Hazard Audit 2016 - Orica

Document number: 21065-RP-001 Sherpa Consulting Pty Ltd (ABN 40 110 961 898) Revision: 0 Phone: 61 2 9412 4555 Revision Date: 11-Nov-2016 File name: 21065-RP-001 Rev 0 Web: www.sherpaconsulting.com

HAZARD AUDIT 2016

AMMONIUM NITRATE FACILITY

KOORAGANG ISLAND

ORICA AUSTRALIA PTY LTD

PREPARED FOR: Antony Taylor

Environment Lead, KI

DOCUMENT NO: 21065-RP-001

REVISION: 0

DATE: 11-Nov-2016

http://www.sherpaconsulting.com/

Document: 21065-RP-001 Revision: 0 Revision Date: 11-Nov-2016 File name: 21065-RP-001 Rev 0

DOCUMENT REVISION RECORD

Rev Date Description Prepared Checked Approved Method of issue

A 27-Sept-16 Issued to client for comment

J Polich S Chia S Chia Email PDF

0 11-Nov-16 Final Issue J Polich S Chia S Chia Email PDF

RELIANCE NOTICE

This report is issued pursuant to an Agreement between SHERPA CONSULTING PTY LTD (‘Sherpa Consulting’) and Orica Australia Pty Ltd which agreement sets forth the entire rights, obligations and liabilities of those parties with respect to the content and use of the report.

Reliance by any other party on the contents of the report shall be at its own risk. Sherpa Consulting makes no warranty or representation, expressed or implied, to any other party with respect to the accuracy, completeness, or usefulness of the information contained in this report and assumes no liabilities with respect to any other party’s use of or damages resulting from such use of any information, conclusions or recommendations disclosed in this report.

Title:

Hazard Audit 2016

Ammonium Nitrate Facility

Kooragang Island

QA verified:

R Bush

Date: 11-Nov-2016


CONTENTS

ABBREVIATIONS ...................................................................................................................................... 6

1. SUMMARY AND RECOMMENDATIONS ......................................................................................... 8

1.1. Background ................................................................................................................................ 8

1.2. Summary of Findings ................................................................................................................. 9

1.3. Recommendations ..................................................................................................................... 9

1.4. Closeout ................................................................................................................................... 10

2. CONTEXT AND SCOPE OF HAZARD AUDIT ............................................................................... 21

2.1. Background .............................................................................................................................. 21

2.2. Audit context ............................................................................................................................ 21

2.3. Audit Purpose and Objectives ................................................................................................. 22

2.4. Scope ....................................................................................................................................... 23

2.5. Exclusions and Limitations ...................................................................................................... 24

2.6. Audit Approach ........................................................................................................................ 24

3. OVERVIEW OF THE SITE .............................................................................................................. 26

3.1. Site location and surrounding land uses ................................................................................. 26

3.2. Site layout ................................................................................................................................ 26

3.3. Organisation and staffing ......................................................................................................... 29

3.4. Process overview ..................................................................................................................... 29

3.5. Properties of materials being handled and processed ............................................................ 30

3.6. Security .................................................................................................................................... 30

3.7. Summary of changes to site since the previous audit ............................................................. 31

4. AUDIT OF SITE ............................................................................................................................... 32

4.1. Site inspections ........................................................................................................................ 32

4.2. Check against industry standards for AN stores ..................................................................... 34

5. AUDIT OF SAFETY MANAGEMENT SYSTEMS ............................................................................ 36

5.1. Overview .................................................................................................................................. 36

5.2. Integrated Management System, SHECMS ............................................................................ 36

5.3. Findings ................................................................................................................................... 36

6. SITE HISTORY ................................................................................................................................ 38

6.1. Previous Studies ...................................................................................................................... 38

6.2. Incident history ......................................................................................................................... 39


7. RECOMMENDATION SUMMARY .................................................................................................. 41

APPENDIX A. AUDITOR APPROVAL

APPENDIX B. EVIDENCE AND REFERENCE DOCUMENT SUMMARY

APPENDIX C. ORGANISATION CHARTS AND INTERVIEWEES

APPENDIX D. AUDIT RECORD WORKSHEETS


TABLES

Table 1.1: 2016 Orica KI Hazard Audit Management System Element Performance Summary

................................................................................................................................................. 11

Table 1.2: 2016 Orica Ki Site Hazard Audit Recommendations ............................................... 16

Table 2.1: Audit Site Visit Summary ......................................................................................... 25

Table 3.1: Site changes since 2013 ......................................................................................... 31

Table 4.1: Assessment of AN against industry guidance ......................................................... 34

Table 6.1: Further Actions 2013 Audit Actions ......................................................................... 38

Table 6.2: Hazard Study Actions Closeout .............................................................................. 39

Table 6.3: Incident summary since 2013 .................................................................................. 39

Table 7.1: 2016 Hazard Audit Recommendation Summary ..................................................... 41

FIGURES

Figure 3.1: Orica KI Site - Aerial Photo .................................................................................... 27

Figure 3.2: Site layout .............................................................................................................. 28


ABBREVIATIONS

AMI Project Ammonia Management Improvement Project

AN Ammonium Nitrate

ANS Ammonium Nitrate Solution

AS Australian Standard

BoS Basis of Safety

CSB (US) Chemical Safety Board

DEC Department of Environment and Conservation

DG Dangerous Goods

DMS Document Management System

DPE (NSW) Department of Planning and Environment

EPL Environment Protection Licence

ERP Emergency Response Plan

FGAN Fertiliser Grade Ammonium Nitrate

FSS Fire Safety Study

HA Hazard Analysis

HAZOP Hazard and Operability (Study)

HIPAP Hazardous Industry Planning Advisory Paper

HIRAC Hazard Identification Risk Assessment Controls

KI Kooragang Island

KPI Key Performance Indicator

MHF Major Hazard Facility

MOC Management of Change

NFPA National Fire Protection Assocation

NH3 Ammonia

NSW New South Wales

PHA / FHA Preliminary / Final Hazard Analysis

PPE Personal Protective Equipment

PSE Process Safety Event

PTW Permit To Work

QRA Quantitative Risk Assessment

SDS Safety Data Sheet

SFARP So Far As Reasonably Practicable

SHE Safety, Health and Environment

SHECMS Safety, Health, Environment and Community Management System

SHES Safety, Health, Environment, Security

SIL Safety Integrity Level

SMS Safety Management System


SSAN Security Sensitive Ammonium Nitrate

TGAN Technical Grade Ammonium Nitrate

TWC Towards World Class

WHS Work Health and Safety

WO Work Order


1. SUMMARY AND RECOMMENDATIONS

1.1. Background

Orica Australia Pty Ltd (Orica) operates an ammonium nitrate facility at Kooragang

Island, NSW. Orica received development approval from the NSW Department of

Planning and Environment (DPE) for an expansion of the Kooragang Island (KI) facility

in 2009 (application no: 08_0129).

The development has been staged, with the first main stage being an uprate of the

existing ammonia plant which was completed and commenced operation in 2012. The

subsequent stage was construction of new nitrate acid (NAP4) and ammonium nitrate

manufacturing plants (AN3), however this has been put on hold due to changes in

economic conditions.

The NSW DPE attached various conditions to the approval including the requirement for

a Hazard Audit (08_0129, Schedule 3, item 20) to be undertaken every 3 years. The first

audit was undertaken after the ammonia plant uprate by Aecom in 2013 (doc ref: Hazard

Audit - 2013 Ammonium Nitrate Plant - Kooragang Island 60274735-RPT Final Rev 0

March 2013).

Orica retained Sherpa Consulting Pty Ltd (Sherpa) as independent auditors approved

by the NSW Department of Planning and Environment (DPE) to conduct the 2016

Hazard Audit. This report contains the findings of the Hazard Audit conducted in August

2016.

The audit was undertaken in accordance with a protocol developed from the NSW

Hazardous Industry Planning Advisory Paper 5 Hazard Audit Guidelines (HIPAP 5),

NSW Hazardous Industry Planning Advisory Paper 9 Safety Management Systems

(HIPAP 9) and ISO19011:2014 Guidelines for Auditing Management Systems.

The audit comprised:

desktop documentation review to prepare for the audit visit.

site visits in August 2016 which included completing the site induction, observing

site operations, discussions with site personnel and a review of the Orca KI site

documentation and Orica’s integrated corporate Safety Health Environment and

Community management system (SHECMS) as implemented at the KI site.

review of supplementary documentation provided by Orica following the site

visit.

The audit focused on changes in operations at KI since the 2013 Hazard Audit and

included specific review of:

The site and plant modifications associated with the expansion project since

2013. This is primarily a set of ammonia risk reduction projects referred to as the

Ammonia Management Improvement (AMI) Project.


Close out of actions arising from 2013 Hazard Audit and other safety studies that

have occurred since 2013.

Degree of implementation of recommendations from the CSB Texas West

investigation report (Final 2016).

Compliance of AN storage arrangements with relevant sections of AS4326

(2008) Storage and Handling of Oxidising Agents.

Assessment against the recommended practices in the industry guidance

(SAFEX Good Practice Guide: Storage of Solid Technical Grade AN, Rev 2).

The audit did not cover environmental performance or conditions of consent as this is

covered by a separate Environmental Audit (last completed in 2014).

1.2. Summary of Findings

Overall, the management of safety hazards at the Orica KI site is considered by the

auditors to be well covered by the integrated Orica corporate Safety, Health,

Environment and Community Management System (SHECMS) at the KI site. There is a

strong safety culture evident at KI and there is a positive attitude at all levels that should

foster on-going improvements in process safety management. An overall assessment

against each element of the audit protocol based on the auditors’ judgment is provided

in Table 1.1 and further details are provided in the detailed audit worksheets for each

element (APPENDIX D). An action list is provided in

As the audit protocol used in the 2013 Hazard Audit (Aecom) and the 2016 Hazard Audit

(Sherpa) covered in this report is not the same, it is not possible to make a direct

comparison in findings. However for information, Table 1.1 also identifies the system

elements where recommendations were made in the 2013 Hazard Audit.

Since the 2013 Hazard Audit, the KI site has also been subject to internal corporate

reviews (ie SHERMIS audit 2015) and regulatory audits (ie NSW DPE for Major Hazard

Facility (MHF) 2014).

Overall, the SHECMS as implemented at the KI site was considered satisfactory by the

auditors for managing the technical safety hazards at the site.

1.3. Recommendations

A total of 28 recommendations to improve safety management at the KI site were

identified and are listed in Table 7.1. These have also been organized by management

system element as per HIPAP 9 and summarised in Table 1.2.

Recommendations are divided into two categories:

1. Actions: These items relate to areas where compliance with a regulatory instrument

or Orica internal company standard could not be confirmed based on the evidence

available to the auditors. This included the system elements relating to Hazard


Identification and Risk Assessment, Management of Change (MOC) and compliance

with closeout of previous Hazard Audit actions.

2. Observations: recommendations have been provided that could enhance existing

systems or where a specific check is recommended for the next Hazard Audit in

2019 to confirm continuance of a system or programme. These items are labelled as

Observation in the recommendation summary.

1.4. Closeout

Following submission of this audit report to DPE, Orica will enter the recommendations

and required completion dates into the Enablon tracking system (adopted Orica-wide)

to ensure actions are closed out and documented as such.


Table 1.1: 2016 Orica KI Hazard Audit Management System Element Performance Summary

Audit Element (HIPAP9) Overall Element

Compliance

2013 Hazard Audit

by Aecom

(Approximate only)

Comments

1

.

SHE Management

System Structure

and Administration

Fully Implemented No findings Orica's integrated corporate Safety Health Environment Community Management System (SHECMS) covers all the main

requirements of a Safety Management System. This includes policy, vision, 21 SHEC Standards and 29 Major Hazard Standards

as well as supporting corporate and site level procedures. All the elements have been implemented at the KI site level. Potential

improvements in a specific element are identified where relevant under the individual element headings.

2. Commitment and

Leadership

Fully Implemented No findings The relevant SHECMS element is Standard 1 Leadership and Accountability.

SHEC management is initiated at the corporate level and managed as an integrated part of site management activities with the

Site Manager having overall responsibility for implementation. The auditor observed a visible commitment to safety management

at KI in the form of a thorough site induction, integration of SHEC items into daily meetings, highly visible BoS and Key

Performance Indicators (KPI) information and the large number of risk reduction projects being implemented.

3. Organization,

Accountabilities

and

Responsibilities

Fully Implemented No findings The relevant SHECMS elements are Standard 1 Leadership and Accountability and Standard 2 Planning, Goals and Targets.

These include an accountability and communications framework.

Potential improvements in resourcing, definition or responsibility for a specific element are identified under the individual element

headings where relevant.

4

.

Objectives, Target

and Plans

Fully Implemented No findings The relevant SHECMS element is Standard 2 Planning, Goals and Targets.

At the site level a SHEC improvement plan is developed annually.

At an individual level all employees have documented personal SHEC objectives that demonstrate the employee’s contribution

to SHEC performance. Potential improvements in objectives or planning are identified under the individual element headings

where relevant.

5. Legal

Requirements and

Codes

Fully Implemented No findings Standard 3 Legal Requirements is the relevant SHECMS element.

A compliance register is available on site

There is good evidence of knowledge of technical codes and standards (corporate and external), Work Health and Safety

regulations, and MHF licence and development approval conditions of consent requirements.

6. Documentation

Fully Implemented No findings Standard 7 Documentation and Document Control is the relevant SHECMS element.

There is an extensive document base covering the SHECMS and supporting procedures at corporate and KI site level which are

available within the Document Management System and accessible via the Orica Intranet (Globe).

Drawings are managed electronically via Vault.

Incident information is in a corporate system Enablon

Site specific records are available either within the relevant site databases (eg Modifications Lotus Notes database, Lotus Notes

Risk Register), SAP for maintenance and Permit to Work (PTW), and in some cases network drives.



Compliance

2013 Hazard Audit

by Aecom

(Approximate only)

Comments

7. Hazard Identification

and Risk Control

Mostly

Implemented

Recommendations

made

Standard 4 Hazard and Change Management is the relevant SHECMS element.

Standard 9 Project Delivery is also relevant.

There are many risk assessments of various types and methodologies for the KI site with a large amount of detail available at

the individual hazard identification and risk scenario level in the Risk Registers. However, an overall KI site risk profile was not

available so it was not possible to identify for example the highest risk on the KI site, or the effect of risk reduction measures

completed to date (or control measures removed) on the overall site risk profile. In addition there are a very large number of

open actions (more than 1000) arising from the periodic hazard study and Process Hazard Identification, Risk Assessment and

Controls (HIRAC) processes that have not been prioritised or resourced. Closure of some modifications associated with the AMI

project is also overdue as residual risk Process HIRACs have not been migrated to the KI Risk Register. Recommendations

have been made to review the potential to summarise the various risk assessments into a single site risk register that provides

an overall KI risk profile, and also develop a prioritisation method and appropriate resourcing to address the large volume of

actions.

8. Operating Procedures

Fully Implemented No findings Standard 8 Operational Control and Standard 13 Personnel and Process Safety are the relevant SHECMS elements.

Operations appear to be covered by extensive procedures, available with the DMS. At the time of the audit the AN area

procedures for response to abnormal situations appeared more developed than the Ammonia Plant procedures.

9. Process Safety

Information

Fully Implemented No findings Key process safety information such as PIDs, PFDs, hazardous area drawings, mechanical design basis and equipment

datasheets was generally available and information relevant to their role accessible by interviewed personnel. Random

inspection found these documents to be up to date.

10. Contractor

Management and

Procurement

Fully Implemented No findings Standard 10 Contractors, Suppliers and Partners is the relevant SHECMS element.

There are formal processes in place for contractor selection and management and contractors appear to be well managed.

Introduction of Track Easy system provides transparency of the status of licences, inductions and PTW training

11. Pre Start-up Safety

Fully Implemented No findings Standard 13 Personnel and Process Safety is the relevant SHECMS element.

Pre-startup safety checks are well covered in the modification acceptance and handover certificates system and also in plant

startup checklists.



Compliance

2013 Hazard Audit

by Aecom

(Approximate only)

Comments

12. Equipment

Integrity

Mostly

Implemented

Recommendations

made

Standard 12 Plant and Equipment Integrity is the relevant SHECMS element.

Standard 9 Project Delivery and Standard 4 Hazard and Change Management are also relevant.

SAP provides comprehensive records of maintenance history and scheduled maintenance activity. There is a low rate of

breakdown maintenance. A risk based inspection regime is in place that covers all types of equipment. A hazardous area

compliance improvement project is well underway. SHEC critical equipment is formally identified. A recommendation was made

to develop a formal process covering required documentation and authorisation / acceptance process for any deferrals of

inspection or maintenance.

13. Safe Work

Practices

Fully Implemented Recommendations

made

Standard 8 Operational Control and Standard 13 Personnel and Process Safety are the relevant SHECMS elements.

Permit to Work Systems are well developed and appear to be well implemented. Some potential improvements linking isolation

plans to permits were identified.

14. Management of

Change

Mostly

Implemented

No findings Standard 4 Hazard and Change Management is the relevant SHECMS element.

There is a formal control of modification and change management process in place which is extensively used with supporting

records available. There is an opportunity to improve the quality of closeout of hazard study actions associated with

modifications. A recommendation was made to implement a periodic check of the quality of closeout of a sample of modifications.

15. Accident/ Incident

Reporting and

Investigation

Fully Implemented No findings Standard 20 Non-conformance, Incidents and Actions is the relevant SHECMS element.

Enablon is used to record all incidents and track associated investigations / actions. Data entry and investigation was

comprehensive and transparent.

16. Training and

Education

Fully Implemented No findings Standard 5 Training, Competency and Awareness is the relevant SHECMS element.

Training and Competency systems were well developed and covered a comprehensive induction (attended by the auditor),

operations, safe work practices and corporate requirements such as use of the DMS, modifications and incident reporting in

Enablon.

No specific improvements were identified.

17. Emergency

Planning and

Response

Mostly

Implemented

No findings Standard 19 Emergency and Crisis Preparedness is the relevant SHECMS element.

Emergency Response plan (ERP) is in place and linked to MHF. It has been recently reviewed and updated to reflect changes

in site operations and neighbours, and drills / exercises completed. There is an opportunity to improve collection and

implementation of learnings from drills and evacuations.



Compliance

2013 Hazard Audit

by Aecom

(Approximate only)

Comments

18. Security and Access

Control

Not reviewed in

audit

Recommendations

made

Standard 8 Security is the relevant SHECMS element.

Security was not reviewed in detail.

KI is secure site and has a SSAN security plan in place.

Recent upgrades since 2013 Hazard Audit include perimeter fence disturbance monitoring and alarms at gatehouse (24 hr

attendance)

The auditor was accompanied by SSAN licensed personnel to areas handling AN.

Locks were observed on AN stores and AN shipping containers.

19. Auditing and

Management Review

Fully Implemented No findings Standard 21 Monitoring, Audit and Review is the relevant SHECMS element.

Numerous internal and external audits are conducted with actions tracked in Enablon.

KPIs are set up for tracking performance of each element of the management system

20. Environmental impacts /

pollution potential

Not reviewed in

audit

Not in scope of Hazard Audit

21. Environmental

Performance

Compliance

Not reviewed in

audit

Not in scope of Hazard Audit

22. Condition of Consent

Compliance

Fully Implemented Recommendations

made

Condition of Consent checks were limited to items relevant to the operational phase and to safety / hazard impacts. These were

found to be complied with.

The audit did not cover items relating solely to the construction phase or matters unrelated to process safety. Environmental (air,

water pollution, Environmental Protection Licence (EPL) compliance) or amenity issues (eg noise, traffic) were not assessed.

23. Industry guideline

compliance (SAFEX)

Fully Implemented Not included A review of the AN areas against the guidance in SAFEX was carried out. The AN storage installations are consistent with the

design and operations guidance in SAFEX. The quantitative risk assessment (QRA) work carried out as part of the preliminary

/ final hazard analysis (PHA/ FHA) for the KI expansion is also generally consistent with the SAFEX QRA guidance.

24. AS4326 Compliance

Fully Implemented Not included A review of compliance of the ammonium nitrate (AN) stores as completed against Section 9 (which has specific requirements

relating to storage and handling of AN and ammonium nitrate solution (ANS)) of AS4326 (2008) The storage and handling of

oxidizing agents. For AN stores these requirements are very similar to the SAFEX guidance.

