

team concluded this root cause was not a likely contributor to the incident, but a corrective action

was still formulated to address this possibility.]

Root Cause # 7: The boiler tubes may have contained a foreign object (addresses tube failure).

Root Cause # 8: The boiler tubes may have had water blockage (addresses tube failure).

Root Cause # 9: The boiler tubes may have had deposits in them from carryover from the steam drum (addresses

tube failure). [Note: the investigation team concluded this root cause was not a likely contributor

to the incident, but a corrective action was still formulated to address this possibility.]

Additional Finding #1: Emissions were visible from the #6 Boiler stack.

Corrective Actions for January 12, 2005 Anticipated Date of Completion

1 Evaluate options to reduce the time required

to transfer CO gas from #5 Boiler to #6 Boiler.


2 Develop program to review and store water

treatment results obtained from laboratory

analysis of attemperating water. (addresses root

cause #2) 10/1/05

3 Establish water targets in the shift supervisor

target sheets. (addresses root cause #2) 7/1/05

4 Train operators and shift supervisors on

importance of attemperating water quality.


5 Install double block and bleed between

deaerator water and attemperating water to

prevent deaerator water from contaminating

attemperating water. (addresses root cause #2) Complete

6 Convert oxygen scavenger in use in deaerator

water to DEHA to eliminate a potential source

of solids. (addresses root cause #2) 6/1/05

7 Eliminate the cross connection from the economizer

inlet water to the attemperating water to prevent

economizer inlet water from contaminating attemperating

water. (addresses root cause #2) Complete

8 Establish surface condenser condensate as the primary

attemperating water source since attemperating water


Corrective Actions for January 12, 2005 (con’t) Anticipated Date of Completion

should be condensate or demineralized water only.


9 Evaluate zeolite water cross connections and determine

an appropriate isolation plan to prevent zeolite water

from contaminating attemperating water. (addresses


10 Conduct engineering review to evaluate attemperating

and boiler feed water system piping materials. (addresses


11 Operation manual and procedures did not

properly identify superheater temperature targets

and implications of high temperature; revise

operating manual and applicable operating procedures.


12 Maintenance was not aware of high superheater

temperature readings and the closure of the

maintenance notifi cations. Evaluate training and

internal communications to improve highlighting of

potential failures of critical instruments. (addresses


13 Evaluate options to improve the precipitator

performance at #6 Boiler. (addresses additional

fi nding #1) 9/1/05

14 Evaluate chemical KI-75 inventory strategy. (addresses

additional fi nding #1) 8/1/05

15 Repair primary furnace fi rebox temperature indicators.

(addresses root cause #6) Complete

16 Ensure #6 Boiler turnaround work scope items are

properly ranked for processing Coker CO gas.


17 Evaluate possible testing methods (blowing a ball

through, similar to a cyclone) for fi eld verifying that

new tubes do not contain a foreign object.


18 Ensure that superheater dryout procedure is

followed on all restarts. 9/1/05

19 Prior to controls modernization of #5 Boiler,

develop a plan to monitor and record superheater

temperatures. (addresses root cause #5) Complete

20 Install a sodium analyzer on the steam drum to

detect any drum carryover, connect the analyzer

readings to the IA controls as part of the #5 Boiler

controls upgrade. (addresses root cause #9) 4/1/06

21 Consult with a boiler specialist to conduct a general

review of boiler procedures and practices, operating

conditions and water chemistry. 7/1/06



of implementation of recommendations formulated during the analysis (450-8.030(B)(2)(iv)):

Root Cause Analysis information is included in answers to #6.


Cause Analyses, or Incident Investigations conducted by the Department (450-8.030(B)(2)(v)):

“CCHS Information”: CCHS completed an audit on September 15, 2000, December, 2001 and August, 2003. There

are no RCA or Incident Investigations that have been conducted by the Department.



Golden Eagle is submitting a list of the Inherently Safer Systems (ISS) that meet the criteria for Inherent or Passive

levels only and that were completed within the last year (see attached).

Item Level of Risk Reduc-tion Implementation Basis Description

A002-2001-0606 Inherent PHA The inherent level of risk reduction

was implemented by reducing

inventory on site through elimination

of piping.




of piping.




of piping.




of piping.




of equipment.

A002-2001-0661 Inherent and Passive PHA The inherent level of risk reduction





of piping.The passive level of risk

reduction was implemented by

increasing the piping/fl ange pressure

and temperature rating which

minimizes the hazard without the

active functioning of any device.

A003-2001-1159 Inherent and Passive PHA The inherent level of risk reduction



of equipment and associated piping.

The passive level of risk reduction

was implemented through piping

modifi cations that eliminated the

potential for liquid accumulation in

low points.

A002-2001-0002 Passive PHA The passive level of risk reduction




low points.


was implemented by rerouting piping

to a safer location which minimizes

personnel exposure to a hazard

without the active functioning of

any device.The passive level of risk

reduction was also implemented

through piping modifi cations that

eliminated the potential for liquid

accumulation in low points.


was implemented by increasing the

piping/fl ange pressure rating which




was implemented by increasing the

piping/fl anges temperature rating

which minimizes the hazard without

the active functioning of any device.


was implemented by replacing old

equipment with new equipment that

meets existing code requirements







modifi cations that eliminated vibration

stress on piping without the active

functioning of any device.

A003-2001-0923 Passive PHA The passive level of risk reduction was

implemented by increasing equipment

pressure rating which minimizes the

hazard without the active functioning

of any device.



to a closed system which minimizes


without the active functioning of any

device.


implemented by increasing equipment

pressure rating which minimizes the

hazard without the active functioning

of any device.



equipment with new equipment that

meets existing code requirements







low points.


implemented through replacement of

old equipment with new equipment

that cannot exceed piping and

equipment design ratings which




was implemented by upgrading vessel

design ratings and vessel containment







modifi cations that eliminate pressure

buildup without the active functioning

of any device.


implemented through the installation

of blinds to eliminate the potential for

cross contamination.



equipment with new equipment

with increased pressure rating which

minimizes the hazard without the use

of an active device.


implemented by upgrading equipment

support system which reduces the

likelihood of equipment failure

without the use of an active device.



to a safer location which minimizes


without the active functioning of any

device.


implemented through design features

that naturally restrict fl ow without the




Section 450-8.028 of County Ordinance 98-48 (450-8.030(B)(2)(vii)):

“CCHS Information”: CCHS issued a Preliminary Audit Findings on April 16, 2004 based on a CalARP/ISO audit/

inspection. Tesoro responded to the Preliminary fi ndings on May 3, 2004.

11. Summarize total penalties assessed as a result of enforcement of this Chapter (450-8.030(3)):

“CCHS Information”: No penalties have been assessed against any facility.


ISO (450-8.030(B)(4)):


“CCHS Information”: CalARP program fees for these nine facilities were $395,679. The Risk Management Chapter

of the Industrial Safety Ordinance fees were $256,893.


this Chapter (450-8.030(B)(5)):

“CCHS Information”: 4000 hours were used to audit/inspect and issue reports on the Risk Management Chapter

of the Industrial Safety Ordinance.


the effectiveness of the local program that raise public safety issues(450-8.030(B)(6)):

This facility has not received any comments to date regarding the effectiveness of the local program.

15. Summarize how this Chapter improves industrial safety at your stationary source (450-8.030(B)(7)):

Chapter 450-8 improves industrial safety by expanding the safety programs to all units in the refi nery. In addition,

the timeframe is shorter to implement recommendations generated from the Process Hazard Analysis (PHA) safety

program than state or federal law. This has resulted in a faster implementation of these recommendations.

Chapter 450-8 also includes requirements for inherently safer systems as part of implementing PHA

recommendations and new construction. This facility has developed an aggressive approach to implementing

inherently safer systems in these areas.

Chapter 450-8 has requirements to perform root cause analyses on any major chemical accidents or releases

(MCAR). This facility has applied that rigorous methodology to investigate any MCARs that have occurred since

January, 1999.

Chapter 450-8 requires a human factors program. This facility has developed a comprehensive human factors

program and is in the process of implementing the program.



not subject to CalARP regulations; recommendations from RCAs) that signifi cantly decrease the severity or

likelihood of accidental releases.