It is noted that the KI site AN stores exceed the maximum storage quantities given in AS4362 (which requires then regulatory

consultation). QRA and MHF licence work has been undertaken on basis of the actual KI AN inventories and agreed by DPE

and Safework hence regulatory consultation requirement is regarded as satisfied.



Compliance

2013 Hazard Audit

by Aecom

(Approximate only)

Comments

25. CSB Investigation

into West Texas

(recommendations)

Mostly

Implemented

Not included A review of the AN stores against the findings of the CSB West Texas investigation was carried out. These deal largely with

separation of combustible materials from AN storage and emergency response preparedness and awareness of emergency

responders. These areas are well addressed at KI. A small number of items with respect to the design basis of the fire protection

systems and AN store ventilation need to be clarified.

26. Closeout of 2013

Hazard Audit

recommendations

Mostly

Implemented

Recommendations

made (against 2009

audit)

A review of the 2013 Hazard audit actions was completed. The majority of these have been addressed however in 2 cases

adequate information supporting the closeout was not available and needs to be verified. A number of other areas are being

implemented as ongoing projects, for example improving valve labelling in existing plant.

27. Closeout of other

study actions

Mostly

Implemented

No findings A review of actions from other studies was carried out. A number of hazard studies (HAZOPs, CSS) for the relevant stages (AMI

project, New Boiler) of the KI expansion project have been completed since the previous audit in 2013. These were reviewed

and the completion status of actions is appropriate for the stage of the projects (ie installation not complete so not all actions

complete). The KI site FSS has also been updated in 2016. There are two open recommendations.


Table 1.2: 2016 Orica Ki Site Hazard Audit Recommendations

Audit Element Recommendations Audit

Protocol

Place(s) Used

1

.

SHE Management System

Structure and Administration

Nothing specific

2. Commitment and Leadership

1. Observation: the available Safety policy at the time of the audit (Sept

2016) was signed in July 2013 by previous CEO (this is a corporate

issue and can't be addressed at the KI site level). Noted that at the

time of the audit there was a review of the SHECMS being

undertaken at corporate level so the policy would most likely be

updated as part of this). Check at next Hazard Audit (2019).

Requirements

: 2.1.1

3

.

Organization, Accountabilities and

Responsibilities

Nothing specific

4. Objectives, Target and Plans

16. Develop a system for managing actions arising from hazard studies

and risk assessments that allows demonstration of progress to be

shown. This should include:

- prioritisation of the actions in a timely manner as they arise out of

studies such as periodic hazard study 2 and 3. (Priority could be

based on addressing non-compliance with regulations, magnitude

of potential risk reduction / effectiveness, ease of installation, cost

etc similar to the SFARP process for MHF)

- implementation schedule and associated resources that suit

allocated priority.

A KPI could also be developed around completion rate or overdue

high priority actions.

Requirements

: 4.1.4, 7.1.5

5. Legal Requirements and

Codes

14. Observation: The TWC system appears to be being phased out. It

was unclear at time of the audit if all compliance information had

been migrated to Enablon. Check in next Hazard Audit (2019).

Requirements

: 5.1.1

13. Observation: Orica has previously had in place Technical Panels to

provide advice to the sites on best practices for the various

technologies (AN, ammonia). These are referred to in the SHEC MS

and the BoS. If this structure is changed, KI will need to update

process for seeking technical advice in various systems, for

example Modifications. Check in next Hazard Audit (2019)

Requirements

: 5.1.5, 7.1.2

6. Documentation

Nothing specific

7. Hazard Identification and

Risk Control

13. Observation: Orica has previously had in place Technical Panels to

provide advice to the sites on best practices for the various

technologies (AN, ammonia). These are referred to in the SHEC MS

and the BoS. If this structure is changed, KI will need to update

process for seeking technical advice in various systems, for

example Modifications. Check in next Hazard Audit (2019)

Requirements

: 5.1.5, 7.1.2

15. An overall risk profile for the KI site should be developed to allow

identification of the highest site risks, and also used to show risk

reduction over time or effect of removal of safeguards. From a

hazard perspective this should cover risk with a safety

consequence. (However it is noted that SHECMS requires that

each site maintain a record of their current hazards in a Major

Requirements

: 7.1.3



Protocol

Place(s) Used

Hazard Register, with Major Hazards definition covering Safety as

well as Health, Environment, Community, Business)

16. Develop a system for managing actions arising from hazard studies

and risk assessments that allows demonstration of progress to be

shown. This should include:

- prioritisation of the actions in a timely manner as they arise out of

studies such as periodic hazard study 2 and 3. (Priority could be

based on addressing non-compliance with regulations, magnitude

of potential risk reduction / effectiveness, ease of installation, cost

etc similar to the SFARP process for MHF)

- implementation schedule and associated resources that suit

allocated priority.

A KPI could also be developed around completion rate or overdue

high priority actions.

Requirements

: 4.1.4, 7.1.5

8. Operating Procedures

17. Observation: The Nitrates area operating procedures include

specific guidance and instructions for responding to abnormal

process situations, the NH3 plant doesn't although there is some

coverage in scenario based training. Orica to review whether the

NH3 plant should adopt a similar approach to developing

procedures for response to abnormal situations as has been done

in the Nitrates areas. Check in next Hazard Audit (2019)

Requirements

: 8.1.4

23. Observation: The MHF Process HIRACs have identified some

procedures as critical controls. It is suggested that Orica determine

a process for differentiating these from other procedures, eg

"critical" tag on document, different review frequency, specific

observations, auditing or training requirements. Check in next

Hazard Audit (2019)

Requirements

: 8.1.4

9. Process Safety Information

18. Observation: The FSS has been updated (Feb 016) and provides a

clear summary of firewater demands however does not refer to the

basis for these (for example an AS or NFPA, process dilution rate

or something else). The protection basis should be identified and

included in the next FSS revision

Requirements

: 9.1.9

10. Contractor Management and

Procurement

Nothing specific

11. Pre Start-up Safety

Nothing specific

12. Equipment Integrity

20. Develop a formal process covering required response to Capstone

pressure vessel failure criticality ratings, and required

documentation and authorisation / acceptance process for any

deferrals of inspection or maintenance.

Requirements

: 12.1.3

7. Develop implementation plan for improving HA compliance with gaps

identifies in HA inspection activities (which were completed Dec

2015) and verify progress in next Hazard Audit (2019)

Requirements

: 12.1.11,

26.1.2

19. Observation: Labelling standard in new equipment was good.

Some areas of older plant also good. Check progress of equipment

labelling project in next audit (2019)

Requirements

: 12.1.12



Protocol

Place(s) Used

13. Safe Work Practices

21. Observation: Lockout isolation sheets appear to be developed as

a list of valves / isolation points on isolation sheet on a case by case

basis. A potential improvement would be to have predefined

isolation plans for common isolations and also to attach the marked

up PIDs to the isolation sheet for all process isolations.

Requirements

: 13.1.2

22. Observation: a potential improvement would be to add the

Modification number to the WO information in SAP so it also

appears with the PTW and it is immediately clear the proposed work

is part of a modification.

Requirements

: 13.1.2

14. Management of Change

24. Observation: Organisational change assessment was not reviewed

in 2016 audit. Ensure this is covered in 2019 Hazard Audit

Requirements

: 14.1.3

25. Observation: the quality of closeout of some hazard study actions

associated with Mods was variable. To monitor this it is suggested

that some sample mods be selected periodically and a detailed

check of closeout action quality be carried out to identify any

patterns and determine if there the need for any actions such as

refresher training.

Requirements

: 14.1.11

15. Accident/ Incident Reporting

and Investigation

26. Observation: It would be useful for KPI tracking for MHF purposes

to include a Process Safety Event (PSE) flag in Enablon. It is

recognised that this would need to be done at a corporate level .

Check progress of PSE tracking at next Hazard Audit (2019)

Requirements

: 15.1.1

16. Training and Education

Nothing specific

17. Emergency Planning and

Response

27. Observation: Notes from emergency response exercise debriefs

are available. However it is suggested that any actions are formally

prioritised and completion tracked (eg using Enablon)

Requirements

: 17.1.4

18. Security and Access Control

Not reviewed

19. Auditing and Management

Review

Nothing specific

20. Environmental impacts /

pollution potential

Not reviewed

21. Environmental Performance

Compliance

Not reviewed

22. Condition of Consent

Compliance

Nothing specific

23. Industry guideline compliance

(SAFEX)

2. Confirm lightening protection is adequate for AN bulk store and AN

bag store

Requirements

: 23.1.4

4. Observation: The wooden walkways between the disused building

adjacent to the AN bulk store are the only identified combustible

building materials in the vicinity of the Bulk Store. Whilst ignition and

escalation are unlikely, removal is suggested which would eliminate

all combustibles in the vicinity of the Bulk Store.

Requirements

: 23.1.4,

25.1.1

12. Observation: Overall reduction in combustibles in vicinity of AN can

only be achieved by removal of wooden pallets and potentially

change in AN bag material. It is suggested that Orica ensure that

Requirements

: 23.1.4,

24.1.7



Protocol

Place(s) Used

the current project investigating use of non-combustible pallets /

bags include a formal SFARP demonstration that supports the

project decision (as required under MHF regulations) and also that

project outcomes be checked in next Hazard Audit (2019)

3. Observation: The QRA (in FHA) appears to use the total inventory

of the Bag Store (Table AV-5) in the consequence assessment.

Given the storage configuration with 8m between stacks there may

be scope to reduce this to a single stack basis in future revision of

the QRA. Orica to review QRA AN bag store basis when QRA update

is next required

Requirements

: 23.1.8


12. Observation: Overall reduction in combustibles in vicinity of AN can

only be achieved by removal of wooden pallets and potentially

change in AN bag material. It is suggested that Orica ensure that

the current project investigating use of non-combustible pallets /

bags include a formal SFARP demonstration that supports the

project decision (as required under MHF regulations) and also that


Requirements

: 23.1.4,

24.1.7

25. CSB Investigation into West

Texas (recommendations)

4. Observation: The wooden walkways between the disused building

adjacent to the AN bulk store are the only identified combustible

building materials in the vicinity of the Bulk Store. Whilst ignition and

escalation are unlikely, removal is suggested which would eliminate

all combustibles in the vicinity of the Bulk Store.

Requirements

: 23.1.4,

25.1.1

5. Confirm the design fire / suppression basis for the fire protection

systems in the AN Bulk and Bag Stores to ensure they are

"adequate", eg meet relevant codes or control measure adequacy

tests adopted in MHF risk assessments.

Requirements

: 25.1.1

6. Observation: It is not clear what "adequate" ventilation is for the AN

storage buildings. It is suggested that this be clarified ie is it to meet

relevant codes or control measure adequacy tests adopted in MHF

risk assessments and whether provided systems achieve this

Requirements

: 25.1.1

26. Closeout of 2013 Hazard

Audit recommendations




Requirements

: 12.1.11,

26.1.2

8. Observation: (2013 Hazard Audit Rec 4) Fire pump test log results

are available in electronic form but not in pump house. If hard copy

local records are not preferred by Orica, it is suggested that

information be provided in the Pump house as to where to find the

records.

Requirements

: 26.1.4

9. (2013 Hazard Audit Rec 7) Clarify the process for providing feedback

on completion of a job completed under a WO, ie if there is an issue

with completion of work confirm how is this captured and how any

patterns are identified over time.

Requirements

: 26.1.7

10. (2013 Hazard Audit Rec 14) The installed pressure / flow capability

of the modified fire water system at the AN Bag store needs to be

confirmed to ensure that it meets the required design basis.

Requirements

: 26.1.14,

27.1.2



Protocol

Place(s) Used

Confirmation the velocities in firewater piping do not exceed AS

requirements is also required

11. Confirm that the separation distance between the H2 cylinders and

the adjacent oxidising gas cylinders is adequate, for example meets

requirements in AS 4332 The storage and handling of gases in

cylinders

Requirements

: 26.1.15

27. Closeout of other study

actions

28. Check progress on compliance with site firewater booster

arrangements against AS2419 in next Hazard Audit (2019)

Requirements

: 27.1.1






Requirements

: 26.1.14,

27.1.2


2. CONTEXT AND SCOPE OF HAZARD AUDIT

2.1. Background

Orica Australia Pty Ltd (Orica) operates an ammonium nitrate facility at Kooragang

Island, NSW, comprising an ammonia plant, a number of nitric acid and ammonium

nitrate manufacturing plants, associated storages and other infrastructure.

The site has been operating since the late 1960s and has been expanded several times.

It is the subject to various development approvals with associated conditions of consent

including preparation of a series of safety and environmental management studies in the

design and commission stages, as well as the requirement for a periodic Hazard Audit

in the operational stage of the facility.

2.2. Audit context

This report is the 2016 Hazard Audit for the Orica Ammonium Nitrate facility located at

15 Greenleaf Rd, Kooragang Island, NSW (the Orica KI site).

Orica retained Sherpa Consulting Pty Ltd (Sherpa) as independent auditors approved

by the NSW Department of Planning and Environment (DPE) to conduct the 2016

Hazard Audit. The auditor approval is contained in APPENDIX A.

The Hazard Audit concurrently covers the requirement for a Hazard Audit associated

with NSW Department of Planning and Environment (DPE) conditions to the approval

for two main developments to the site:

08_0129 (2009) Orica Ammonium Nitrate Expansion Project

N91/00593/003 (April 1998) Ammonium Nitrate Plant Upgrade

2.2.1. 2009 Expansion

Orica received development approval from the NSW Department of Planning and

Environment (DPE) for an expansion of the KI facility in 2009 (application no: 08_0129).

The proposal covered expansion of the existing ammonium nitrate (AN) manufacturing

facility, comprising modifications and upgrades to existing plants and infrastructure and

the development of additional nitic acid and AN plants (NAP4 and AN3). Subsequently,

modifications to the consent were made (MOD1 in 2012, MOD2 in 2014 and MOD3 in

2015).

The proposed development has been staged (as agreed with DPE) with the first main

stage being an uprate of the existing ammonia plant which was completed and

commenced operation in 2012.

The subsequent stage was construction of new nitrate acid (NAP4) and ammonium

nitrate manufacturing plants (AN3), however this has been put on hold due to changes

in economic conditions.


Hazard Audit Extract from 08_0129 Schedule 3 Item 20:

A previous Hazard Audit was undertaken by Aecom in 2013 approximately one year

after the ammonia plant uprate commenced operations (doc ref: Hazard Audit - 2013

Ammonium Nitrate Plant - Kooragang Island 60274735-RPT Final Rev 0 March 2013).

2.2.2. 1998 Expansion

Orica received development approval from the NSW Department of Planning and

Environment (DPE) for an expansion of the KI facility in 1998. The proposal covered

expansion of the existing ammonium nitrate (AN) manufacturing facility and

development of additional nitic acid plant (NAP3). This project has been completed and

has been operational for some time.

Hazard Audit Extract from N91/00593/003 Schedule 2 Item 12:

2.3. Audit Purpose and Objectives

The overall purpose is to undertake the Hazard Audit in compliance with condition of

consent requirements.


The Hazard Audit objectives are to determine that:

Orica management and personnel understand and demonstrate Safety, Health

and Environment (SHE) leadership.

Safety concerns are being managed in accordance with regulatory requirements

and commitments in the environmental management plan and hazard and risk

assessments for the site.

Relevant NSW Regulations and Orica safety expectations have been identified

and complied with.

An adequate Safety Management System (SMS) framework for risk

management of safety issues (identification, assessment, tracking and close-out)

has been established.

Adequate safety management system documentation has been prepared by

Orica.

Audit actions from the previous Hazard Audit and similar audits have been

closed.

Orica has allocated sufficient resources for managing environmental and safety

issues.

Industry standard guidance (e.g. SAFEX, AS4326) are being followed.

Where appropriate, recommendations to improve the overall safety of the facility will be

provided.

2.4. Scope

The Audit covered the operations and associated plant/equipment of the Orica KI site.

The nature of an audit means that a sample of activities is examined. In this case the

audit focused on:

Site inspection of the ammonia plant and road tanker loadout area, NAP3/AN2

plants and AN stores.

Documentation review and site inspection of changes in operations at KI since

the previous 2013 Hazard Audit was completed

Specific reviews were undertaken as follows:

The site and plant modifications associated with the expansion project since

2013. This is primarily a set of ammonia risk reduction projects referred to as the

Ammonia Management Improvement (AMI) Project.

Close out of actions arising from 2013 Hazard Audit and other studies that may

have occurred since 2013.



Investigation Report (Final January 2016)

Compliance with AS4326 (2008) Storage and Handling of Oxidising Agents.


(SAFEX Good Practice Guide: Storage of Solid Technical Grade AN, Rev 2

2014).

2.5. Exclusions and Limitations

The audit did not cover environmental performance or conditions of consent as this is

covered in a separate Environmental Audit (last completed in 2014).

Security aspects were not assessed in detail as there is a detailed security plan in place

and the site is subject to Security Sensitive AN (SSAN) regulatory requirements.

At the time of conducting this audit (August 2016), there were various major projects in

progress and at different stages of advancement. In particular:

A set of ammonia risk reduction projects referred to as the Ammonia Management

Improvement (AMI) Project. A significant proportion of this project is complete

including installation of ammonia storage flare and nitrates flare, consolidation of the

ammonia supply to the AN plants to a single smaller storage vessel and removal of

NAP2 ammonia storage bullet, and connection of various ammonia vent streams to

scrubbers. The audit included review of the design, commissioning and modification

closeout process for the parts of this project that were operational.

A new boiler (Site Steam Upgrade project). This is largely installed but not

commissioned. The audit covered review of closeout of the design stage safety

studies only.

A replacement ammonia pipeline between the KI site and the wharf. This project has

experienced some delays due to issues arising during preparatory works. The audit

did not cover this project

2.6. Audit Approach

The audit involved site visits, discussions with a site personnel and a review of site and

corporate documentation.

To provide a structure for the Audit, the auditors utilised an internally developed audit

protocol covering elements of a typical SMS.

The protocol is based on the requirements of published management systems structures

including:

AS/NZS ISO 19011: 2014 Guidelines for auditing management systems


NSW DPE Guidelines Hazardous Industry Planning Advisory Paper (HIPAP) No.5

Hazard Audit (2011)

NSW DPE Guidelines HIPAP No.9 Safety Management (2011).

2.6.1. Evidence summary

A summary of documentation sighted or reviewed in this audit is listed in APPENDIX B.

Details of the protocol and the specific evidence used to support comments for each

element are provided in the completed audit worksheets in APPENDIX D

2.6.2. Audit schedule and personnel interviewed

The audit schedule was as follows:

Preliminary documentation was provided by Orica to Sherpa in mid July 2016

A 3 day site visit carried out in early August 2016.

After the site visit supplementary documentation was provide to the auditors by

Orica and reviewed over August 2016

Draft audit report prepared September 2016.

A closeout phone conference was carried out and the final report issued in

October 2016 for provision to DPE.

Details of the audit site visit schedule are shown in Table 2.1.

The organisational structure and people interviewed are shown in APPENDIX C.

Specific personnel interviewed in relation to each element are noted in the completed

audit worksheets in APPENDIX D

Table 2.1: Audit Site Visit Summary

Date Duration Description Leader

1. 02/08/2016

10.00 Audit kickoff

Induction

Interviews

Jenny Polich

2. 03/08/2016

10.00 Interviews

Site visit - AN Bulk and Bag stores

Stuart Chia

3. 04/08/2016

8.00 Site visit - Ammonia Plant

Site visit - NAP3/AN2, including new

ammonia storage arrangements as part of

AMI Project

Interviews

Closeout meeting

Jenny Polich


3. OVERVIEW OF THE SITE

3.1. Site location and surrounding land uses

The Orica KI manufacturing site is located on Kooragang Island near the mouth of the

Hunter River within the Port of Newcastle, approximately 3.5 km north of Newcastle in

New South Wales. The site adjoins Greenleaf Road to the east and Heron Road to the

west.

The surrounding land use is industrial as follows:

North - The Incitec Pivot Fertiliser distribution centre adjoins the Orica KI at the

northern boundary

North West – Kooragang Berth No.2, used for the unloading of cement,

vegetable oil, woodchip and bulk products (fertiliser, ammonia, and ammonium

nitrate)

South – Warehousing and Despatch Facility warehouse adjacent to the southern

boundary of the Orica KI

East –strip of land between Greenleaf Road and the Orica KI site – formerly

disused bulk storage tanks have been recommissioned for biodiesel by Pacific

Oils since 2013.