This question was broadly answered under question 15 above. Some examples of changes that have been made

due to implementation of the ordinance are as follows. There are some units that were not covered by RMP,

CalARP or PSM. Those units are now subject to the same safety programs as the units covered by RMP, CalARP

and PSM. They have had PHAs performed on them according to the timeline specifi ed in the ISO and the PHA

recommendations have been resolved on the timeline specifi ed in the ISO. A list of inherently safer systems as


required by the ISO for PHA recommendations and new construction is attached to this fi ling as mentioned in the

response to question 9. With respect to Compliance Audits, there was a compliance audit performed in June, 2003

in addition to the CCHS audits mentioned above. All audit fi ndings are being actively resolved. Root Cause Analysis

fi ndings and recommendations for MCARs are listed in the response under question 6.

17. Summarize the emergency response activities conducted at the source (e.g., CWS or CAN activation) in

response to major chemical accidents or releases:

Please refer to #6 which has the CWS classifi cations for the major chemical accidents and releases as well as any

information regarding emergency responses by agency personnel.


Annual Performance Review and Evaluation SubmittalJuly 7, 2005


1. Name and address of Stationary Source: Chevron Corporation. Richmond Refi nery, 841 Chevron Way,

Richmond, California 94802

2. Contact name and telephone number (should CCHS have questions): Matt Brennan, 510-242-1862

3. Summarize the status of the Stationary Source’s Safety Plan and Program (42-01 §6.43.160(b)(1)): The June

2004 Safety Plan refl ects the program elements within the Refi nery. Additionally, the Refi nery follows the

program requirements specifi ed by the requirements of the Richmond Industrial Safety Ordinance.

4. Summarize Safety Plan updates (i.e., brief explanation of update and corresponding date) (42-01

§6.43.160(b)(2)): In June 2004, the Site Safety Plan was updated and issued to refl ect process improvements and

to address recommendations resulting from the November 2003 Cal/ARP & Richmond ISO Audits.


source will provide individuals with copies of the document (42-01 §6.43.160(b)(2)): CCHS response

6. Provide any additions to the annual accident history reports (i.e. updates) submitted pursuant to §6.43.090(e)(2)

of City Ordinance 42-01 (§6.43.160(b)(3) (i.e., provide information identifi ed in §6.43.090(e)(1) for all major

chemical accidents or releases occurring between the last accident history report submittal (2004) and the annual

performance review and evaluation submittal (June 30, 2005): There have been no new major chemical accidents

or releases during the defi ned time frame. The June 2004 Site Safety plan includes the required updates to the

accident history section.

7. Summary of each Root Cause Analysis §6.43.090(c) including the status of the analysis and the status of

implementation of recommendations formulated during the analysis §6.43.160(b)(4): All corrective actions

resulting from the previously reported events have been implemented with the exception of one item resulting

from the refi nery-wide power outage in October of 2002 (CWS Level 2 event). The project design for the item,

[Revise relay protection for RLOP feeder] which was initally scheduled for completion in November 2004, was

revised and enhanced. Work is in progress.


Cause Analyses, or Incident Investigations conducted by the Department §6.43.160(b)(5): 100% of all audit and

inspection recommendations have been resolved. The County has not performed any Root Cause Analysises or

Incident Investigations during this reporting period.


reduction (i.e., intensifi cation) and substitution §6.43.160(b)(6):

Strategy ISS Solution Employed

Minimize Removed a section of 2” Dead leg piping on the discharge of P605.

Minimize Removed unused ¾” nipples and bleeder valves from the V613 Fuel Gas piping.

Minimize Disconnected and demolished Hot Flush Piping from C650 that is no longer used.



Minimize Replaced piping spool between E650 and V650, eliminating a Deadleg.

Minimize Dismantled Jet Additive Piping and Injection Equipment that is no longer used,

reducing the contents of hazardous materials in the Plant.

Minimize Reduced the amount of Fresh Sulfuric Acid used in the Alkylation Unit by

optimizing acid strength control.

Minimize Start-up of E-248 heat exchanger may result in piping fl ange leaks. Changed gasket

design from spiral wound to CMG which improves seal ability by 400%.

Minimize Minimize ignition sources on the Long Wharf. Primary source is unauthorized

vehicles driving out on the wharf. Installed security gate that only allows vehicles

with special transmitter access to the wharf.

Minimize C-1000 wash water column is not needed to wash feed stock to the C5 SHU.

Removed column from service and installed new piping to reduce storage quantity.

Minimize Pumps P-17 and P-21 hydrocarbon pumps are no longer needed. Removed pumps

from service thereby eliminating two VOC and Reg. 8 sources.

Substitute Replaced C711 and associated Reboiler with a new Column employing stripping

steam. The Reboiler was eliminated and replaced with stripping steam.

Substitute Changed catalyst in Reactors R-3550, R-3560 and R-3570 to a new type allowing the

reactors to operate at a lower temperature and pressure.

Moderate Upgraded P447/A Pump Seals to API Plan 23 which will reduce the potential of

loss of cooling in Seal Flush Cooler due to fouling caused by high temperature

seal fl ush exchanging heat with cooling water resulting in seal failure and release to

environment of fl ammable and hazardous material. This new design lowers the fl ush

supply temperature to below boiling eliminating the possibility of fouling.

Moderate High temperatures from relief drum V-705 may cause the fl are gas recovery

compressors to shutdown resulting in fl aring. Modifi ed compressors to operate at

higher inlet temperature.

Moderate Pipeline/Cargo hose at Long Wharf can rupture due to overpressure. High pressure

shutdown devices installed on all loading pumps.

Moderate Upgraded P1167 Pump Seal to API Plan 23 which will reduce the potential of

loss of cooling in Seal Flush Cooler due to fouling caused by high temperature

seal fl ush exchanging heat with cooling water resulting in seal failure and release to

environment of fl ammable and hazardous material. This new design lowers the fl ush

supply temperature to below boiling eliminating the possibility of fouling.

Moderate Potential corrosion of V-1431 caustic wash drum inlet distributor piping causing

leaks to environment. Reduced length of distributor piping which resulted in

eliminating the corrosion mechanism by not allowing the process fl ow to enter the

turbulent regime which could have made it corrosive.

Moderate Potential corrosion of V-1440 and V-1441 inlet distributor piping could cause leaks

to environment. Reduced length of distributor piping which resulted in eliminating

the corrosion mechanism by not allowing the process fl ow to enter the turbulent

regime which could have made it corrosive.


Moderate Sections of 1-1/2” and 3” C-660 bottoms piping are no longer in use and act as a

large dead leg with a potential for leaks to the environment. Demolished piping



thereby eliminating the potential for high corrosion and leaks.

Moderate Removed dead leg leading to DCMA #4 from service and eliminated a potential leak

source.

Moderate Vessel V-712 may overpressure if the 6” bypass valve is open around the pressure

controller overwhelming the pressure relief valves. Replaced the 6” valve with a 4’

bypass valve eliminating any potential to overpressure V-712.

Moderate Upgraded P1128 and P1128A Pump Seals to API Plan 23 which will reduce the

potential of loss of cooling in Seal Flush Cooler due to fouling caused by high

temperature seal fl ush exchanging heat with cooling water resulting in seal failure

and release to environment of fl ammable and hazardous material. This new design

lowers the fl ush supply temperature to below boiling eliminating the possibility of

fouling.

Moderate Upgraded P1129 and P1129A Pump Seals to API Plan 23 which will reduce the

potential of loss of cooling in Seal Flush Cooler due to fouling caused by high

temperature seal fl ush exchanging heat with cooling water resulting in seal failure

and release to environment of fl ammable and hazardous material. This new design

lowers the fl ush supply temperature to below boiling eliminating the possibility of

fouling.

Moderate The TKN reactors average at least two unplanned shutdowns every fi ve years due

to plugged beds caused by poor quench distribution. Modifi ed distribution piping in

reactors allowing for excellent fl ow distribution and reducing the potential for hot

areas in the catalyst beds.

Moderate The FCC pumps that use hot MCO as seal fl ush may cause the coolers to foul

resulting in seal failures and leaks to the environment. Installed new piping to bring

cool MCO to the pumps thereby eliminating the possibility of fouling the coolers.