The nearest residential area is Stockton around 800m away from the KI site. An aerial

photo showing the location of site is provided in Figure 3.1.

3.2. Site layout

The Orica KI site includes:

An Ammonia Plant

Three Nitric Acid Plants, NAP1, NAP2 and NAP3 (raw material for AN plants)

Two AN Plants, AN1 and AN2 which manufactures Technical Grade AN (TGAN,

a granulated / prilled product) and ammonium nitrate solution (ANS).

Storage and loadout facilities for anhydrous ammonia, solid ammonium nitrate,

AN solution, nitric acid

Offices and amenities located adjacent to Greenleaf road on the eastern side of

the plant.

A layout showing the main plant locations is given in Figure 3.2.


Figure 3.1: Orica KI Site - Aerial Photo

Pacific Oil

(new)

Incitec

site

Berth

Warehousing

Woodchips and agri

products

Document: 21065-RP-001

Revision: 0

Revision Date: 11-Nov-2016

Document ID: 21065-RP-001 Rev 0

Figure 3.2: Site layout

NOTE: This figure has been reproduced from the Aecom 2013 Hazard Audit report and

the approximate locations of major new equipment identified.

New Ammonia storage for

Nitrates (AMI Project)

Nitrates flare

(AMI Project)

Ammonia storage

flare (AMI Project)


3.3. Organisation and staffing

There are approximately 170 people based at KI. The number can fluctuate significantly

depending on contract personnel who may be employed for specific projects.

The site is operational 24 hours per day, 7 days per week with the gatehouse and control

rooms permanently manned.

Numerous contract tanker drivers from a number of logistics providers are inducted into

the site and have swipe card access.

At the time of the 2016 audit the majority of personnel reported through the

Manufacturing division with safety and environment personnel reporting independently

via the Safety, Health, Environment and Security (SHES) division.

The organisation chart in place at the time of the audit for these divisions is shown in

APPENDIX C.

3.4. Process overview

A simplified and brief summary of the process only is provided.

3.4.1. Ammonia Plant

The Ammonia Plant at Kooragang Island produces ammonia by:

Reforming natural gas with steam to produce synthesis gas (syngas; a mixture

of hydrogen (H2), water, carbon monoxide (CO) and carbon dioxide (CO2)) over

a nickel catalyst at around 30 barg.

The gas stream is then passed through a shift converter, where the CO is

converted to CO2 and H2.

The process gas is then fed to a CO2 removal process, using Methyl Diethyl

Amine (MDEA) solution re-boiler to adsorb CO2 followed by a catalysed

polishing step

The clean syngas, is compressed to around 60 barg, washed and fed to the

ammonia converters (catalysed reaction) which convert the syngas to ammonia.

Various purification, pressure reduction and chilling steps occur and the

ammonia discharging from the refrigeration system is send to atmospheric

pressure and pressurised tanks for storage.

3.4.2. Nitric Acid

There are three similar Nitric Acid plants:

Liquid ammonia from storage is evaporated using water, or steam, and

superheated to prevent any liquid carry over.

It is fed to a static mixer, used to produce a uniform ammonia-air mixture


The ammonia-air mixture is reacted in a catalysed ammonia converter, forming,

nitrous oxide, nitrogen and water and cooled.

The cooled gas stream is then directed to the Absorption Column where

additional air and water is required to drive the reactions to completion producing

nitric acid

the nitric acid, at a concentration between 55 and 65%, is pumped to the nitric

acid storage tanks.

3.4.3. Nitrates Plants

There are four essential steps in the production of ammonium nitrate (AN):

Neutralisation - nitric acid is neutralised with ammonia to produce a concentrated

solution of ammonium nitrate in an instantaneous exothermic reaction

Evaporation - water is evaporated from the solution to give a suitably high

concentration of solution for solidification or as a commercial product.

Prilling and drying or granulation - producing ammonium nitrate in a solid form;

Screening, cooling and coating - to give the commercial product.

AN is stored as bulk or bagged product before despatch.

3.5. Properties of materials being handled and processed

The major hazardous materials stored onsite are ammonia (toxic and flammable) and

ammonium nitrate solid and solution (strong oxidiser and potentially explosive). There

are also numerous other hazardous materials as detailed in the site dangerous goods

(DG) manifest and associated depot drawings. .

3.6. Security

At Orica KI, a site security plan is in place which includes:

personnel and vehicle access arrangements, including supervised access points

and electronic access systems;

security of overall boundary and buildings

security arrangements associated with the manufacture and storage of security

sensitive ammonium nitrate (SSAN) for specific areas within the overall secure

site

security monitoring and assurance.

This audit did not cover the security arrangements in detail.


3.7. Summary of changes to site since the previous audit

Important changes, of relevance to this audit, since the last audit (2013) were identified

and have been summarised in Table 3.1.

Table 3.1: Site changes since 2013

Title Description

Plant and Equipment (major changes)

AMI Project – Nitrates flare installation

AMI Project – Ammonia Storage flare installation

AMI Project – Ammonia bullet replacement for Nitrates feed installation

New Boiler – construction commenced but not operational

Safeguards Breakaway connections at ammonia road tanker removed due to mechanical failures

Chlorguard auto shutdown devices on chlorine drums

Systems Enablon implemented (corporate level) for incident reporting (replaced SHERMIS)

Enablon implemented (corporate level) for incident reporting (replaced SHERMIS)

Enablon implemented (corporate level) for incident reporting (replaced TWC)

SAP fully rolled out for maintenance and integrity and all plant items transferred

SAP Permit To Work module rolled out

Trak Easy web based training records package introduced. Currently covers licences (eg SSAN, forklift, crane), PTW and inductions for employees and contractors - being expanded to cover other items

Vault software introduced for all drawing control

Organisation and staffing

Site environment, risk and safety personnel now have independent reporting chain and report through SHES (not Manufacturing)

Responsible Engineers role introduced

Neighbours Pacific Oils biodiesel storage facility operational

Tasmania Mines (South east of site

Vue Cement (formally Hydro, north west of site)


4. AUDIT OF SITE

This part of the audit provides a summary of the site inspection of the KI site activities

and associated equipment.

The inspection was executed with the Environment Lead over several days in August

2016 and supporting maintenance records from SAP were provided by the maintenance

team both during and after the site visit. As noted in the sections below, site equipment

was observed to be in good condition, the standard of housekeeping was high and

discussions with operators in control rooms indicated a high level of hazard awareness,

operations, response to alarms and abnormal conditions and other training, and a good

ability to navigate through operator interface screens.

4.1. Site inspections

4.1.1. Ammonia plant

A walkaround of the ammonia plant indicated the following

Equipment was generally in good condition, some surface corrosion. One leak

observed in a valve near flash drums (will be addressed in shutdown – refer to

audit checksheets in APPENDIX D). Minimal odours.

Personal Protective Equipment (PPE) signage appeared adequate. Valve and

pipe labelling was present but not consistent over the whole plant.

Hoses inspected all had tagging and were within test.

Housekeeping standard was high. Minimal rubbish or redundant equipment,

bunds clear.

Discussions in the control room involving a shift team leader (highly experienced, 20

years plus) and a new superintendent (several months at site) indicated:

Good understanding of plants and its hazards

Understanding of training and procedures. Good knowledge of abnormal

conditions, controlled shutdown screen. No specific procedures on response to

abnormal conditions.

Good understanding of the SAP based PTW system and documentation in

control room correct.

4.1.2. NAP3/AN2

A walkaround of the NAP3/AN2 plant indicated the following

Equipment was generally in good condition, some surface corrosion. No leaks

observed. Minimal odours.


PPE signage appeared adequate. Valve and pipe labelling was present but not

consistent over the whole plant.

Hoses inspected all had tagging and were within test.

Housekeeping standard was high. Minimal rubbish or redundant equipment,

bunds clear.

Discussions in the control room involving a shift team leader (experienced, 20 years)

indicated:

Good understanding of plants and its hazards.

Knowledgeable about AMI project changes

Good understanding of the SAP based PTW system and documentation in

control room correct.

4.1.3. AMI Projects

A walkaround of the new ammonia storage equipment (vessel, pumps) supplying

Nitrates and Nitrates flare indicated the following

Equipment was in excellent condition. No leaks or evidence of previous leaks

observed.

Housekeeping standard was very high. No rubbish or redundant equipment,

bunds clear.

All equipment (including electrical and instrument cabling) and pipe labelling

clear and of a high standard.

Changes to process were reflected in operating procedures and operator training

had occurred.

Specific response to abnormal conditions covered in the Nitrates operating

procedures.

4.1.4. AN Bulk and Bag Store

A walkaround of the AN bulk and Bag stores indicated the following

Equipment was in reasonable condition. Some redundant equipment remains.

Dust levels in stores were low, no observable ventilation issues.

Housekeeping standard was high. No rubbish or redundant equipment or

packaging materials.

No significant quantities of combustible materials.

No evidence of significant leakage of oil or hydraulic fluids.

FEL and forklift had dedicated parking areas.


Separations maintained and clear of obstacles or other materials between walls

and AN product, and between stacks of AN product

Refer to Section 4.2 for comments around compliance with industry guidance.

4.1.5. Other Facilities

Fire protection equipment appeared to be tagged and within test.

A number of transformer and switchroom upgrade projects have been completed.

4.2. Check against industry standards for AN stores

As required by the conditions of consent a review of the AN storage requirements in

relevant industry guidelines was carried out:


investigation report (Final 2016)

Compliance with relevant sections of AS4326 (2008) Storage and Handling of

Oxidising Agents.


(SAFEX Good Practice Guide: Storage of Solid Technical Grade AN, Rev 2).

The results are summarised in Table 4.1 below for each guideline. Broadly the KI site

already addresses the recommendations and guidance. Refer to audit checksheets in

APPENDIX D for additional details and actions and observations.

Table 4.1: Assessment of AN against industry guidance


Compliance

Comments

23. Industry guideline

compliance

(SAFEX)

Fully Implemented A review of the AN areas against the guidance in SAFEX

was carried out. The AN storage installations are consistent

with the design and operations guidance in SAFEX. The

QRA work carried out as part of the PHA/ FHA for the KI

expansion is also generally consistent with the SAFEX

QRA guidance.


Fully Implemented A review of compliance of the AN stores as completed

against Section 9 (which has specific requirements relating

to storage and handling of AN and ANS) of AS4326 (2008)

The storage and handling of oxidizing agents. For AN

stores these requirements are very similar to the SAFEX

guidance.

It is noted that the KI site AN stores exceed the maximum

storage quantities given in AS4362 (which then requires

regulatory consultation). QRA and MHF licence work has

been undertaken on basis of the actual KI AN inventories



Compliance

Comments

and agreed by DPE and Safework hence regulatory

consultation requirement is regarded as satisfied.

25. CSB Investigation

into West Texas

(recommendations)

Mostly

Implemented

A review of the AN stores against the findings of the CSB

West Texas investigation was carried out. These deal

largely with separation of combustible materials from AN

storage and emergency response preparedness and

awareness of emergency responders. These areas are well

addressed at KI. A small number of items with respect to

the design basis of the fire protection systems and AN store

ventilation need to be clarified.


5. AUDIT OF SAFETY MANAGEMENT SYSTEMS

5.1. Overview

This part of the audit was to determine if Orica has implemented a comprehensive safety

management system for controlling the risk of potential safety and process safety

hazards at the KI site.

5.2. Integrated Management System, SHECMS

Orica’s corporate policies as outlined in the SHECMS overview and standards

demonstrate the company commitments to satisfying the stringent standards demanded

by the community and legislative forces, management are committed to managing risks

to the community, their workforce including contractors. These commitments are broadly

captured in Orica’s corporate safety policy which applies to all Orica facilities globally.

SHE issues at KI are managed through the implementation of the SHECMS which

contains the policies, organisational arrangements, corporate standards and procedures

required to support the on-going integrity of control measures required for safe and

environmentally compliant operation. Operational and maintenance procedures are

customised at the site level.

5.3. Findings

Details of the assessment against each element of the audit protocol is given in

APPENDIX D. A high level summary of the key findings for each element is presented

in the summary of the report in Table 1.1.

Each element has been assigned a rating using a traffic light system based on auditor

judgement after review of the available information as follows:

Category Description

Not Applicable Not relevant to site

Not reviewed in

audit

Is relevant but not reviewed (out of scope, covered by something else or

insufficient time)

Non-compliance Non-compliant with a regulatory instrument or condition of consent (may

be What is done or how it is done that is non-compliant)

Nothing in Place No framework or supporting examples

Being Developed A framework or high level guidance but few supporting examples

Mostly Implemented A framework or high level guidance with a number of supporting

examples. However some areas could be clarified or not consistent with

industry practices

Fully Implemented A framework or high level guidance with full supporting examples. May

still be some observations regarding additional clarity, best practice etc


Category Description

Exceptional (best

practice & share)

A framework and high level guidance with full supporting examples,

performance tracking and evidence of long term continuous improvement

, benchmarking

Overall, the management of safety issues at the KI site is considered by the auditors to

be adequately covered by the SHEC MS as implemented at site level.

No Non-compliances or Nothing in Place ratings were assigned. All elements were

assessed as Fully Implemented or Mostly Implemented.

As noted in the present audit, a strong safety culture is evident at KI and there is a

positive attitude at all levels that will foster on-going improvements in environmental and

process safety management.

Key findings organized against management system elements are presented in the

assessment summary in Table 1.2 in the summary section of this report, with the overall

list of actions for all elements provided in Section 7 of this report.


6. SITE HISTORY

6.1. Previous Studies

6.1.1. Closure of 2013 Hazard Audit actions

As noted under Item 26 of the audit protocol, closure of actions arising from the previous

2013 hazard audit is largely complete, however there were two items where insufficient

evidence was available to verify closure as per Table 6.1 and also three items where a

new recommendation was raised in relation to further progressing the closeout action

completed.

Table 6.1: Further Actions 2013 Audit Actions

Element Recommendations

26. Closeout of 2013

Hazard Audit

recommendations

9. (2013 Hazard Audit Rec 7) Clarify the process for providing feedback

on completion of a job completed under a WO, ie if there is an issue

with completion of work confirm how is this captured and how any

patterns are identified over time.









8. Observation: (2013 Hazard Audit Rec 4) Fire pump test log results

are available in electronic form but not in pump house. If hard copy

local records are not preferred by Orica, it is suggested that

information be provided in the Pump house as to where to find the

records.

11. Confirm that the separation distance between the H2 cylinders and

the adjacent oxidising gas cylinders is adequate, for example meets

requirements in AS 4332 The storage and handling of gases in

cylinders

6.1.2. Other Studies

As noted under Item 27 of the audit protocol, closure of actions arising from hazard

studies associated with the staging of the AMI project and New Boiler Project are

complete as appropriate to the stage of the projects. Table 6.2 shows two

recommendations relating to closeout against actions in the site Fire Safety Study.


Table 6.2: Hazard Study Actions Closeout

Element Recommendations

27. Closeout of other study

actions

28. Check progress on compliance with site firewater booster

arrangements against AS2419 in next Hazard Audit (2019)






6.1.3. Closure of 2013 NSW DPE Audit actions

In June 2013, NSW DPE undertook a Compliance Audit of KI as part of the NSW

Potentially Hazardous Industries campaign. Orica advised that the site has been closing

the actions and showed correspondence to verify that it has been engaging with NSW

DPE.

6.2. Incident history

As per the relevant SMS system element, all incidents and near misses are reported

and entered into Enablon.

From a hazard viewpoint, the incidents in Table 6.3 were summarized from Enablon that

have occurred at KI since 2013 and had a potential safety impact of “serious” or “very

serious”. Note these incidents were localised and contained on site hence did not have

an actual impact outside the site. In most cases with the exception of the items

highlighted in yellow there was also no potential for offsite effects. In the case of the

ammonia incident other control measure failures would also need to occur for an offsite

effect to be experienced.

Table 6.3: Incident summary since 2013

Event ID Event Date

Type Short Description Classification Potential Severity

2014-00000914

08/07/14 01:00 pm

Near Miss 2201JAT tripped but trip valve did not stop the turbine

Property Damage / Loss or Failure

3 -Lost Work, Temporary Disability

2015-00005653

10/03/15 08:00 am

Incident (Non work related) Employee lost footing and fell on concrete path whilst travelling from Main Gate to Administration Building

Injury/Illness 3 -Lost Work, Temporary Disability

2015-00005923

24/03/15 12:35 pm

Near Miss ID & FD fan turbines tripped but continued to run.




Event ID Event Date

Type Short Description Classification Potential Severity

2015-00009421

21/08/15 05:00 pm

Incident Maintainer servicing BBAC received an electric shock to right hand

Injury/Illness 4 -Fatality, Total Permanent Disability

2015-00009426

21/08/15 08:45 pm

Incident Worker received electric shock while unplugging Lifeguard multi-outlet device


2015-00011372

18/11/15 01:30 pm

Incident Acid burn to IE maintainer when removing plug.


2015-00011605

26/11/15 01:30 pm

Incident Cleaner received electric shock


2015-00012065

13/12/15 08:00 am

Incident Syn gas leak from standpipe at 104F via 103J casing drains

Environmental 3 -Lost Work, Temporary Disability

2015-00012069

09/12/15 01:30 am

Near Miss Trip test failed on IF fan turbine



2015-00012097

14/12/15 02:30 am

Near Miss ID Fan failed to trip on overspeed


2016-00012477

04/01/16 12:00 am

Near Miss Pipe support fell to ground from riser to 101F


2016-00014510

03/04/16 12:00 am

Incident Break away coupling broke and did not fully seal, resulting in leak of Ammonia

Environmental 3 -Lost Work, Temporary Disability

2016-00014592

07/04/16 08:15 am

Incident Trolley collapsed under the weight of ID Fan shaft resulting in shaft rolling out breaking it`s storage box



2016-00014993

26/04/16 07:00 am

Near Miss Unsecured Floor Grate Injury/Illness 3 -Lost Work, Temporary Disability


7. RECOMMENDATION SUMMARY

A total of 28 recommendations to further improve safety management at the KI site were

identified throughout the audit and have been summarised in Table 7.1.

These recommendations are divided into two categories:

1. Actions: These items relate to areas where compliance with a regulatory instrument

or Orica internal company standard could not be confirmed based on the evidence

available to the auditors. This included the system elements relating to Hazard

Identification and Risk Assessment, Management of Change (MOC) and compliance

with closeout of previous Hazard Audit actions.

2. Observations: recommendations have been provided that could enhance existing

systems or where a specific check is recommended for the next Hazard Audit in

2019 to confirm continuance of a system or programme. These items are labelled as

Observation in the recommendation summary.

Following submission of this audit report to DPE, Orica will enter the recommendations

and required completion dates into the Enablon tracking system (adopted Orica-wide)

to ensure actions are closed out and documented as such.

Table 7.1: 2016 Hazard Audit Recommendation Summary

Recommendations Audit Protocol

Place(s) Used

1. Observation: the available Safety policy at the time of the audit (Sept 2016) was signed in July 2013

by previous CEO (this is a corporate issue and can't be addressed at the KI site level). Noted that at

the time of the audit there was a review of the SHECMS being undertaken at corporate level so the

policy would most likely be updated as part of this). Check at next Hazard Audit (2019).

Requirements :

2.1.1

2. Confirm lightening protection is adequate for AN bulk store and AN bag store

Requirements :

23.1.4

3. Observation: The QRA (in FHA) appears to use the total inventory of the Bag Store (Table AV-5) in

the consequence assessment. Given the storage configuration with 8m between stacks there may

be scope to reduce this to a single stack basis in future revision of the QRA. Orica to review QRA AN

bag store basis when QRA update is next required

Requirements :

23.1.8

4. Observation: The wooden walkways between the disused building adjacent to the AN bulk store are

the only identified combustible building materials in the vicinity of the Bulk Store. Whilst ignition and

escalation are unlikely, removal is suggested which would eliminate all combustibles in the vicinity of

the Bulk Store.

Requirements :

23.1.4, 25.1.1

5. Confirm the design fire / suppression basis for the fire protection systems in the AN Bulk and Bag

Stores to ensure they are "adequate", eg meet relevant codes or control measure adequacy tests

adopted in MHF risk assessments.

Requirements :

25.1.1

6. Observation: It is not clear what "adequate" ventilation is for the AN storage buildings. It is suggested

that this be clarified ie is it to meet relevant codes or control measure adequacy tests adopted in MHF

risk assessments and whether provided systems achieve this

Requirements :

25.1.1

7. Develop implementation plan for improving HA compliance with gaps identifies in HA inspection

activities (which were completed Dec 2015) and verify progress in next Hazard Audit (2019)

Requirements :

12.1.11, 26.1.2



Place(s) Used

8. Observation: (2013 Hazard Audit Rec 4) Fire pump test log results are available in electronic form

but not in pump house. If hard copy local records are not preferred by Orica, it is suggested that

information be provided in the Pump house as to where to find the records.

Requirements :

26.1.4

9. (2013 Hazard Audit Rec 7) Clarify the process for providing feedback on completion of a job

completed under a WO, ie if there is an issue with completion of work confirm how is this captured

and how any patterns are identified over time.

Requirements :

26.1.7

10. (2013 Hazard Audit Rec 14) The installed pressure / flow capability of the modified fire water system

at the AN Bag store needs to be confirmed to ensure that it meets the required design basis.

Confirmation the velocities in firewater piping do not exceed AS requirements is also required

Requirements :

26.1.14, 27.1.2

11. Confirm that the separation distance between the H2 cylinders and the adjacent oxidising gas

cylinders is adequate, for example meets requirements in AS 4332 The storage and handling of

gases in cylinders

Requirements :

26.1.15

12. Observation: Overall reduction in combustibles in vicinity of AN can only be achieved by removal of

wooden pallets and potentially change in AN bag material. It is suggested that Orica ensure that the

current project investigating use of non-combustible pallets / bags include a formal SFARP

demonstration that supports the project decision (as required under MHF regulations) and also that


Requirements :

23.1.4, 24.1.7

13. Observation: Orica has previously had in place Technical Panels to provide advice to the sites on

best practices for the various technologies (AN, ammonia). These are referred to in the SHEC MS

and the BoS. If this structure is changed, KI will need to update process for seeking technical advice

in various systems, for example Modifications. Check in next Hazard Audit (2019)

Requirements :

5.1.5, 7.1.2

14. Observation: The TWC system appears to be being phased out. It was unclear at time of the audit

if all compliance information had been migrated to Enablon. Check in next Hazard Audit (2019).

Requirements :

5.1.1

15. An overall risk profile for the KI site should be developed to allow identification of the highest site

risks, and also used to show risk reduction over time or effect of removal of safeguards. From a

hazard perspective this should cover risk with a safety consequence. (However it is noted that

SHECMS requires that each site maintain a record of their current hazards in a Major Hazard

Register, with Major Hazards definition covering Safety as well as Health, Environment, Community,

Business)

Requirements :

7.1.3

16. Develop a system for managing actions arising from hazard studies and risk assessments that

allows demonstration of progress to be shown. This should include:

- prioritisation of the actions in a timely manner as they arise out of studies such as periodic hazard

study 2 and 3. (Priority could be based on addressing non-compliance with regulations, magnitude

of potential risk reduction / effectiveness, ease of installation, cost etc similar to the SFARP process

for MHF)

- implementation schedule and associated resources that suit allocated priority.

A KPI could also be developed around completion rate or overdue high priority actions.

Requirements :

4.1.4, 7.1.5

17. Observation: The Nitrates area operating procedures include specific guidance and instructions for

responding to abnormal process situations, the NH3 plant doesn't although there is some coverage

in scenario based training. Orica to review whether the NH3 plant should adopt a similar approach

to developing procedures for response to abnormal situations as has been done in the Nitrates

areas. Check in next Hazard Audit (2019)

Requirements :

8.1.4



Place(s) Used

18. Observation: The FSS has been updated (Feb 016) and provides a clear summary of firewater

demands however does not refer to the basis for these (for example an AS or NFPA, process dilution

rate or something else). The protection basis should be identified and included in the next FSS

revision

Requirements :

9.1.9

19. Observation: Labelling standard in new equipment was good. Some areas of older plant also good.

Check progress of equipment labelling project in next audit (2019)

Requirements :

12.1.12

20. Develop a formal process covering required response to Capstone pressure vessel failure criticality

ratings, and required documentation and authorisation / acceptance process for any deferrals of

inspection or maintenance.

Requirements :

12.1.3

21. Observation: Lockout isolation sheets appear to be developed as a list of valves / isolation points

on isolation sheet on a case by case basis. A potential improvement would be to have predefined

isolation plans for common isolations and also to attach the marked up PIDs to the isolation sheet

for all process isolations.

Requirements :

13.1.2

22. Observation: a potential improvement would be to add the Modification number to the WO

information in SAP so it also appears with the PTW and it is immediately clear the proposed work is

part of a modification.

Requirements :

13.1.2

23. Observation: The MHF Process HIRACs have identified some procedures as critical controls. It is

suggested that Orica determine a process for differentiating these from other procedures, eg

"critical" tag on document, different review frequency, specific observations, auditing or training

requirements. Check in next Hazard Audit (2019)

Requirements :

8.1.4

24. Observation: Organisational change assessment was not reviewed in 2016 audit. Ensure this is

covered in 2019 Hazard Audit

Requirements :

14.1.3

25. Observation: the quality of closeout of some hazard study actions associated with Mods was

variable. To monitor this it is suggested that some sample mods be selected periodically and a

detailed check of closeout action quality be carried out to identify any patterns and determine if

there the need for any actions such as refresher training.

Requirements :

14.1.11

26. Observation: It would be useful for KPI tracking for MHF purposes to include a Process Safety Event

(PSE) flag in Enablon. It is recognised that this would need to be done at a corporate level . Check

progress of PSE tracking at next Hazard Audit (2019)

Requirements :

15.1.1

27. Observation: Notes from emergency response exercise debriefs are available. However it is

suggested that any actions are formally prioritised and completion tracked (eg using Enablon)

Requirements :

17.1.4

28. Check progress on compliance with site firewater booster arrangements against AS2419 in next

Hazard Audit (2019)

Requirements :

27.1.1

Document number: 21065-RP-001 Revision: 0 Revision Date: 11-Nov-2016 File name: 21065-RP-001 Rev 0 APPENDIX A Page 1

APPENDIX A. AUDITOR APPROVAL

Document number: 21065-RP-001 Revision: 0 Revision Date: 11-Nov-2016 File name: 21065-RP-001 Rev 0 APPENDIX B Page 1

APPENDIX B. EVIDENCE AND REFERENCE DOCUMENT SUMMARY

Evidence / Document Revision Revision Date Author Comment Place(s) Used

Project Staging Plan 8/18/2015 Orica Approvals Requirements : 22.1.3

Development Consent - Notice of Modification

(1)

7/11/2012 DPE Approvals # 08_0129


(2)

17/12/2015 # 08_0129 MOD 2 Approvals # 08_0129 MOD 2


(3)

17/12/2015 DPE Approvals # 08_0129 MOD 3

Orica Kooragang Island, Ammonia Production

Limit Increase, Modification of Project Approval

08_0129

D 28/4/2015 AECOM Approvals EA - MOD 3 EA Final

Boiler Project Scoping Report 11/5/2014 Orica Approvals Letter to DPE

Kooragang Island Facility Uprate Modification

request

3 20/4/2011 AECOM Approvals Mod 1 EA Modification Report submitted to

DPE

Kooragang Island Modification Environmental

Assessment, Modification of Project Approval

08_0129

3 13/11/2013 AECOM Approvals MOD 2 60304607 Orica Acid Combined

MOD 13 11 13 FINAL

Development Consent NAP3 April 1998 DPE Approvals N91/00593/003

Site walk around - general areas eg

Transformers, fire systems, storages, Cl2

dosing for water treatment

Attended by Jenny Polich, Antony Taylor Requirements : 12.1.12,

26.1.1, 26.1.3, 26.1.13,

26.1.15

Site walk around - Ammonia Plant Attended by Jenny Polich, Antony Taylor Requirements : 12.1.12

Site walk around - AN bulk store and AN bag

store

Attended by Jenny Polich, Antony Taylor Requirements : 23.1.4,

23.1.6, 24.1.1, 24.1.5,

24.1.6, 25.1.1

Site walk around - AN bulk store and AN bag

store

Attended by Jenny Polich, Antony Taylor Requirements : 26.1.14



Hazard Audit - 2013 Ammonium Nitrate Plant -

Kooragang Island (60274735-RPTFinal)

0 27/03/2013 AECOM Audit - 2013 Haz Audit

Compliance Audit Report 0 (Final) Jun-13 DPE Audit - by DPE

Hazard Audit Implementation plan update 22/09/2015 Orica Audit - compliance status Requirements : 19.1.1,

22.1.7

Anhydrous Ammonia Storage and Handling –

Basis of Safety (SHE-GBL-PRO-PPS-1120)

2 7/10/2014 Orica BoS Requirements : 7.1.2

NH3 Storage Poster Final Orica BoS Requirements : 7.1.2

Dangerous Goods and Pollutants Register

Depot Drawings 10-200001-(sheets 01 to 20)

Orica DG Manifest Requirements : 5.1.2,

23.1.3, 26.1.5

Schedule 11 Hazardous Chemicals Register 9 25/11/2015 Orica DG manifest

Periodic updatees from 2010 to Nov 2015

Requirements : 5.1.2,

9.1.1, 23.1.3, 24.1.7,

24.1.8, 26.1.5

FEL Spec - AN Area Loader Build Specification

- Kooragang Island (KIW-3000)

17/8/2015 Orica DMS Document Requirements : 23.1.4,

23.1.6, 24.1.3

Orica investigation requirements DMS Document Requirements : 15.1.3

Certificate of Appointment - Responsible

Engineers - Kooragang Island Site (KIW-1051)

5 18/9/2015 Orica DMS Document

Appendix A2 Site Layout 11/24/2015 Orica Drawing

Enablon - Events at KI Serious or Potentially

Serious Injury-04082016-5

4/8/2016 Orica Enablon report export Requirements : 15.1.2,

15.1.4

Enablon - Events at KI with no investigation

required (ALL)-04082016-2

4/8/2016 Orica Enablon report export Requirements : 15.1.2,

15.1.4

Site Emergency Data - External Services to site

isolation point locations (DWG no. 10-20000-07)

A 6/4/2009 Orica (G. Strutt) ERP

Site Emergency Data - Substations and

Switchrooms Distributed Control Systems

Location Plan (DWG no. 10-20000-08)

F 6/4/2009 Orica (G. Strutt) ERP Requirements : 26.1.13

Orica Kooragang Island Emergency Response

Plan (KIW-1020)

14 25/11/2015 Orica ERP Requirements : 17.1.1,

22.1.4, 23.1.4



Orica KI Site FSS Report E 14/02/2016 Pinnacle FSS Requirements : 9.1.9,

23.1.4, 24.1.6, 25.1.1

KOORAGANG ISLAND AMMONIA

OPERATIONS HAZARDOUS AREA

VERIFICATION DOSSIER Doc no E-10031-HD-

0001

A 15/12/2015 EEHA Engineers Hazardous area Requirements : 26.1.2

Ammonia Operations 2015 HA Inspections doc

ref E-10031

1 15/12/2015 EEHA Engineers Hazardous area Requirements : 26.1.2

HAC Report Orica KI Nitrates Plant doc ref KIW-

2515_1

1 14/07/2014 HATCH Hazardous area Requirements : 26.1.2

Ammonia Management Improvement Project

Kooragang Island HAZOP Report (20632-001)

0 1/12/2015 Sherpa Consulting HAZOP Requirements : 22.1.3,

26.1.6

Kooragang Island Facility Site Steam System

Upgrade Project HAZOP Report (20932-RP-

001)

0 22/6/2015 Sherpa Consulting HAZOP Requirements : 22.1.3,

26.1.6

GPG 02: Good Practice Guide: Storage of Solid

Technical Grade Ammonium Nitrate

Rev 02 March 2014 International Industry Working

Group on Ammonium Nitrate

SAFEX International

Industry info

CSB Investigation Report - West Fertiliser

Company Fire and Explosion (2013-02-I-TX)

0 (Final) Jan 2016 U.S. Chemical Safety and Hazard

Investigation Board

Industry info

KI Status of Noel Hsu’s recommendations

relating to CSB’s West, Texas report

Industry info Requirements : 22.1.3,

25.1.1

Examples of completed SIF test sheets Orica Integrity

SIF test records - L: drive Orica Integrity Requirements : 12.1.10

Turnaround Timing Risk Assessment Sheet -

Capstone High Criticality Pressure Vessels- SP

update

Orica Integrity - Capstone criticality report Requirements : 12.1.3

TA deferrals - NH3 Plant Summary - Criticality

report

14/7/2015 Orica Integrity - Email: Overdue SI in the upcoming Report

16_LUTE06F02 Deferral to TA Orica Integrity - Email: Overdue SI in the upcoming Report Requirements : 12.1.3



Shut 15 NH3 Storage Flare Ex ITPs Integrity - example ITPs Requirements : 10.1.1,

10.1.2

KIW-3370 NH3 SIF Register 1 Oct 2014 Orica Integrity - SIL Requirements : 12.1.10,

22.1.4

KIW-2514 Nitrates SIF Test Register 2 June 2016 Orica Integrity - SIL Requirements : 12.1.10,

22.1.4

KI Fire pump system testing results 6/4/2016 Wormald Integrity - Testing results cover annual fire pump flow

test and sprinkler tests from Sept 2013 to April 216

Requirements : 26.1.4

Orica KI Safety Report Plan MHF Facility 10037 1 31/8/2010 Orica MHF

MHF Licence Conditions 11/4/2015 SafeWork NSW MHF Requirements : 5.1.2,

23.1.3

MHF Safety Case Appendix 024 and 049 2015 Orica MHF Requirements : 7.1.5

RM-03A Management Of Change (Doc ID:

DMS569077183 )

0 8/2/2016 Orica Modification

KIW-2563 Overarching Management of Change

Procedure

6 25/5/2016 Orica Modification Requirements : 14.1.1

Modification Initiation Checklist 0 Orica Modification example

MOD KI011126 (Chlorguard Installation) Orica Modification example Requirements : 26.1.1

MOD KI011787 (AN Bag store FW) Orica Modification example Requirements : 14.1.11,

26.1.14, 27.1.2

MOD KI009696 (H2 cylinder relocation) Orica Modification example Requirements : 26.1.15

KI Organisation chart Orica Org chart Requirements : 1.1.2,

2.1.1, 3.1.1

Example of Lock out Isolation Sheet - 2201 JAT

oil leak repair

26/7/2016 PTW / isolation Requirements : 13.1.2

PTW #60054603 AN2 plant ( Pneu Inst Air

Clean)

8/3/2016 PTW / isolation Requirements : 13.1.2,

26.1.9, 26.1.10

PTW #60063503 Ammonia Plant (Tank;MDEA

Storage)


26.1.9



PTW #60062300 Ammonia plant (TSV NPT

Thermal)


26.1.9

Orica Kooragang Island Update PHA Shipping

Update (31/32551/242220)

- GHD QRA

Kooragang Island Phase 1 Uprate Final Hazard

Analysis (31/24733/172898)

Mar-10 QRA Requirements : 23.1.5,

23.1.8, 23.1.9, 24.1.8

Ammonia Management Improvement Project

Final Hazard Analysis Report (H348981)

1 4/7/2015 HATCH QRA - AMI FHA Requirements : 7.1.3,

22.1.3, 23.1.4

Report for Kooragang Island Uprate PHA MOD1

Report (31/24733/00/192842)

5 Mar-12 GHD QRA - Orica KI PHA Update MOD 1 Report - Rev 5 -

FINAL - Public[1]

Kooragang Island Uprate PHA MOD 2

(31/29356)

1 May-14 GHD QRA - Orica KI PHA Update MOD 2 Report (226105)

- Rev 1 (Version 1)

2015 Model Shipping Update Results (QRA risk

contours)

3/6/2015 QRA - revised risk contours for MOD3. Requirements : 22.1.3,

23.1.5

KI2540 : B - PW-01 - Permit to Work 5 Oct 2015 Orica Safe Work Practices Requirements : 13.1.1

KIW2512 PTW Isolation Requirements KI

Specific Procedure

Rev 008 Orica Safe Work Practices Requirements : 12.1.23,

13.1.2

FW Routines.XLS - SAP task summary 15/8/2016 SAP - export to Excel summary report Requirements : 12.1.1,

12.1.23, 26.1.3, 26.1.4

Chlorguard PM tasks - SAP Summary SAP - export to Excel summary report Requirements : 12.1.1

SIF Testing Summary - PT269 Maintenance

Plan History from SAP

SAP - export to Excel summary report Requirements : 12.1.1,

12.1.10, 22.1.4

SDS NITROPRIL Substance No:

000022017701

Version: 8 06/05/2015

Orica SDS Requirements : 7.1.2,

23.1.1

SHEC Handbook 2014 Edition Orica SHEC MS Requirements : 2.1.1,

6.1.5

SHECMS Overview and Standards Original issued 21/3/2014 Orica (GM Global Sustainability) SHEC MS Requirements : 1.1.1,

1.1.2, 1.1.3, 1.1.4, 2.1.1,

3.1.1, 6.1.5



KI Site TWC SHEC Compliance register SHEC MS Requirements : 5.1.1

Induction Package SHEC MS - Auditor completed the site induction Requirements : 16.1.1,

16.1.3

Contractor SHEC Commitment Charter Orica SHEC MS - handed out in Induction Requirements : 10.1.4

Contractor Health Questionnaire Card Orica SHEC MS - handed out in Induction Requirements : 10.1.4

Safety and Heath Policy July 2013 SHEC MS - Included in SHEC Overview doc Requirements : 2.1.1

AN1 Wet Section Abnormal WI's (DMS) Orica Training - DMS document summary Requirements : 8.1.4

Consolidated SHEC Training Matrix.XLS Orica Training Excel book Requirements : 16.1.1

Track Easy training records - Onsite View

Employee David Fulmer

3 Aug 2016 Orica Training Track Easy - report summary Requirements : 16.1.3

Track Easy training records - Onsite View

Employee Glen Bernard (maintenance Fitter)

3 Aug 2016 Orica Training Track Easy - report summary Requirements : 16.1.3

Relative community distance – Orica KI vs West

Fertilizers

Annual production figures 2013, 2014 , 2015 Requirements : 22.1.1

KI Risk Register PHS1 and 2 records 2009,

2015

Requirements : 7.1.2

Lotus Notes Mods database Requirements : 14.1.1

Document number: 21065-RP-001 Revision: 0 Revision Date: 11-Nov-2016 File name: 21065-RP-001 Rev 0 APPENDIX C Page 7

APPENDIX C. ORGANISATION CHARTS AND INTERVIEWEES

The attached charts show the organisational structure in place at the time of the 2016 audit.

Indicates people interviewed as part of the audit with a complete list of the audit team following the charts.


Audit Participants:

Name Title Company Role Comment

Jenny Polich Principal Engineer Sherpa Auditor Approved as auditor by DPE

Stuart Chia Principal Engineer Sherpa Lead Auditor Approved as auditor by DPE

Sherree Woodruffe Environment and Community Lead Orica Auditee SHES

Antony Taylor Environment Lead Orica Auditee SHES

Yasmine Vosper Risk Specialist Orica Auditee SHES

Risk registers / Hazard studies, Emergency Response

Responsible Fire Systems Engineer

Paul Hastie Operations Manager Orica Auditee Manufacturing

Acting Site Manager (as Scott Reid on leave at time of audit)

Les Willis Lead Engineer Instrument and Control Orica Auditee Manufacturing

Scott Petersen Lead Mechanical Engineer Orica Auditee Manufacturing

Responsible Mechanical Engineer

Dave Brown Ammonia Plant Team leader D shift Orica Auditee Manufacturing

20 years +

Rod Osland NAP1 / AN2 Plant Team Leader Orica Auditee Manufacturing

7 years

Belinda Risk Specialist Orica Auditee SHES

Incident Reporting and Investigation

Bruce Volkiene Maintenance Manager Orica Auditee Manufacturing

Mick Gill Technical Manager Orica Auditee Manufacturing

Bob Amundsen Training Coordinator Orica Auditee Manufacturing

Brenda Mataka Shift Superintendent (E shift) Orica Auditee Manufacturing

Fairly new starter (4 months)

Scott Andrews Site Operations Support Superintendent Orica Auditee Manufacturing

Facilities Maintenance including AN stores

Peter Tapp Project Manager Orica Auditee Manufacturing

Project Manager for all the AMI projects

Document number: 21065-RP-001 Revision: 0 Revision Date: 11-Nov-2016 File name: 21065-RP-001 Rev 0 APPENDIX D Page 1

APPENDIX D. AUDIT RECORD WORKSHEETS

2016 Hazard Audit Orica KI Site

21065 Orica KI 2016 Haz Audit FINALPage 1 of 74

Print Date: 11/11/2016

GeneralAdministration

Facility InformationCompany: Orica Australia Pty Ltd

Business Unit: Manufacturing

Facility: Kooragang Island Ammonium Nitrate Facility

Project ID: 21065

Project Name: 2016 Hazard Audit

Study DurationStart Date: 02/08/2016

End Date: 30/09/2016

Template Overview

This audit template has been developed to cover the elements in the following guidance documents:

- HIPAP5 (2011) Hazard Audit Guidelines - HIPAP9 (2011) Safety Management Systems- ISO19011 (2014) Guidelines for Auditing Management Systems

Elements 1 - 20 are typical management system checks (ie relatively generic for any SHE MS / SMS and are from HIPAP9Elements 21 onwards are specific checks of site licences (eg EPL, MHF, DG notification) and approval conditions (eg NSW DPE, including hazard studies) and checksheets should be customised to match relevant requirements.