Moderate Pumps P-472 and P-472A operate beyond the design rate resulting in seal failures

and leaks to the environment. Installed speed controllers and discharge restriction

orifi ces to prevent operation outside of design.

Simplify Replaced section of R1410G&H Carbon Steel Discharge Piping with Alloy 20 Piping

for increased reliability / greater corrosion resistance.

Simplify Replaced section of P1440/A Carbon Steel Piping with Alloy 20 Piping for increased

reliability / greater corrosion resistance.

Simplify Replaced unreliable V1410 Level S/D Switches with Level Transmitters with alarm

points. Gives Operators additional Level Indication that indicates when Level is near

trip point.

Simplify Replaced Pilot Operated Pressure Relief Valve with a more reliable Bellows Sealed

Pressure Relief Valve. Provided block valves so valves can be serviced more readily.

Simplify Installed a Flow Control Valve in the C400 Overhead to V400 to increase process

control reliability and reduce potential for Plant upset.

Simplify Minimized / Eliminated 20 Plant Shutdowns on loss of Instrument Air by increasing

the delay time in Pressure Switch 64PL2500 to 5 seconds.



Simplify Installing a remotely operated Emergency Block Valve on P144A/B Suction to so

Pumps can be blocked in from a remote location.

Simplify Installed maximum set-point / output change limits in Honeywell DCS to avoid

major plant upsets due to typographical errors on set-point / output changes.

Simplify Replaced F651 Carbon Steel Convection Tubes with 1-1/4Cr-1/2Mo. for greater

corrosion / oxidation resistance.

Simplify Replaced Fresh Acid piping between P472/A and T1821 with Alloy 20 for increased

reliability / increased corrosion resistance.

Simplify Replaced Carbon Steel E632 inlet piping (caustic) with Monel for increased reliability

/ increased corrosion resistance.

Simplify Standardized 4 Cat and 5 Cat Control System GUS graphic buttons between

different Control Consoles to minimize confusion when Operators transition to

another Console.

Simplify Installed new type of Inert Topping Material in R1310 that has a greater capacity

for holding particulate that will keep particulate matter out of Catalyst. Particulate

matter in Catalyst causes high pressure drop and necessitates a shutdown to skim the

catalyst. This new material will allow longer run times, reduces the amount of non-

routine operations.

Simplify Installed new Catalyst in R900 in the C5 SHU that has been shown to increase run

life, decreasing the amount of non-routine operations.

Simplify V1900/V1901 High Level Shutdown: Removed two displacer type Alarm Switches

and replaced them with a single “guided wave radar” level transmitter, reducing

instrument complexity and increasing reliability.

Simplify Upgraded V470 Overhead Piping to Stainless Steel for increased reliability /

increased corrosion resistance.

Simplify Upgraded V717 Overhead Piping to Stainless Steel for increased reliability /

increased corrosion resistance.

Simplify Removed in-service valves and piping associated with Instruments PDI510 and

PDI511 which were also removed, eliminating 8 Valves in VOC service that were

potential leak points, and eliminating Dead-leg piping.

Simplify Upgraded metallurgy of C710 Bottoms to E712 Piping to Stainless Steel to increase

reliability and increase corrosion resistance.

Simplify Dismantled redundant Differential Pressure Switch PDSH 14644. Its function is

served by Pressure Differential Transmitter 84PDT644.

Simplify Different units used for fl ow measurement in relief system. Standardized relief fl ow

measurement in refi nery to one standard unit (MMSCFD).

Simplify Control valve PC-312 is too small and the bypass line operates in the open position

allowing for possible plant pressure upsets. Installed larger control valve with bypass

line closed thereby eliminating the overpressure potential.

Simplify LPG truck drivers are required to connect a separate bonding cable to prevent static

electricity discharge. This may be confusing to the drivers because other facilities

have self grounding loading hoses with no separate bonding cable. Replaced all

loading hoses with the self grounding type.