This template is generally used for carrying out a Hazard and / or Environment Audit as required under NSW Department of Planning Condition of Consent conditions




MethodologyMethodology

Type: Hazard Audit

Scope: Kooragang Island FacliitiesThe audit covers: 1. A sample of areas from all KI operations and associated plant/equipment. AN stores, Ammonia Plant and AN2/NAP3 Plant used as example areas. 2. The focus was on the site and plant modifications since prevous Hazard Audit in 2013. This is primarily the collection of risk reduction projects refered to as the AMI Project. 3. The closeout of any actions arising from the 2013 Hazard Audit or other studies that may have occurred since 2013 4. The degree of implementation of recommendations from the CSB Texas West investigation report5. Consistency of site with industry good practice: ie the SAFEX guidelines for Storage of TGAN

Exclusions: 1. Environmental compliance requirements for the development consent conditions or environmental protection licence (EPL) conditions are excluded as this is covered by a separate Environment Audit. Any projects being undertaken as part of Pollution Reduction Programmes were not reviewed.

NOTE: The audit elements comprised review of Orica documents and verification via records and discussions with personnel available at the time of the audit.Due to the sampling nature of third party audits some issues, non-compliances or improvements might not have been identified in the audit. This does not imply that these issues do not exist, or are in compliance.

Objective: Complete independent hazard audit as specified in condition of consent:- Assess whether the project is complying with the hazards related approval conditions (Approval 08_0129 Schedule 3 cl 20))- Verify the integrity of safety systems and that the facility is being operated in accordance with its hazards-related conditions of consent (HIPAP 5) - Review the SMS required under Condition 3 of Schedule 3 (Approval 06-0089 Schedule 4 cl 4e))

Job is intended to: Satisfy NSW DPE condition of consent requirement to complete a three yearly Hazard Audit in accordance with HIPAP no 5

Job is not intended to: This is not an audit against Orica's corporate SHECMS, nor is it a certification audit against any management systems such as as ISO9001, ISO18001, or ISO14001.

Auditor Guidance: Interview Guidance:1. Check persons name and role2. Discuss their role, what they do on a day to day basis3. How long have they been there? 4. Do they have a job description, does it contain reference to SHE responsibilities?5. Are they aware of the safety / env policy ?6. What type of training have they done? On start of position and ongoing? What aspects of SHE did their training cover? Is there are summary of their training requirements (training matrix, job description etc) 7. Are they aware of the MHF process and were they involved? 8. What do they think the main hazards and risks on site are? What are the most important safeguards?9. Have they ever been involved in incident reporting / investigation? 10. What type of emergencies may occur on site, how do they know and what do they do if one occurs?11. Job specific questions - eg maintenance, mods, compliance, operations procedures etc




1. Audit ElementsAudit Element (HIPAP9)

Overall Element

CompliancHIPAP Comments Personnel Interviewed

Antony Taylor

Sherree Woodruffe

Fully Implemented

1. SHE Management System Structure and Administration

3 Orica's integrated corporate Safety Health Environment Community Management System (SHECMS) covers all the main requirements of a Safety Management System. This includes policy, vision, 21 SHEC Standards and 29 Major Hazard Standards as well as supporting corporate and site level proceedures. All the elements have been implemented at the KI site level. Potential improvements in a specific element are identified where relevant under the individual element headings.

Sherree Woodruffe

Paul Hastie

Antony Taylor

Fully Implemented

2. Commitment and Leadership

2.1 The relevant SHECMS element is Standard 1 Leadership and Accountability.SHEC management is initiated at the corporate level and managed as an integrated part of site management activities with the Site Manager having overall responsibility for implementation. The auditor observed a visible committment to safety management at KI in the form of a thorough site induction, integration of SHEC items into daily meetings, highly visible BoS and KPI information and the large number of risk reduction projects being implemented.

Sherree Woodruffe

Paul Hastie

Mick Gill

Fully Implemented

3. Organization, Accountabilities and Responsibilities

3.3.1 The relevant SHECMS elements are Standard 1 Leadership and Accountability and Standard 2 Planning, Goals and Targets. These include an accountability and communications framework. Potential improvements in resourcing, definition or responsibility for a specific element are identified under the individual element headings where relevant.

Sherree WoodruffeFully Implemented

4. Objectives, Target and Plans

3.2.3 The relevant SHECMS element is Standard 2 Planning, Goals and Targets. At the site level a SHEC improvement plan is developed annually. At an individual level all employees have documented personal SHEC objectives that demonstrate the employee’s contribution to SHEC performance. Potential improvements in objectives or planning are identified under the individual element headings where relevant.

Yasmine Vosper

Antony Taylor

Fully Implemented

5. Legal Requirements and Codes

3.2.1 Standard 3 Legal Requirements is the relevant SHECMS element. A compliance register is available on site There is good evidence of knowledge of technical codes and standards (corporate and external), WHS regulations, and MHF licence and development approval conditions of consent requirements.

Fully Implemented

6. Documentation 3.3.5 Standard 7 Documentation and Document Control is the relevant SHECMS element. There is an extensive document base covering the SHECMS and supporting procedures at corporate and KI site level which are available within the DMS and accessible via the Orica Intranet (Globe). Drawings are managed electronically via Vault. Incident information is in a corporate system EnablonSite specific records are available either within the relevant site databases (eg Modifications Lotus Notes database, Lotus Notes Risk Register), SAP for maintenance and PTW, and in some cases network drives.

Yasmine Vosper

Mick Gill

Mostly Implemented

7. Hazard Identification and Risk Control

4.2 Standard 4 Hazard and Change Management is the relevant SHECMS element.Standard 9 Project Delivery is also relevant.There are many risk assessments of various types and methodologies for the KI site with a large amount of detail available at the individual hazard identification and risk scenario level in the Risk Registers. However, an overall KI site risk profile was not available so it was not possible to identify for example the highest risk on the KI site, or the effect of risk reduction measures completed to date (or control measures removed) on the overall site risk profile. In addition there are a very large number of open actions (more than 1000) arising from the periodic hazard study and Process HIRAC processes that have not been prioritised or resourced. Closure of some modifications associated with the AMI project is also overdue as residual risk Process HIRACs have not been migrated to the KI




Audit Element (HIPAP9)Overall Element


Risk Register. Recommendations have been made to review the potential to summarise the various risk assessments into a single site risk register that provides an overall KI risk profile, and also develop a prioritisation method and appropriate resourcing to address the large volume of actions.

Bob Amundsen

Dave Brown

Paul Hastie

Peter Tapp

Fully Implemented

8. Operating Procedures 4.3 Standard 8 Operational Control and Standard 13 Personnel and Process Safety are the relevant SHECMS elements.Operations appear to be covered by extensive procedures, available with the DMS. At the time of the audit the AN area procedures for response to abnormal situations appeared more developed than the Ammonia Plant procedures.

Les Willis

Mick Gill

Peter Tapp

Scott Petersen

Fully Implemented

9. Process Safety Information

4.4 Key process safety information such as PIDs, PFDs, hazardous area drawings, mechanical design basis and equipment datasheets was generally available and information relevant to their role accessible by interviewed personnel .

Paul Hastie

Bob Amundsen

Scott Andrews

Fully Implemented

10. Contractor Management and Procurement

4.54.12

Standard 10 Contractors, Suppliers and Partners is the relevant SHECMS element. There are formal processes in place for contractor selection and management and contractors appear to be well managed. Introduction of Track Easy system provides transparency of the status of licences, inductions and PTW training

Mick Gill

Peter Tapp

Fully Implemented

11. Pre Start-up Safety 4.6 Standard 13 Personnel and Process Safety is the relevant SHECMS element. Pre-startup safety checks are well covered in the modification acceptance and handover certificates system and also in plant startup checklists.

Bruce Volkiene

Les Willis

Mick Gill

Peter Tapp

Scott Petersen

Scott Andrews

Mostly Implemented

12. Equipment Integrity 4.7 Standard 12 Plant and Equipment Integrity is the relevant SHECMS element. Standard 9 Project Delivery and Standard 4 Hazard and Change Management are also relevant.SAP provides comprehensive records of maintenance history and scheduled maintenance activity. There is a low rate of breakdown maintenance. A risk based inspection regime is in place that covers all types of equipment. A hazardous area compliance improvement project is well underway. A recommendation was made to develop a formal process covering required documentation and authorisation / acceptance process for any deferrals of inspection or maintenance.

Paul Hastie

Rod Osland

Dave Brown

Bob Amundsen

Fully Implemented

13. Safe Work Practices 4.8 Standard 8 Operational Control and Standard 13 Personnel and Process Safety are the relevant SHECMS elements.Permit to Work Systems are well developed and appear to be well implemented. Some potential improvements linking isolation plans to permits were identified.

Mick Gill

Peter Tapp

Mostly Implemented

14. Management of Change 4.9 Standard 4 Hazard and Change Management is the relevant SHECMS element.There is a formal control of modification and change management process in place which is extensively used with supporting records available. There is an opportunity to improve the quality of closeout of hazard study actions associated with modifications. A






recommendation was made to implement a periodic check of the quality of closeout of a sample of modifications.

Belinda

Sherree Woodruffe

Fully Implemented

15. Accident/ Incident Reporting and Investigation

4.105.3

Standard 20 Non-conformance, Incidents and Actions is the relevant SHECMS element.Enablon is used to record all incidents and track associated investigations / actions. Data entry and investigation was comprehensive and transparent.

Bob Amundsen

Sherree Woodruffe

Fully Implemented

16. Training and Education 4.113.3.33.3.4

Standard 5 Training, Competency and Awareness is the relevant SHECMS element.Training and Competency systems were well developed and covered a comprehensive iinduction (attended by the auditor), operations, safe work practices and corporate requirements such as use of the DMS, modifications and incident reporting in Enablon. No specific improvements were identified.

Yasmine Vosper

Sherree Woodruffe

Paul Hastie

Mostly Implemented

17. Emergency Planning and Response

4.13 Standard 19 Emergency and Crisis Preparedness is the relevant SHECMS element.Emergency plan is in place and linked to MHF. It has been recently reviewed and updated to reflect changes in site operations and neighbours, and drills / exercises completed There is an opportunity to improve collection and implementation of learnings from drills and evacuations.

Antony TaylorNot reviewed in audit

18. Security and Access Control

4.14 Standard 8 Security is the relevant SHECMS element.

Security was not reviewed in detail. KI is secure site and has a SSAN security plan in place. Recent upgrades since 2013 Hazard Audit include perimeter fence disturbance monitoring and alarms at gatehouse (24 hr attendance) The auditor was accompanied by SSAN licensed personnel to areas handling AN. Locks were observed on AN stores and AN shipping containers.

Belinda

Sherree Woodruffe

Fully Implemented

19. Auditing and Management Review

4.15, 5.4, 5.5

Standard 21 Monitoring, Audit and Review is the relevant SHECMS element.Numerous internal and external audits are conducted with actions tracked in Enablon. KPIs are set up for tracking performance of each element of the management system

Not reviewed in audit

20. Environmental impacts / pollution potential

n/a Not in scope of Hazard Audit


21. Environmental Performance Compliance

n/a Not in scope of Hazard Audit

Antony Taylor

Yasmine Vosper

Fully Implemented

22. Condition of Consent Compliance

06_0089 Condition of Consent checks were limited to items relevant to the operational phase and to safety / hazard impacts. These are found to be complied with.

The audit did not cover items relating solely to the construction phase or matters unrelated to process safety. Environmental (air, water pollution, EPL compliance) or amenity issues (eg noise, traffic) were not assessed.

Scott Andrews

Yasmine Vosper

Fully Implemented

23. Industry guideline compliance (SAFEX)

06_0089 A review of the AN areas against the guidance in SAFEX was carried out. The AN storage installations are consistent with the design and operations guidance in SAFEX. The QRA work carried out as part of the PHA/ FHA for the KI expansion is also generally consistent with the SAFEX QRA guidance.






Scott Andrews

Yasmine Vosper

Fully Implemented

24. AS4326 Compliance 06_0089 A review of compliance of the AN stores as completed against Section 9 (which has specific requirements relating to storage and handling of AN and ANS) of AS4326 (2008) The storage and handling of oxidizing agents. For AN stores these requirements are very similar to the SAFEX guidance. It is noted that the KI site AN stores exceed the maximum storage quantities given in AS4362 (which requires then regulatory consultation). QRA and MHF licence work has been undertaken on basis of the actual KI AN inventories and agreed by DPE and Safework hence regulatory consultation requirement is regarded as satisfied.

Scott Andrews

Yasmine Vosper

Mostly Implemented

25. CSB Investigation into West Texas (recommendations)

06_0089 A review of the AN stores against the findings of the CSB West Texas investigation was carried out. These deal largely with separation of combustible materials from AN storage and emergency response preparedness and awareness of emergency responders. These areas are well addressed at KI. A small number of items with respect to the design basis of the fire protection systems and AN store ventilation need to be clarified.

Antony Taylor

Bruce Volkiene

Les Willis

Mostly Implemented

26. Closeout of 2013 Hazard Audit recommendations

Hazard Audit - 2013 (60274735-RPTFinal)

A review of the 2013 Hazard audit actions was completed. The majority of these have been addressed however in 2 cases adequate information supporting the closeout was not available and needs to be verified. A number of other areas are ongoing projects.

Antony Taylor

Mick Gill

Peter Tapp

Mostly Implemented

27. Closeout of other study actions

Site FSS Rev E (Feb 2016)

A review of actions from other studies was carried out. A number of hazard studies (HAZOPs, CSS) for the relevant stages (AMI project, New Boiler) of the KI expansion project have been completed since the previous audit in 2013. These were reviewed and the completion status of actions is appropriate for the stage of the projects (ie installation not complete so not all actions complete). The KI site FSS has also been updated in 2016. There are two open recommendations.




2. Audit WorksheetAudit Element: SHE Management System Structure and Administration

Overall Element ComplianceFully Implemented

Requirements

Requirement/ Expectation Auditor Guidance Compliance Commentary Evidence and Document References Recommendations Finding

SHECMS Overview and Standards

1. SHEC MS includes 21 general SHEC Standards and 29 Major Hazard Standards. They apply to all Orica sites where Orica controls engagement of contractors, suppliers (such as KI). The stanadrds incudes some mandatory requirements and form the basis for the development and application of SHECMS Procedures, Guidance Documents and Work Instructions at all levels of Orica

2. SHEC MS overview includes governance structure and management framework. SHEC is integrated into other management functions . Specific SHEC Committees established at the Board and site level which includes representatives from management and SHEC functional groups. This is in place at KI which has site SHEC committee and site specifc safety and environment personnel

Generic MS elements (eg Plan, Do, Measure< Act / Plan, Implement, Check and Correct, Review etc) plus specific elements to suit the facility hazards and risks

Fully Implemented

1. SHE management structure

KI Organisation chart


1. Corporate SHEC Systems Manager role (not at KI)

2. Site specific dedicated KI Environment / Community and Safety leads who report through SHES (separate to Manufacturing reporting path that most KI personnel are on) support KI Manufacturing personnel

Who was involved in developing SMSWho updates it?

1. Overall 2 yearly review cycle for SHECMS overall.

2. Via KI site SHEC committees

How is feedback provided?

Fully Implemented

2. Participation/consultation


1. Corporate SHEC MS system applicable globallyMay be an integrated system (eg BMS, EHSMS, IMS etc)If separate do they mesh well?Efficiencies / duplication between systems?

Fully Implemented

3. Links to other systems (OHS/QA/EMS)


1. Corporate SHEC MS system applicable globally Fully Implemented

4. Maintaining continuity of safety management systems (making SMS system dependent and not individual




Audit Element: SHE Management System Structure and Administration


Requirements


dependent)

1. Refer to change management audit element for comments on organisational change.

Being Developed

5. Maintaining continuity of responsibility for process safety / environmental management under organisational change




Audit Element: Commitment and Leadership


Requirements


Safety and Heath Policy


SHEC Handbook


1. Observation: the available Safety policy at the time of the audit (Sept 2016) was signed in July 2013 by previous CEO (this is a corporate issue and can't be addressed at the KI site level). Noted that at the time of the audit there was a review of the SHECMS being undertaken at corporate level so the policy would most likely be updated as part of this). Check at next Hazard Audit (2019).

1. Safety and Health Policy signed by previous CEO Ian Smith (ie corporate level policy, not a site specifc policy). (Separate policies for Env and Community). Noted that at the time of the audit there was a review of the SHECMS being undertaken at corporate level so the policy woudld most likely be updated as part of this

2. Available electronically and displayed in hard copy on various noticeboards

Commitment from senior executive management

1. SHEC MS overview includes governance structure and management framework. SHEC is integrated into other management functions . Specific SHEC Committees established at the Board and site level which includes representatives from management and SHEC functional groups. This is in place at KI which has a site SHEC committee and site specifc safety and environment personnel.

Framework for provision of adequate resources and measurable / trackable improvement objectives

1. Statement included in Safety and Health policyCommitment to compliance with legislation / codes/ standards

1. MH specific standards are included in SHEC MS handbook - not at policy level except as general compliance with legislation,

Explicit reference to Major Hazards / Prevention of MA

1. Included in Induction package. Induction includes issue of SHEC Handbook to person being inducted

Communication and training requirements

1. Yes - includes reference to nature of operations / industry

Clear definition of scope with respect to nature , scale and risks of activities

1. Overall vision includes "No Accidents Today" Long term objectives

1. In Environment policyCommitment to prevention of pollution

1. Not knownCommunication and consultation during development

1. Last sign off by Ian Smith July 2013. SHECMS review cycle is 2 years (Corporate review was occurring at tie of KI site audit, a SHECMS update may be issued in 2016)

Policy maintenance and review - typically once per year

Fully Implemented

1. SHE Policy - clear, concise statement of commitment that sets the goal as to the performance standards to be achieved




Audit Element: Commitment and Leadership


Requirements


1. Available electronically and displayed in hard copy on various noticeboards

2. Included in Induction package

3. SHEC committee meetings occur

4. Daily meetings include SHEC issues

Common methods:- Safety Committees- OHS reps- Inductions / Training- Notice Boards- Meetings- Internet/ intranet- Annual reports

Fully Implemented

2. Communications re policy(internal/external)

1. The SHECMS applies to all Orica controlled sites and activities and should be applied at all project and operational phases. Where Orica does not have operational responsibility, but has an equity stake, such as a Joint Venture Partnership, Orica SHECMS documents are made available to the partner

2. High visibility of safety initatives, up to date Process Safety KPIs etc - lots of displays in work areas and meeting areas.

3. Comprehensive induction process (attended by auditor)

Does the site (at all levels, show commitment to safety by:- Active management/ supervisor involvement- Consultation/ co-operative approach- Information flows and follow up- Consistency of current facility safety practices- Supervisor acting as role models

Fully Implemented

3. Commitment demonstrated - resourcing (people / budget), language, working environment




Audit Element: Organization, Accountabilities and Responsibilities


Requirements




1. Communication requirements / roles are covered in QAP20C

Is there a management and/or organizational structure highlighting communication and safety interfaces at a Corporate and Business Function Level?

1. Corporate SHEC Systems Manager role

2. At Site level SHEC MS implementation is overall responsibility of SIte Manager, who then delegates various aspects of implementation to other roles


Is there a specific management representative for coordinating the establishment, implementation and maintenance of the SMS (HSE Management system)

Fully Implemented

1. Organisational structure

1. position descriptions include Safety / Auditing and policy / procedure update responsibilities

Where are roles and responsibilities documented and do personnel understand their role in safety? eg task matrix, job description

1. yes - as covered in Induction and SHEC MS governance framework

Are supervisors/ line managers accountable for safety of personnel and authority to take action to make it safer?

Fully Implemented

2. Definition of accountabilities / responsibilities


Fully Implemented

3. Accessibility of persons of responsibility and accountability to staff




Audit Element: Objectives, Target and Plans


Requirements


1. KI overall objectives in Annual SHEC Improvement Plan.

2. At individual level all employees have documented personal SHEC objectives that: that demonstrate the employee’s contribution to SHEC performance

Does the organization have in place a mechanism to setting, completing and review of improvement objectives (that should be SMART orientated)

Fully Implemented

1. Safety / environment objectives setting and monitoring

1. Yes. KPIs discussed on a daily basis at morning meetings

Are there Safety / Env Performance Standards (or KPIs) to ensure safe operation (and control of major accidents)? How is this controlled and cascaded to personnel?

1. KPIs tracked (some lag indicators - personnel safety, number of spills, environmental non-compliances some lead - eg number of process excursions, trips, rate of unplanned maintenance etc) .

Do the site Safety Performance Standards (or KPIs) cover human factors, operations, design and planned inspection systems (for the control of major accidents, pollution prevention etc? Example: - % of job descriptions incorporating required competencies etc.

Fully Implemented

2. Setting KPI's

1. KPIs include various Process Safety indicators which make up Process Safety Scorecard (eg process excursions outside SOW, no of trips, no of relief events, no of open mods).

Overall tracking of performance (OHS, Process safety and env indicators tracked over time against targets)

Fully Implemented

3. Process safety and environmental performance monitoring and reporting mechanism

16. Develop a system for managing actions arising from hazard studies and risk assessments that allows demonstration of progress to be shown. This should include: - prioritisation of the actions in a timely manner as they arise out of studies such as periodic hazard study 2 and 3. (Priority could be based on addressing non-compliance with regulations, magnitude

1. Risk reduction improvement projects are documented in the SHEC Improvement Pan. The AMI project has implemented a number of improvements over 2014 - 2016 such as installation of scrubber and flare systems to capture ammonia emisisons (vent and pressure relief cases) and consolaidtioof ammonia supplly storage to AN plants from several large ammonia bullets to a single smaller capacity ammonia storage vessel.

2. SHEC committee and operations personnel look after small safety improvements.

3. A process called Towards World Class (TWC) which has set a compliance priority has been in place at KI previously, however this seems to be transitioning out.

Plan should: - Designate responsibility - Resources Required - Timeframe

Mostly Implemented

4. Is there a documented site SMS Plan (or SHE Plan) for planned delivery of measures to meet long term and short term targets.




Audit Element: Objectives, Target and Plans


Requirements


of potential risk reduction / effectiveness, ease of installation, cost etc similar to the SFARP process for MHF) - implementation schedule and associated resources that suit allocated priority. A KPI could also be developed around completion rate or overdue high priority actions.

4. As noted in the HAZID and Risk Control Element, the KI site has undertaken a large amount of periodic hazard study and HIRAC review work since 2013. There are over 1000 open actions as a result of the studies which have not been prioritised and could help inform future risk reduction work. This number of actions would also be difficult to resource.




Audit Element: Legal Requirements and Codes


Requirements


KI Site TWC SHEC Compliance register

14. Observation: The TWC system appears to be being phased out. It was unclear at time of the audit if all compliance information had been migrated to Enablon. Check in next Hazard Audit (2019).

1. As per SHEC MS STANDARD 3 - LEGAL REQUIREMENTS, sites must have a SHEC Legal and regulatory requirements register that is reviewed annually

2. A process called Towards World Class (TWC) which has set a compliance priority and timing for improvement projects has been in place at KI, however this seems to be transitioning out and migrated to Enablon which will be used globally for complliance tracking ( Enablon is in use currently throughout Orica including the KI site for Incident tracking and Investigation and also Audit tracking).

What systems are in place to identify and interpret:- Legal requirements- Agreements/ Consents from Authorities

Fully Implemented

1. Applicable safety legislation (Planning approvals, MHF regulation, DG regulation, OHS regulation etc)

MHF Licence Conditions

Dangerous Goods and Pollutants Register Depot Drawings 10-200001-(sheets 01 to 20)

Schedule 11 Hazardous Chemicals Register

1. DG notification last updated in Nov 2015. Depot drawing and manifest appears to reflect inventories identified on site, includes new systems such as AN plant new ammonia storage

DG self-notification / licence - up to date and available

1. Not in scope EPL - up to date and available

1. MHF licence issued in 2015 (valid until 2020) with conditions

MHF - up to date and available

Fully Implemented

2. Licences (DG, EPL etc)

1. Access to corporate standards via intranet Globe, also to industry standards such as SAFEX guidance, AS and API standards. Others obtained as required eg NFPA

What systems are in place to identify and interpret:- National Codes and Standards- other engineering / technical standards

Fully Implemented

3. Applicable standards - AS, API, NFPA etc

1. Covered by corporate standards and industry codes. Orica is a memeber of relevant indsutry groups such as SAFEX.

What systems are in place to identify and interpret:- Codes of Practice

Fully Implemented

4. Industry code of practice

13. Observation: Orica has previously had in place Technical Panels to provide advice to the sites on best practices for the various technologies (AN, ammonia). These are referred to in the SHEC MS and the BoS. If this

1. Technical Panels, however don't seem to be active at moment o used at KI

What systems are in place to identify and interpret:- Corporate / global standards

1. Corporate Audits (company auditor), insurance audits. Also regulator audits (eg DPE in 2014, MHF audits by Safework)

2. Audit actions tracked in Enablon

How is it done ? Who does it ? Updates ? How often ?


5. Corporate standards/procedures




Audit Element: Legal Requirements and Codes


Requirements


structure is changed, KI will need to update process for seeking technical advice in various systems, for example Modifications. Check in next Hazard Audit (2019)

1. Global Mark audits for ISO accreditation (last done in 2013) - management system compliance. Actions go into QOL for closeout (though weren't in there at time of env audit)

How is it done ? Who does it ? Updates ? How often ?

1. Compliance register does not cover Condition of Consent requirements, and does not have a due date for all items. Also no reminder flags for overdue. Also refer to Audit Element re Conditions of Consent

Areas of non-compliance?

Mostly Implemented

6. Compliance review

1. Compliance register is held by SHEC&Q Manager.

2. Relatively poor awareness of operational constraints in Conditions of Consent

3. Reasonably good awareness of DG requirements, WHS / MHF requirements

4. Changes in Vopak Corporate Standards formally communicated. Major changes (eg LOTO in 2012) - corporate trainer trains a specific individual (eg Declan K for LOTO) who then helps update procedures and then trains the rest of people requiring it

How does site receive, communicate, implement and/or monitor (mandatory) legal and Company requirements.

Mostly Implemented

7. Awareness/training

1. On QOL (Vopak standards) and on network drives (AS , API etc)

Do personnel have access to codes, standards? (intranet, manuals etc)

Fully Implemented

8. Documentation/accessibility

1. Not identifiedIs there an objective or KPI relating to standards compliance, keeping up to date with improving standards?

Being Developed

9. KPI's




Audit Element: Documentation


Requirements


1. SHEC MS and supporting corporate procedures available on Globe , KI site specific procedures are on DMS. All personnel have access via their login

These should be controlled documents (eg SOP)

Fully Implemented

1. Is the SMS (HSE Management System) readily accessible, easily located and used by Personnel.

1. refer to individual elements, generally records available in various Databases or reporting tools. At time of audit, key systems:- Enablon - Incident tracking, Compliance, Audit action tracking- Lotus Notes Risk Registers - Hazard Studies, Risk assesmnets / HIRACS- Track Easy - Training and Licence Status - SAP - Maintenance and PTW

eg:- HAZID and risk assessments- Communications (safety)- Training records/ certificates/ attendance sheets- Completed PTW forms - Completed MOC forms- Audit reports

Fully Implemented

2. Site be able to demonstrate that effective records are kept

1. New employees introduced to Globe and DMS as part of induction. Observations: all interviewees were confident in navigating the various systems

Fully Implemented

3. Do personnel reference or use SMS documentation (and these have not been locally altered or revised or conflicts with actual operations)

1. Auditors told that IT backups in place (not verified) Not reviewed in audit

4. Is there a process to identify critical information and process to secure, copy, backup such information.

SHEC Handbook


1. Available on Globe and DMS. All personnel have a login

2. Document control procedure GEN07C defines document control and review / approval requirements

Where is SMS documented?Who has access?How?

Fully Implemented

5. Document control system/ accessibility of information




Audit Element: Hazard Identification and Risk Control

Overall Element ComplianceMostly Implemented

Requirements


1. KI is using the Orica Hazard Study process for hazard identification and and associated Process HIRAC method for Major Hazard risk assessment. Observation: It is noted that KI site advised that Orica corporately has adopted a different risk assessment approach recently at some other plants, however due to the complexity of the KI site and high familiarity of presonnel with the HS / HIRAC process, KI management has decided to stay with the existing methodology

2. This HS process is applied to projects (HS1 to 6) as well as periodically (PHS1 to 3) to operations.

Is there a documented approach to HAZID / Risk assessment and risk control requirements?

Fully Implemented

1. Hazid, Risk assessment ant control process

Anhydrous Ammonia Storage and Handling – Basis of Safety (SHE-GBL-PRO-PPS-1120)

NH3 Storage Poster

KI Risk Register PHS1 and 2 records 2009, 2015

SDS NITROPRIL Substance No: 000022017701

13. Observation: Orica has previously had in place Technical Panels to provide advice to the sites on best practices for the various technologies (AN, ammonia). These are referred to in the SHEC MS and the BoS. If this structure is changed, KI will need to update process for seeking technical advice in various systems, for example Modifications. Check in next Hazard Audit (2019)

1. HS1 contains checksheets for assessing material hazards

2. Basis of Safety documentation and posters are available and prominently displayed at the KI site for typical materials such as ammonia and AN

3. SDS access via ChemAlert (since about 2013). It was noted that the SSAN SDS provided to the auditor may not have been representative of the AN product produced at KI as it does not appear to have the correct bulk density on it

Material hazards awareness (physical, chemical properties, reactivity etc, SDS accessibility)

1. Hazops carried out for all projects and modifications as required. Records and closeout details available on Lotus Notes Risk Register

2. PHS 1 and 2, as well as update of process HIRACs are on a 5 year cycle and this matched to the MHF 5 yearly review cycle. PHS 1/2 last carried out in 2015

3. PHS3 (periodic HAZOPS) are being carried out. NAP1 is complete, Ammonia Plant was in progress at time of the audit and almost complete, AN1 is scheduled for 2017

4. Recognised techniques HAZID / HAZOP used for Hazard studies and MHF Safety Case HAZID. The

Uses appropriate and recognised techniques, eg HAZID, HAZOP

Fully Implemented

2. Hazard identification - process safety






Requirements


HAZID info is then used to populate the risk assessment (HIRAC) inputs for high consequence scenarios

1. A sample of hazard studies reviewed indicated consideration of all phases such as startup /normal operations / trip recovery. Modifications have specific hazards studies The construction / demolition aspects are assessed using Hazcon or similar techniques

All hazards identified for all facility (covering all phases - commissioning, startup, operations, mods)

1. yes. surrounding land use industrial , no identified sensitive land users, nearest residential is Stockton about 800m away

Takes into account facility location and site specific factors

1. Types of scenarios include explicit consideration of AN and ammonia release events in related industries including West Texas, Toulouse

2. Basis of Safety documentation and posters are available and prominently displayed at the KI site for typical materials such as ammonia and AN

3. Technical panels within Orica to provide advice to the sites on best practices for the various technologies. However discussions with interviewees indicated that these panels were not very active currently

Attempt made to identify and assess applicability of incidents / 'typical major accidents at other similar facilities (globally within or outside company, eg within similar industries)?

1. HAZID and HAZOP teams show a range of personnel including ops, maintenance and design / engineering.

Appropriate range of personnel participated in HAZID / risk assessment

Ammonia Management Improvement Project Final Hazard Analysis Report (H348981)

15. An overall risk profile for the KI site should be developed to allow identification of the highest site risks, and also used to show risk reduction over time or effect of removal of safeguards. From a

1. Recognised techniques HAZID / Bowties / LOPA used for MHF Safety Case

2. QRA covering various stage of development using PHAST / SAFETI. Last update in 2015

Uses appropriate and recognised risk techniques, eg LOPA, matrix, bowtie, QRA or combination

1. Orica corporate risk matrix used for MHF and HIRACs.

2. HIPAP for QRA as required in NSW

Risk criteria are fit for purpose

Mostly Implemented

3. Risk Assessments of existing operations (qualitative or quantitative, risk tolerability criteria)






Requirements


hazard perspective this should cover risk with a safety consequence. (However it is noted that SHECMS requires that each site maintain a record of their current hazards in a Major Hazard Register, with Major Hazards definition covering Safety as well as Health, Environment, Community, Business)

1. There is a lot of detail available for individual scenarios in process HIRACs but no site-wide risk register which provides an overall site risk profile.

2. It was not possible at the time of the audit to generate a risk profile to determine which were currently the highest risks on site, for eaxmple an overall list of all "High" risks, or all Process Safety Risks with a consequence level of high (eg single fatality) or greater. A summary of MIs was available in the MHF Safety Case however this did not reflect some of the risk reduction work (such as AMI project) that has occurred.

Easily locatable / accessible Risk register or similar

1. There is no site-wide risk register which provides an overall site risk profile covering safety (or any other types of risk)

2. Standard 4 of SHECMS requires that each site or region must maintain a record of their current hazards in a Major Hazard Register. From a safety perspective, A Major Hazard is defined in SHECMS as any event that may credibly result in a fatality (which would cover both process safety and OHS events).

3. If was not possible to get an overall picture of tthe risk profile, how this may have reduced since the last audit or what the highest risks on site currently are.

4. It is noted that at the last 2013 Audit it was noted that breakaway couplings had been fitted at NH3 road tanker bay as a risk reduction measure. These have experienced repeated failures resulting in small ammonia releases (as per Enablon records but details under legal privelege) and have been removed. It is not clear what the effect of removal on risk is and if this has affected the overall facility risk profile in a significant way

is the HAZID/ Risk Assessment/ Risk Register - recent - reflects current operations/ configuration

1. Some consideration of human factors evident in Process HIRACs.

Evidence of consideration of staffing level, response times, ergonomics, human error

Mostly Implemented

4. Human factors in managing risks






Requirements


2. Significant project implementing control system upgrade and best practice Alarm Management completed in 2013 / 2014 to reduce load on operators

assessment, attitudes, operator/ process interface adequacy and complexity

MHF Safety Case Appendix 024 and 049

16. Develop a system for managing actions arising from hazard studies and risk assessments that allows demonstration of progress to be shown. This should include: - prioritisation of the actions in a timely manner as they arise out of studies such as periodic hazard study 2 and 3. (Priority could be based on addressing non-compliance with regulations, magnitude of potential risk reduction / effectiveness, ease of installation, cost etc similar to the SFARP process for MHF) - implementation schedule and associated resources that suit allocated priority. A KPI could also be developed around completion rate or overdue high priority actions.

1. MHF Safety Case report Appendices show some consideration of risk control hierarchy via accepted / rejected controls summaries

2. Process HIRACS show this at a detailed level

Risk reduction hierarchy considered

1. some evidence in AMI projectInherent safety

1. Ignition control - as expected for a hazardous industrial site handling, induction covers control of igition sources. Hazardous areas defined and drawings available and electrical equipment generally suitable (as per HA verification activities) . PTW process in place

Control of ignition

1. Some evidence of adoption of newer technology, eg improved instrumentation, major control system upgrade and software tracking process excursions, trips etc. Flares recently installed to capture ammonia emissions.

Technology changes

1. Yes as per NSW MHF regulatory requirementsResidual risk management - Does the hazard identification, risk assessment & control process allow for further risk reduction (i.e. all efforts to minimize the risks to 'So Far As Practicable

1. It was not possible at the time of the audit to generate a summary of all the open actions arising from the PHS3 process. The auditor was advised that there are more than 1000 open items in eth Risk Register plus those arising from the Process HIRACs completd as part of eth 2015 MHF Safety Case (Note that this does not include Project or Modification hazard study actions). The actions have generally not been prioritised although this has started to occur in the Ammonia Plant PHS3 being conducted.

Management and prioritisation of actions arising from HAZID / Risk Assessment

Mostly Implemented

5. Ongoing risk reduction (adequacy of control measures for major hazards control in terms of redundancy, effectiveness, reliability, availability and survivability)






Requirements


1. MHF Safety Case Report includes performance standards and Critical Operating parameters

2. COPs and excursion tracking have been integrated into the control systems at amonia and NAP / AN plants to allow tracking of process excursions and process trips

For hazard control measures - pressure/ vacuum, high/ low temperature, overfill, pump suction, dead head, load sensing, leak detection

Fully Implemented

6. Performance Standards

1. Yes, 5 yearly process as per MHFDoes the hazard identification, risk assessment & control process allow for periodic evaluation of effectiveness of controls?

Fully Implemented

7. Continual improvement

1. Personnel are very aware of MHF and major hazards and key control measures

9. Are personnel aware of the HAZID/ Risk Assessment/ Risk Register and understand the nature of the hazards, control measures and risks?

1. Broadly yes.10. Are personnel aware of the size and range of impacts caused by a Major Accident

1. Not explicitly covered in audit11. Are personnel aware of the potential size and range of impacts to the environment / pollution incidents?

Fully Implemented

8. Communications and awareness




Audit Element: Operating Procedures


Requirements


1. Documented operating procedures for most tasks can be found on DMS. These are version controlled.

Procedures should be available for:- start-up, normal operation, temporary operations, emergency shutdown, normal shutdown, start-up and high risk activities.

1. Hazards are covered thoroughly by existing procedures and training materials

Do procedures cover OH&S requirements for:- Special Hazards- Physical and chemical properties- Precautions to take during normal operations/ maintenance/ emergencies

Fully Implemented

1. Are there documented procedures?

1. Refer to Training elementWhat type of training occurs and is there a competency assessment

2. Are assigned personnel trained in the Operating Procedures

1. Buddy training. Operators cannot undertake tasks unless the competency requirements have been met (theory and practical)

Fully Implemented

3. What is the procedure for assigning personnel not trained or not familiar with a particular operation?

AN1 Wet Section Abnormal WI's (DMS)

17. Observation: The Nitrates area operating procedures include specific guidance and instructions for responding to abnormal process situations, the NH3 plant doesn't although there is some coverage in scenario based training. Orica to review whether the NH3 plant should adopt a similar approach to developing procedures for response to abnormal situations as has been done in the Nitrates areas. Check in next Hazard Audit (2019)

23. Observation: The MHF Process HIRACs have

1. Yes and also in control system with automatic data collection and reporting of excursion and trips

2. Ammonia plant has a single screen summarising all SHE critical alarms

3. Ammonia plant has a Trickle Feed graphics screen for ordered plant shut down (ie can't do it in wrong order)

Are safe operating limits included in procedures?

1. COPs are covered in Safety Case Report appendix

2. The Nitrates area operating procedures include specific WI guidance for responding to abnormal process situations, the NH3 plant doesn't. However the ammonia plant training does include some scenarios for how to respond to a particular trips.

3. The MHF Process HIRACs identify "critical controls", in some cases these are operating procedures (though an overall ist was not availble at time of audit). It is not clear how "critical procedures" are differentiated from other procedures, eg by a tag on the document or whether there are any special review of prcedures,

How are 'critical operating parameters COP' defined? Are they documented in terms of a) consequence and b) actions required to correct deviations?

Mostly Implemented

4. Safe Operating limits / Critical Operating Parameters




Audit Element: Operating Procedures


Requirements


identified some procedures as critical controls. It is suggested that Orica determine a process for differentiating these from other procedures, eg "critical" tag on document, different review frequency, specific observations, auditing or training requirements. Check in next Hazard Audit (2019)

checking or training requirements compared to other procedures

1. Defeat of safety critical equipment form and a risk assessment with sign off.

5. Is there a process followed by site for bypassing or inhibiting safety systems. What is the protocol and line of authority?