Simplify Continual entry errors for critical controllers made by board operators’ resulting in

major plant upsets. Developed a Honeywell setpoint/output entry error protection

program that eliminates the possibility of entering an incorrect value.



over to the City Attorney’s Offi ce) taken with the Stationary Source pursuant to City Ordinance 42-01

§6.43.160(b)(7): CCHS Response

11. Summarize total penalties assessed as a result of enforcement of this Chapter §6.43.160(c): CCHS Response


ISO §6.43.160(d): CCHS Response


this Chapter §6.43.160(e): CCHS Response


the effectiveness of the local program that raise public safety issues§6.43.160(f): None

15. Summarize how this Chapter improves industrial safety at your stationary source §6.43.160(g): The refi nery

perceives that it has had fewer incidents that did or could have reasonably resulted in a Major Chemical Accident

or Release. However this is not indicative of a trend since the Ordinance has only been in effect for a short

period of time. Chevron believes it will take 7 to 10 years to fully realize the positive effects of the current ISO.




likelihood of accidental releases: Refer to the ISS Solutions implemented (noted in question 9)


response to major chemical accidents or releases: There were no activations of the CWS during this reporting

period.




1. Name and address of Stationary Source: General Chemical - Richmond Works,

525 Castro Street, Richmond, California__ 94801

2. Contact name and telephone number (should CCHS have questions): David Connolly; (510) 237-3869,

3. Summarize the status of the Stationary Source’s Safety Plan and Program (42-01 §6.43.160(b)(1)): The Safety

Plan and Program was submitted to the City of Richmond and the County on January 2003.

4. Summarize Safety Plan updates (i.e., brief explanation of update and corresponding date) (42-01

§6.43.160(b)(2)): The Safety Plan was most recently updated in June 2004.

5. List of locations where Safety Plans are/will be available for review, including contact telephone numbers if

the source will provide individuals with copies of the document (42-01 §6.43.160(b)(2)): CCHS Offi ce, 4333

Pacheco Boulevard, Martinez; Bay Point Library (library closest to the stationary source); General Chemical Bay

Point Works – See contact in #2, above.

6. Provide any additions to the annual accident history reports (i.e. updates) submitted pursuant to §6.43.090(e)(2)

of City Ordinance 42-01 (§6.43.160(b)(3) (i.e., provide information identifi ed in §6.43.090(e)(1) for all major

chemical accidents or releases occurring between the last accident history report submittal and the annual

performance review and evaluation submittal (June 30)): There have been no major accidental chemical releases

from January 2003 to the present.

7. Summary of each Root Cause Analysis §6.43.090(c) including the status of the analysis and the status of

implementation of recommendations formulated during the analysis §6.43.160(b)(4): There have been no root

cause analyses during this period.


Cause Analyses, or Incident Investigations conducted by the Department §6.43.160(b)(5): The County

completed an Unannounced Inspection in October 2004 and submitted the report to General Chemical in

October 2004. Corrective actions were completed.


reduction (i.e., intensifi cation) and substitution §6.43.160(b)(6): A PHA was conducted on the new DCS Control

System in November 2004. ISS was considered during this process and were either already addressed or will be

addressed within one year of conducting the PHA, as required by the ISO.


over to the City Attorney’s Offi ce) taken with the Stationary Source pursuant to City Ordinance 42-01

§6.43.160(b)(7): No enforcement actions were taken during this time period.


11. Summarize total penalties assessed as a result of enforcement of this Chapter §6.43.160(c): No penalities have



ISO §6.43.160(d): CalARP Program fees for these eight facilities are - $314,013, the Risk Management Chapter

of the Industrial Safety Ordinance fees are - $319,669.


this Chapter §6.43.160(e): 4,000 hours were used to audit/inspect and issue reports on the Risk Management

Chapter of the Industrial Safety Ordinance.


the effectiveness of the local program that raise public safety issues§6.43.160(f): The facility has not received

any comments regarding the effectiveness of the local program that raise public safety.

15. Summarize how this Chapter improves industrial safety at your stationary source §6.43.160(g): This Chapter

helps minimize potential risk and exposure to employees, the community and the environment.




likelihood of accidental releases: Several PHAs were conducted for processes that are not subject to CalARP

regulations. Many recommendations from these PHAs have been completed or are in the process of being

addressed.


response to major chemical accidents or releases: There have been no emergency response activities conducted

at this site in response to major chemical accidental releases during this period.


Documents

haz mat iso attachment E 2005 - Contra Costa County