Fully Implemented

5. Temporary unavailability of equipment - impact on operations




Audit Element: Process Safety Information


Requirements



1. All drawings in Vault Assess the currency of PSI -Who by and how is Process Safety Information maintained and kept up to date?

1. DG notification available and within dateHazardous materials - quantities - DG self notifications, inventory lists

1. SDS access via ChemAlert (since about 2013). It was noted that the SSAN SDS provided to the auditor may not have been representative of the AN product produced at KI as it does not appear to have the correct bulk density on it

Hazardous materials - MSDS

1. All drawings in Vault. Generally PIDs appear to be upadted as part of mods and cloe out of actions referred to specific version of PID where update was made

P&IDs (reflecting As Built)

1. All drawings in Vault. Generally used by process engineers

PFDs and mass and energy balances

1. All drawings in Vault . Dossiers on network and up to date

Hazardous Area Classification and drawings

1. All drawings in Vault Layouts, plot plans and general arrangement drawings

1. Registers in SAP

2. Lock board and LOTO process covering locks

Registers (eg PSVs, Ex Eqpt, Locks, blinds )

Fully Implemented

1. Current process safety information

1. Covered in BoS and corporate standards for specific items eg AN pumping

Does it exist? Fully Implemented

2. Design safety philosophy

1. Process and functional decriptons, equipment datasheets are generally available

Fully Implemented

3. Design basis

1. All drawings in Vault Fully Implemented

4. Drawings showing underground utilities and services

1. All drawings in Vault Fully Implemented

5. PV / mechanical Drawings

1. Process and functional decriptons, equipment Fully 6. Equipment data sheets




Audit Element: Process Safety Information


Requirements


datasheets are generally available Implemented

1. Electrical and loop drawings generally available Fully Implemented

7. Valve and instrumentation data sheets including PSV's, control loop set points

1. Ammonia leak detction in various areas..Layouts available. SAP system includes maintetance tasks

Fully Implemented

8. Fire & Gas system (flame/ smoke detectors, flammable/ toxic gas detectors)

Orica KI Site FSS Report 18. Observation: The FSS has been updated (Feb 016) and provides a clear summary of firewater demands however does not refer to the basis for these (for example an AS or NFPA, process dilution rate or something else). The protection basis should be identified and included in the next FSS revision

1. Fire system drawings and FSS exist and recnet site wide FSS . Includes hydraulic calcs and demand cases but not basis fo cases (ie why a specific water flow is required and what basis it ahs ben deveoped from ,eg a fire protection standard or a process case eg ANS tank drenching on temperature excursion )

Drawings

1. covered in FSS (last update Feb 2016)Sizing case, max water demand

1. FSS approved by FBFB approval

Fully Implemented

9. Fire protection systems (firewater system, deluge/ spray system, fixed/ portable foam system)

1. Drawings not sighted. SCADA in control room though Extensive upgrade occurre in 2011 - 2013


10. Computer control system documentation

1. Confined space register and risk assessments as per WHS requirements

Fully Implemented

11. Register of formally classified confined spaces


12. Emergency system services (emergency power, UPS, backup instrument air)

1. With maintenance department Fully Implemented

13. Vendor operation/ maintenance manuals




Audit Element: Contractor Management and Procurement


Requirements


Shut 15 NH3 Storage Flare Ex ITPs

1. Contractual plus certificatesQA / ITP process Fully Implemented

1. Quality assurance of procurement (spares, equipment, raw materials, reagents)

Shut 15 NH3 Storage Flare Ex ITPs

1. Design sign off, ITPs, examples from AMI project sighted

2. Spec includes details of any required certifications

Check who signs off Fully Implemented

2. Equipment fit for purpose

1. Prequalification process in place

2. Contractor injuries / incidents / near misses frinclude in Enablon, can be reported separately

3. Maintenance and procurement used to be a single role, now split - new procurement manager may not have history of contractor performance - though RFI does require input form all managers (infrastructure, maintenance, SHEC&Q)

Is there a formal selection process? Fully Implemented

3. Contractor selection/criteria/procedures

Contractor Health Questionnaire Card

Contractor SHEC Commitment Charter

1. Inductions, SHE plans , JSEAs, Orica specific PTW training for contractors who are Permit Receivers

Management of contractors on site Fully Implemented

4. Contractor awareness of site procedures/hazards

1. For large projects - formal SHE acceptance checklist. For PTW, inspection of work area before closing permit Clear ITPs , examples from AMI project sighted

Fully Implemented

5. Handover after maintenance

1. Some permanent contractors on site

2. Records of licences and renewal dates (eg SSAN clearance, PTW training) for contractors on Track Easy and linked to induction currency

Fully Implemented

6. Continuity of services




Audit Element: Pre Start-up Safety


Requirements


1. Covered in checklist that is part of Mod process - examples of completed form sighted for AMI project

Fabrication / installation in accordance with design


Procedures in place

1. Difficult to find examples of completed operator training in relation to mods. Operations Change Notices used for minor changes, eg LSHH in bund sumps

Operators have been trained


All pre-commissioning checks in place (blow throughs, leak and pressure tests complete)


2. HAZOP closeouts in Risk Register

Hazard study actions closed out


Physical state check includes:- blinds / spades removed- drain and vent valve positions- isolation valve positions- leak / pressure checks completed- purging planned / done- insulation checked

Fully Implemented

1. Pre Start-up safety review




Audit Element: Equipment Integrity


Requirements


FW Routines.XLS - SAP task summary

Chlorguard PM tasks - SAP Summary

SIF Testing Summary - PT269 Maintenance Plan History from SAP

1. SAP system in place, since previous 2013 audit. all equipment has been migrated to SAP. SAP covers all planned maintenance (time based) , condition monitoring and breakdowns / unplanned maintenance.

2. Checks of MHF critical items on SAP system - reports generated by maintenance planners as supplementary information after the audit site visit .

Does the site have a Preventative Maintenance (PM) System that has easily accessible records (Mainpac, Maximo, SAP etc).

1. No critical items significantly overdue (a few days in a year interval). The term "statutory inspection" is used to categorise PMs associated with any critical function as well as regulatory requirements such as PV inspections

2. KPI is in place around reducing unplanned breakdown maintenance - target around 15% of total maintenance task hours (which it is) and also around overdue inspections for critical items (none currently overdue)

Review PM system for current status and OUTSTANDING / OVERDUE items (especially statutory or company requirements).

Fully Implemented

1. PM system exists

1. Identify "SHEC critical" equipment based on Orica corporate guidance which includes criticality assessment process. In addition, MHF process identifies "critical controls"

2. Critical equipment (and procedures) also an output from MHF / LOPA work - can generate reports as needed. (The term "statutory inspection" is used to categorise PMs associated with any critical function as well as regulatory requirements such as PV inspections)

Definition and process for identifying "critical" equipment

Fully Implemented

2. Critical items have been identified

Turnaround Timing Risk Assessment Sheet - Capstone High Criticality Pressure Vessels- SP update

16_LUTE06F02 Deferral to TA

20. Develop a formal process covering required response to Capstone pressure vessel failure criticality ratings, and required documentation and

1. A reliability based maintenance system (RMS) is in use for mechanical and structural inspection and maintenance planning. This distinguishes between critical and non-critical items and uses a qualitative risk ranking approach. Covers pressure systems, bunding , machinery, structures

Mostly Implemented

3. Reliability data to determine maintenance schedules






Requirements


authorisation / acceptance process for any deferrals of inspection or maintenance.

2. Capstone software (a quantitative approach) for assessing failure likelihood / criticality based on actual inspection history has recently been implemented for pressure vessels in NAP and ammonia plants. The meaning of "High" criticality, the actions to be taken in this case and the process for documenting and authorising acceptance of an extension / deferral in inspections time for pressure vessels using the Capstone software was not clear.

3. Mods procedure includes requirement to assess " Any change in the methods of operation, inspection or maintenance activities (as set down in procedures, operating instructions and training materials); Any change to the frequency or acceptable conditions for scheduled checks of process and safety related systems (eg. shutdown systems, critical alarms, gas tests, plant logs, etc). "

1. Checks of MHF critical items on SAP system - reports generated by maintenance planners as supplementary information after the audit site visit .

Audit checks of PM tasks to cover:(a) methodology/work instruction available(b) performance standard (c) testing frequency defined(d) testing completed to schedule(e) if fault detected, details of action taken.

Fully Implemented

4. Preventive maintenance schedule - safety critical equipment (eg Pump seal replacements, function testing of protection systems, flexible hose testing and replacement etc), information management and record keeping.

1. Not reviewedIdentify pollution control equipment and check it is inspected / maintained and records are in PM system,


5. Pollution control equipment included in PM system

1. In SAP as statutory inspections -as per Capstone and RMS

Fully Implemented

6. Pressure Vessel inspections

1. Pipelines tested as per AS2885. Records available

2. In SAP as statutory inspections -as per Capstone and RMS

Check records for :- PVIs- atm tank 10 yearly - pipeline AS 2885 or similar - critical piping as per AS

Fully Implemented

7. Hardware integrity inspections included (intrusive, NDT, corrosion loops, inspection schedules, documentation)

1. Not reviewedCheck pipelines - Insulating Flanges, cathodic protection records, action taken if


8. Cathodic protection monitoring






Requirements


issues detected

1. In SAP as statutory inspectionsConfirm all PSVs in PM systemNot overduerecords of pass / fail and any fixes available

Fully Implemented

9. PSV servicing

KIW-2514 Nitrates SIF Test Register

KIW-3370 NH3 SIF Register

SIF test records - L: drive

SIF Testing Summary - PT269 Maintenance Plan History from SAP

1. SIFs in SAP as statutory inspections This includes individual SIF loop function tests and overall 10 yearly logic solver verification (NAP3 - 2014, ammonia scheduled Feb 2017)

2. SIF test records available since 2012.

3. New SIFS as part of AMI - register is in draft, PMs in SAP in process of being entered

Identify critical instruments / loops - bow ties, MHF work etc

Fully Implemented

10. Instrument calibrations / critical instrumented protection functions (IPFs)

7. Develop implementation plan for improving HA compliance with gaps identifies in HA inspection activities (which were completed Dec 2015) and verify progress in next Hazard Audit (2019)

1. 1. Comprehensive HA dossier has been prepared covering all operational areas HA visual inspections have been carried out in AN areas (2013/2014) and Ammonia areas (2015) Prioritisation of identified items has been completed. Not scheduled at time of audit though some work may be included in 2017 shutdown

Check HA drawings existsInspect a sample of equipment (Xd, Xi etc) to look for any obvious non-compliancesCheck maintenance practices and competencies for HA E&I contractors

Fully Implemented

11. Hazardous area classification integrity

Site walk around - Ammonia Plant

Site walk around - general areas eg Transformers, fire systems, storages, Cl2 dosing for water treatment

19. Observation: Labeling standard in new equipment was good. Some areas of older plant also good. Check progress of equipment labeling project in next audit (2019)

1. Equipment items in new areas such as flares, Nitrates ammonia storage were clearly labeled. A labeling project has been put in place to upgrade labeling in existing plants - due to complete at end 2017

2. sample of hoses inspected during walk arounds - all clearly tagged

Fully Implemented

12. Equipment labeling and identification in field

1. Shift log, half hour handover period. Quite detailed records for last 6 months.

Fully Implemented

13. Shift hand-over procedures

1. Site is generally very tidy, no obvious housekeeping issues.

Fully Implemented

14. Housekeeping standards and monitoring housekeeping integrity

1. Password protected Fully 15. Software/ programmable control systems






Requirements


2. Various SIL rated PLCs

Implementedsecurity

1. part of inspection regime Not Applicable

16. Corrosion underneath insulation

1. in place for major rotating machinery Fully Implemented

17. Vibration monitoring

1. Not explicitly covered in audit.Minimum pipe size of 25mm was adopted for ammonia piping in AMI project


18. Small bore pipework integrity

1. Not reviewed although some of this is in SAPPiping supportsTank floorsPlinthsStacksColumn supportsRoofed areas


19. Support integrity

1. Not reviewed Not reviewed in audit

20. Inert gas blanketing

1. Critical spares are identified as part of the criticality review

Fully Implemented

21. Critical spares

1. Three flares installed as part of AMI project. Access appears adequate

Fully Implemented

22. Access to flare


KIW2512 PTW Isolation Requirements KI Specific Procedure

1. Fire services contractor (permanent contractor) . Records in SAP No obvious gaps in monthly / 6 monthly tasks. Fire pump is within test period

Check specialist contractor completes tasks as per relevant standards (AS, NFPA etc) , logs available, operator awareness and does periodic ops test or deluges

Fully Implemented

23. Fire protection systems - register/ description, location, inspection and testing frequency, records and training

1. It is possible to generate a report of WOs from SAP for repairing leaks (need to think about keywords though), and also Enablon for loss of containment and failure of trips or siimlar

2. There were a small number of relatively minor leaks in each reporting system (around 5 - 10 since 2013)

Ability to identify integrity issues from incident tracking / near miss system (leaks, mechanical, instrument etc)

Fully Implemented

24. Incident History




Audit Element: Safe Work Practices


Requirements


KI2540 : B - PW-01 - Permit to Work

1. A new PTW module in SAP has been rolled out over 2015 and associated PTW procedure substantially updated. There is a PTW and associated specialist permits (Hot Work , Roof access, Confined Space, Excavation), two separate risk assessments - the JSERA and a Process Risk Assessment (PRA). These are separate forms that are linked to the Permit by the WO number. A new role (Permit receiver) was defined an checking requirement in field clearly defined. Training was conducted and all training and currency is recorded on Track Easy for Orica personnel and also any contractors who are authorised Permit Receivers

2. Active permit in control room and at job location

(hot work, confined spaces, excavation work, heavy equipment, lock out/ tag out, isolation)

Fully Implemented

1. Check the PTW system and status of records

PTW #60054603 AN2 plant ( Pneu Inst Air Clean)

PTW #60062300 Ammonia plant (TSV NPT Thermal)

PTW #60063503 Ammonia Plant (Tank;MDEA Storage)

KIW2512 PTW Isolation Requirements KI Specific Procedure

Example of Lock out Isolation Sheet - 2201 JAT oil leak repair

21. Observation: Lockout isolation sheets appear to be developed as a list of valves / isolation points on isolation sheet on a case by case basis. A potential improvement would be to have predefined isolation plans for common isolations and also to attach the marked up PIDs to the isolation sheet for all process isolations.

22. Observation: a potential improvement would be to add the Modification number to the WO information in SAP so it also appears with the PTW and it is immediately clear the proposed work is part of a modification.

1. A sample of permits was reviewed. These were filled in correctly. Isolation plans appear to be developed by Permit Issuer on a job by job basis. There is a KI site specific isolation standard that details standard of mechanical and electrical isolation required for particular hazards (as well as hydraulic, pneumatic energy sources)

2. Isolation sheets were in lock boxes with group lock number and lock board noted on them. Group lock number is noted on permit and green group lock attached to the lock board for each permit issued under that isolation. Not directly linked to permit - ie don't have WO on the isolation sheet as link but have lock board and lock number on permit. Isolations are developed on a job by job basis - not predefined, PIDs showing isolation points not attached. Isolation and locks checked in field against sheet and signed off on isolation sheet.

3. Did not check LOTO in field

4. If work is associated with a MOD, the WOs do not link to a MOD number. It is the Permit Issuers responsibility to consider whether the work is a modification and confirm that status is ACCEPTED.

Link between PTW, isolation plans, approval of Mods

Mostly Implemented

2. Check the PTW system / isolation against procedure




Audit Element: Safe Work Practices


Requirements


1. Permits can be extended up to a maximum of 7 days. However each permit has an expiry time at end of shift and must be handed back as incomplete and then reissued by next shift

2. There is a daily Permit Status report located in each control room which lists permits active, people signed on

Check that there is shift handover procedure and how it handles open permit to work Check detail in log bookLook for long term "out of service" items

Fully Implemented

3. Determine handover between shifts




Audit Element: Management of Change


Requirements


KIW-2563 Overarching Management of Change Procedure

Lotus Notes Mods database

1. Detailed Mods procedure in place. "Change" definition covers Temporary or permanent alteration to; Equipment, Procedures, Process settings Organisation structures

2. Site Lotus Notes Mod database goes back to 2006 (around 6000 mods since this time)These are supported by material attached directly into the database or links to electronic directories.

3. Audit focused on mods since 2013 (range from 2013 is MOD nos 11257 to 12176). Around 230 open mods at time of audit (excluding 2017 planned work for shutdown)

eg hardware - other than replacing like for like, materials of construction, software and programmable electronic systems, operating/ maintenance/ startup/ shutdown/ emergency procedures, personnel, contractor, technology, operating parameters, organisational, variance, taking one or more safety systems offline while plant still on-line

Fully Implemented

1. Definition of change

1. Like for like not specifically defined in procedure. Only way of identifying these would be to go through SAP records or CAPEX to see which did not have a modification

Check definitionsCross check with ops and maintenance personnel if they can identify like for like

Keep an ear out for changes that are discussed but can't be found in Mod register

Fully Implemented

2. Like for like / replacement in kind

24. Observation: Organisational change assessment was not reviewed in 2016 audit. Ensure this is covered in 2019 Hazard Audit

1. Organisational structure change is included in the definition in procedure ( "Any alteration to the level of resources required or available, the functions performed by people and/or workgroups or reporting relationships (including use of contracted resources")

2. No examples of org change in mods database - audit did not cover this as auditor was advised that this was done by senior management and confidential hence not in database but with HR. Site manager away at time of audit so access could not be obtained .


3. Is there a process for Organizational Change and determine if it assesses the impact on facility safety.

1. Electronic workflow in MOD database includes checklists

2. Specific forms for software change request (KI 3828)

Fully Implemented

4. Forms






Requirements


1. Electronic workflow in MOD database includes all review and approval steps

Fully Implemented

5. Approval levels

1. Defined in procedure. Action lists for Mods are generally filled in and closed out

Fully Implemented

6. Review levels (check list, HAZOP etc) and confirmation of action closure prior to proceeding with operation of mod

1. Refer to item 11 below Fully Implemented

7. Records maintenance (P&ID update, operating procedures/maintenance procedures update)

1. Very good awareness of when to use the procedure.

Fully Implemented

8. Awareness when to use the procedure

1. Mod database shows a relatively low number of temporary mods with short timeframes to closure

2. Definition of temporary modification and maximum timeframe in procedure (max allowable is 6 months)

3. KI has added a specific step to the corporate workflow standard for temporary mods - final step is REMOVED

Check that there are not a lot of long duration open temporary modsConfirm definition of temporary

Fully Implemented

9. Temporary changes (sunset clause), return to initial condition

1. Process Safety Lead / Lag indicators have been rolled out. This includes some typical indicators re temporary mods, length of time mods open, number of open mods etc

Confirm that there are some metrics around MODs, eg number open, length of time temporary mods open etc

Fully Implemented

10. KPI's

MOD KI011787 (AN Bag store FW)

25. Observation: the quality of closeout of some hazard study actions associated with Mods was variable. To monitor this it is suggested that some sample mods be selected periodically and a detailed check of closeout action quality be carried out to identify any patterns and determine if there

1. Sample MODs reviewed; (KI011126, KI012171, KI011639, some examples from AMI) All MOD description properly filled in. Most MODs with P&ID updates have been correctly reflected on latest issue of P&IDs in Vault. Risk assessments and review meetings have been carried out for all MOCs audited.

2. A number of spot checks were done on action closeouts in the AMI project MODs and associated Hazard studies There were over 60 separate mods associated with the AMI project. (43 now closed). Project manager has tracking sheet EN290.00.PA.012 MOD Status. XLS as it is difficult to use Mods database to get

Select a MOC involving new equipment/ modified process, determine how design requirements are specified, procured, QA process for installation and commissioned.Select a MOC involving new equipment/ modified process, determine how 'critical parameters' or 'operation' has been transferred from design to operations team - this includes training.Select a MOC involving new equipment/ modified process, determine if critical documentation has been updated for: - P&ID, Hazardous Area drawings etc.. - Operating Procedure (and training

Mostly Implemented

11. Example reviews






Requirements


the need for any actions such as refresher training.

an overall picture of statusLooked at MODs 11114, 11817) and various supporting information such as Commissioning check sheets, ITPs, PID revisions

3. Generally the AMI projects showed good compliance. However: - when checking the detail of some HAZOP action closeouts (See 15-0882 Nodes 7,8 eg item 08720) there were some inconsistencies in information eg the referenced version of the PID did not show the expected information or notes etc when checked

4. There is a delay in closing some AMI mods as the process HIRACs (ie scenarios and residual risks) have not yet been transferred to KI site Risk Register hence the mod status can't be COMPLETED.

5. MOD KI011787 for changing the fire water configuration at the AN bag store. This MOD status is COMPLETED. However could not find evidence in mod database or commissioning records that the revised design met the pressure / flow targets that were previously not met and that it was tested to perform to target flow / pressure. Also not clear whether high velocities in piping was addressed in MOD for AN bag store FW system

packages) - Start-up or shutdown procedures - Preventative Maintenance - Equipment Registers - Emergency Plans




Audit Element: Accident/ Incident Reporting and Investigation


Requirements


26. Observation: It would be useful for KPI tracking for MHF purposes to include a Process Safety Event (PSE) flag in Enablon. It is recognised that this would need to be done at a corporate level . Check progress of PSE tracking at next Hazard Audit (2019)

1. Definition is in corporate procedure and Enablon drop downs

2. Process safety events area defined but not a category in Enablon. Need to search based on another field (loss of process fluid)

Check:- incident definition exists- understanding of personnel of incident definition?- near misses included

Fully Implemented

1. Definition of incident

Enablon - Events at KI Serious or Potentially Serious Injury-04082016-5

Enablon - Events at KI with no investigation required (ALL)-04082016-2

1. Since 2014 Enablon is the Orica corporate tool for reporting all incidents and near misses, and tracking incident investigations and action management.

2. Generally personnel aware of Enablon and how to raise incident / near miss report

3. There are example of audit actions etc entered into Enablon

Do site personnel understand how to report an incident?

Are outcomes from task observations, audits, findings from emergency drills etc captured in action management system - are they incidents or is there a separate system ?

1. Records are in Enablon - fairly easy to retrieve. Report for incidents with potentially "serious" or worse incident classification in Injury /Illness category retrieved since Enablon started in 2014. 23 incidents in this periods, mostly OHS (back, electricity) also some loss of containment and trip failures

Are records easily accessible

1. Not checkedIs reporting to external authorities required - when / how/ who

Fully Implemented

2. Reporting system (incidents, accidents, near misses, loss of containment)

Orica investigation requirements

1. Investigation triggers (based on potential consequence), team requirements and competencies are defined in corporate procedures

2. Methodology is ICAMs for more significant incidents

Minimum competencies for incident investigation Who should be on the team?

Fully Implemented

3. Investigation system (who does team composition, external specialist involvement)

Enablon - Events at KI 1. Outcomes of incident investigations and action Outstanding incident investigations or Fully 4. Follow up and close out of actions arising




Audit Element: Accident/ Incident Reporting and Investigation


Requirements


Serious or Potentially Serious Injury-04082016-5

Enablon - Events at KI with no investigation required (ALL)-04082016-2

status are available in various reports in Enablon

2. Clear process for accepting an incident (ie a Validator OKs every entry) and for managing investigations and Actions.

3. Any resetting of Action due dates can only be done first by Site Manager and then Manufacturing GM (maximum of twice in total)

incidents not investigated ? Implemented

1. Yes - eg audit actions that require a risk reduction hardware change

Do changes as outcomes of incident investigation make it into Mod system ?

Fully Implemented

5. Relationship to change management for actions implemented

1. Numerous examples of lessons learned from inn SHEC committees, morning meeting etc,

Check mechanism for transferring/ sharing lessons learnt from accidents/ near misses at or other Company operating sites

Analysis of common causes etc undertaken

Fully Implemented

6. Communication of lessons learned




Audit Element: Training and Education


Requirements


Consolidated SHEC Training Matrix.XLS

Induction Package

1. There is SHEC training needs analysis - covers all roles including management

How are training needs identified at a corporate level?How are training needs identified at a business function level so that employees perform his or her job properly (and complying to all SMS requirements)?

1. Training needs covers - inductions, operational procedures, SHE, ERP, MHF awareness, CSE, first aid, internal tools such as Enablon

As a minimum, training should cover: - Induction and Refresher Requirements - Risk Management - Emergency preparedness and response training matrix or similar?

1. There is training matrix (2016 updated) - covers all roles including management

Is there a training matrix? Is the training matrix current

Fully Implemented

1. Training philosophy (who, what level, how often) and identification of training needs

1. Competency requirement are recognised at operator level eg Tier 1/2 /3. and Tier 4 supervisor. Aso for PTW and specialist high risk work (cranes, CSE etc)

Competence identification testing & assurance - are there different competency levels, How is competence measured.

1. Combination of internal Orica courses and externalTrainer (train the trainer / Cert 4) competence - other qualifications of trainer

Fully Implemented

2. Competency requirements

Induction Package

Track Easy training records - Onsite View Employee David Fulmer

Track Easy training records - Onsite View Employee Glen Bernard (maintenance Fitter)

1. For new employees package includes:- Induction (including video) - site tour- SHE Awareness - Permit to Work - Meet relevant personnel / managers- Introduction to Systems (DMS, Enablon) - buddy training and workbooks for theory (operations personnel)

Check with newer employees what the training package isAre they aware of what training they need to do?Do they feel competent?

1. Frequency in matrix and reminders for licence renewals in Track Easy

Refresher training

1. Documented operating procedures can be found on DMS.

How are changes to operating procedures handling - what training / communication

Fully Implemented

3. Training programs (new employees, contractors, refresher for existing employees)

1. Training matrix indicates that a lot of required training has not been completed - ie blank / no

Is training to personnel up to date and as per training matrix ?

Fully Implemented

4. Measuring performance and effectiveness




Audit Element: Training and Education


Requirements


records . NOTE: actual knowledge of personnel and ability to describe training received was quite good so this may be a records keeping issue rather than a gap in training.

2. KPIS in terms of % overdue / incomplete" target

Are there KPIs associated with overall training programme?

1. Combination of hard copy records for each employee (operations personnel) and some electronic records (Track Easy, licences etc)

Evidence of training and competency (test and assessment results, certificates etc) - all roles (contractors, drivers, employees)

Fully Implemented

5. Records management

1. Overall there was good knowledge of site operations, hazards, MHF type activities, incidents reporting requirements, responsibilities with respect to SHEC

2. Knowledge of required training is fairly good amongst new operations staff

Knowledge of requirements eg chemical hazards, MHF scenarios, emergencies, reporting requirements

Fully Implemented

6. Knowledge within organisation




Audit Element: Emergency Planning and Response


Requirements


Orica Kooragang Island Emergency Response Plan (KIW-1020)

1. ERP in place. Table of contents indicates this is consistent with HIPAP. Has been reviewed and accepted by FB and Safework as part of MHF licence application. Most recent ERP update was Rev 4, Nov 2015. This includes:- recent changes such as flares installed by AMI project- identification of Pacific Oils biodiesel facility, new neighbours who moved to site across road in 2014 and may also be the source of an external incident .

2. Covers scenarios for all areas on the KI site as well as pipelines to DG wharf

Formal on site emergency plan that covers: Type of emergency conditions Roles and responsibilities Early warning of a major accident - emergency control centre Response actions to control incidents Use of emergency equipment Chain of Command (and interface with external)

Fully Implemented

1. ERP (structure)

1. Site exercise conducted every 6 months (to Safe Houses) , also desktop 3 scenarios, 1 per year with emergency services (to evac point near Stockton Bridge - next planned was mid August 2016 just after audit)

Scheduled emergency exercises

1. Carried out by contractor, records in SAP, no obvious gaps

Testing of fire fighting systems and equipment - Testing of shutdown or ESD systems

1. Operations personnel appear familiar with requirements and have participated in drills and in some case real events .

Knowledge of requirements of emergency plan by ops and other personnel

Fully Implemented

2. Training and drills

1. ERP covers all scenarios anticipated for the KI site and has been regularly updated.

Type of emergency conditions - are they appropriate for a facility and is response proportionate

1. MHF is referred to in ERP. Does the Plan link to identified Major Accidents / MHF scenarios?

Fully Implemented

3. Emergency definition

27. Observation: Notes from emergency response exercise debriefs are available. However it is suggested that any

1. ERP in place. Table of contents indicates this is consistent with HIPAP. Has been reviewed and accepted by FB and Safework as part of MHF licence application. Most recent ERP update was Rev 4, Nov 2015. This includes:

Changes in surrounding neighbours/ contacts - Changes resulting from MOCsChanges as a result of exercisesChanges in roles / responsibilities

Mostly Implemented

4. Review and Update




Audit Element: Emergency Planning and Response


Requirements


actions are formally prioritised and completion tracked (eg using Enablon)

- recent changes such as flares installed by AMI project- identification of Pacific Oils biodiesel facility, new neighbours who moved to site across road in 2014 and may also be the source of an external incident . "

1. Notes from debriefs are kept however suggested actions are not formally prioritised or completion tracked.

Debrief and learnings

1. Plan developed in coordination with em services and neighbours

2. 12 x role cards for relevant ER team roles

3. Person in Command (PIC) for each Safe House. All operators trained to fill this role

Defined roles & responsibilities for emergencies with offsite impact Providing assistance to emergency services - Offsite actions to mitigate the impact of the accident

1. Not mentioned in ERPMutual Aid provisions

Fully Implemented

5. Involvement of neighbours and emergency services

1. Included in ERP together with contact lists. Notifying neighbours

1. Included in ERP. Immediate notification procedures for government agencies are detailed in the following procedures: KIW-1512: C-BG-06 Notification of Pollution Incidents (also Appendix V in this plan) for pollution incidents and KIW-1835: C-BG-06 Notification of WorkCover for fatalities, serious injuries or illnesses, dangerous incidents or major hazard events.

Notifying external authorities

Fully Implemented

6. Communications (internal, external, current)




Audit Element: Security and Access Control

Overall Element ComplianceNot reviewed in audit

Requirements


1. Fence, security gates, CCTV, 24 manned site Not reviewed in audit

1. What are the security arrangement of the facility to prevent unauthorized access to site.

1. Fence, security gates, CCTV, 24 manned site Not reviewed in audit

2. How is the facility secured after hours

1. Not covered - security plan as part of MHF - not reviewed in detail


3. How are documents, computer software and hardware protected?

1. Not covered - security plan as part of MHF - not reviewed in detail


4. What is the security of material and inventory control?




Audit Element: Auditing and Management Review


Requirements


Hazard Audit Implementation plan update

1. Combination of internal and external audits including last corporate SHERMIS audit (2015) and external such as ISO9001, DPE audits

2. Enablon used for audit frequency and action tracking

3. Hazard Audit implementation plan stauts last reported to DPE in Sept 2015

What is the arrangement for ensuring the adequacy of the SMS and that it remains 'fit for purpose'?

1. KPIs set for audits and completion of actionsWhat are the qualitative and quantitative performance measures and benchmarking?

Fully Implemented

1. Types of audits (electrical, process safety, OHS, insurance, hazardous area integrity, workforce inspections)

1. Orica Corporate sets frequency of SHECMS audits Who (and how does the company) establishes the scope of SMS audits and timeframe?

Fully Implemented

2. Internal (audit team, frequency, auditor qualifications, objectivity)

1. ISO9001Is the facility certified to any ISO standards (eg ISO14000, 9000, 18000 series) Any other external audits required - eg Conditions of Consent

Fully Implemented

3. External (within corporation, external specialist organisation, qualifications of auditors, frequency)

1. Enablon includes audit actions and status . Status reported as part of SHE stats and monthly SHE reporting. Audits actions are generally closed out

What is the status of actions from the audits?

Fully Implemented

4. Follow up and close out

1. SHEC committee - How are the audits disseminated to the facility

1. Monthly management meetings

2. Annual review process

How and when is the management review undertaken of audit findings to determine continuous improvements at the site (and other facilities operated by the Company)

1. % number of overdue auditsto schedule included and action closeout rates

KPI's (close out of previous audit actions)

Fully Implemented

5. Feedback and continual improvement




Audit Element: Environmental impacts / pollution potential


Requirements


What can end up in stormwater, is containment adequate?


1. Liquid wastes - Stormwater

Containment sufficient for credible fire scenarios?Basis documented?


2. Liquid wastes - firewater containment

All process equipment / leak points / storage areas within contained areas?Drum / package storage in contained area?Workshops in contained area?


3. Liquid wastes - process areas / spill containment

What are the loads, are they consistent with best practice, could they be reduced?


4. Liquid wastes - effluent / reduction potential



5. Solid wastes / reduction potential



6. Groundwater / soil contamination



7. Air emissions - odour



8. Air emissions - eg VOCs, NOX / SOx ? CO2 etc




Audit Element: Environmental Performance Compliance


Requirements



1.




Audit Element: Condition of Consent Compliance


Requirements


Annual production figures 2013, 2014 , 2015

1. NH3 annual production around 360,000 tpa (within consent). As AN3/ NAP4 has not gone ahead the excess ammonia is being shipped to Yarwun.

2. AN and HNO3 annual production below licence conditions

5. The Proponent shall not produce more than the following at the Project Site:a) 385,000tpa of ammonia product (from MOD 3 of DA);b) 605,000tpa of nitric acid product;c) 750,000tpa of ammonium nitrate product;

Fully Implemented

1. # 08_0129 MOD 3 Schedule 2 Limits on Approval

1. Site inspections, document reviews and staff interviews indicate that the site is well maintained with a good housekeeping standard, personnel are knowledgeable and the elements of an SMS (the Orica corporate SHEC MS) is implemented on the KI site.

12. The Proponent shall ensure that all plant and equipment used on the Project Site is:c) maintained in a proper and efficient condition; andd) operated in a proper and efficient manner.

2. # 08_0129 Schedule 2 Operation of Plant and Equipment

Project Staging Plan

Ammonia Management Improvement Project Kooragang Island HAZOP Report (20632-001)

Kooragang Island Facility Site Steam System Upgrade Project HAZOP Report (20932-RP-001)


2015 Model Shipping Update Results (QRA risk contours)

KI Status of Noel Hsu’s recommendations relating to CSB’s West, Texas report

1. The expansion project has been staged as agreed with DPE and is documented in the Project Staging Plan. Hazard studies have been staged accordingly. Relevant project stages since 2013 and status at time of 2016 audit are: 1.AMI Project. A Pre-Start up Compliance report Phase 4 AMI (dated August 2015) was submitted to DPE by Orica. THis is about 75% through the physical implementation and commissioning phase 2. New KI Boiler. Construction commenced but not completed or commissioned

14. At least 1 month prior to the commencement of construction of each Project stage (except for construction of those preliminary works that are outside the scope of the hazard studies), or within such further period as the Secretary may agree, the Proponent shall prepare and submit for the approval of the Secretary the studies set out under subsections a) to d) (the pre-construction studies).

1. Since 2013 two HAZOPs have been carried out for two components of the project as follows: - AMI Project .- Site Steam Upgrade Project (New Boiler). The HAZOPs were submitted to and approved by the DPE.

2. Status of actions is available in the relevant study in the Risk Register. The majority of actions have been completed however there are some open actions as appropriate to the stage of the projects.

f) A Hazard and Operability Study for the Project, chaired by a qualified person, independent of theProject, approved by the Secretary prior to the commencement of the study. The study shall be consistentwith the Department of Planning’s Hazardous Industry Planning Advisory Paper No. 8, ‘HAZOPGuidelines’. The study report must be accompanied by a program for the implementation of all recommendations

Fully Implemented

3. # 08_0129 Schedule 3 Pre-construction






Requirements


made in the report. If the Proponent intends to defer the implementation of a recommendation, reasons must be documented;

1. The FHA was last updated in 2015 to reflect the AMI project and also changes in ammonia shipping frequency

2. The FHA did not include an evaluation of all relevant findings and recommendations from the official investigation report(s), asavailable, relating to the accident at West, Texas in April 2013 (Final CSB Investigation Report was released in Jan 2016 after FHA) . However most of these are not items that can be accounted for in a QRA - refer to relevant section of this Audit. Orica has also undertaken an internal review of the recommendations and these are generally already addressed at KI.

g) A Final Hazard Analysis of the Project, consistent with the Department of Planning’s Hazardous Industry Planning Advisory Paper No. 6, ‘Guidelines for Hazard Analysis’. The Final Hazard Analysis shall: report on the implementation of the recommendations of the Preliminary Hazard Analysis; re-evaluate and reconfirm the relevant data and assumptions from the Preliminary Hazard Analysis; re-evaluate and reconfirm all control measures for prevention and mitigation of incidents; and evaluate all relevant findings and recommendations from the official investigation report(s), as available, relating to the accident at West, Texas in April 2013.

1. Since 2013 two HAZOPs have been carried out for two components of the project as follows: 1.CSS AMI Rev C (dated 2 April 2015). 2.CSS Boiler Rev B (dated 15 June 2015). These were submitted to and approved by the DPE. The majority of actions have been completed however there are some open actions as appropriate to the stage of the projects.

h) A Construction Safety Study for the Project, consistent with the Department of Planning’s HazardousIndustry Planning Advisory Paper No. 7, ‘Construction Safety Study Guidelines’. For a Project in which the construction period exceeds 6 months, the commissioning portion of the Construction Safety Study may besubmitted 2 months prior to the commencement of commissioning.


SIF Testing Summary - PT269 Maintenance Plan

1. The expansion project has been staged as agreed with DPE and is documented in the Project Staging Plan. Hazard studies have been staged accordingly

15. The Proponent shall develop and implement the plans and systems set out under subsections a) to c), no later than 2 months prior to the commencement of commissioning of each Project stage, or within such further period as the Secretary

Fully Implemented

4. # 08_0129 Schedule 3 Pre-commissioning






Requirements


History from SAP

KIW-2514 Nitrates SIF Test Register

KIW-3370 NH3 SIF Register

may agree. The Proponent shall submit, for the approval of the Secretary, documentation describing those plans and systems. Commissioning shall not commence until approval has been given by theSecretary.

1. nothing relevant i) Transport of Hazardous Materials - Arrangements covering the transport of hazardous materials including details of routes to be used for the movement of vehicles carrying hazardous materials to or from the site (Initial Operations and Project). The routes selected shall be consistent with the Department of Planning’s Hazardous Industry Planning Advisory Paper No 11, ‘Route Selection’. Suitable routes identified in the study shall be used except where departures are necessary for local deliveries or emergencies.

1. Periodic updates of ERP. The last one in Nov 2015 covers AMI installed so far (flares, new ammonia storage for Nitrates)

j) Emergency Plan - The Proponent’s Emergency Plan and detailed procedures shall be updated to include the Project and must be maintained for the life of the Project. The plan shall include detailed procedures for the safety of all people including consideration of the safety of all people outside of the facility who may be at risk from the Project. The Plan shall be consistent with the Department of Planning’s Hazardous Industry Planning Advisory Paper No. 1, ‘Industry Emergency Planning Guidelines’.

1. SHEC MS as implemented at KI site has all elements of HIPAP 9 as verified in this Hazard Audit

2. SIF loops and testing frequencies available in SAP.

k) Safety Management System - The Proponent’s Safety Management System shall be updated to includethe Project and must be maintained for the life of the Project. The document shall






Requirements


Spot checks indicate these are consistent with SIL ratings assumed in PHA. Test records available on network

clearly specify all safety related procedures, responsibilities and policies, along with details of mechanisms for ensuring adherence to the procedures. The procedures shall ensure that the testing frequencies of all safety critical equipmentand systems are consistent with the frequencies applied in the fault tree analyses undertaken in thePreliminary Hazard Analysis/Final Hazard Analysis. Records shall be kept on-site and shall be available forinspection by the Secretary upon request. The Safety Management System shall be developed inaccordance with the Department of Planning’s Hazardous Industry Planning Advisory Paper No. 9, ‘Safety Management’.

1. The scope of this is generally covered in the AMI project

18. Within 12 months of the commencement of Final Operations of the Project, the Proponent shall prepare a program for further risk reduction to the neighbouring land uses. The program shall:r) be approved by the Secretary;s) identify the overpressure propagation risk from the Project as per Figure 10.5 of the EA;t) identify the main risk contributors and analyse the appropriate measures to be implemented to reduce therisk; andu) include an implementation schedule with due dates and a person responsible for the implementation ofeach measure.Note: In the case that the propagation risk from the Project is reduced earlier than

Fully Implemented

5. # 08_0129 Schedule 4 Risk Reduction Program






Requirements


anticipated in the EA, and it meets the NSW criteria, this condition will be satisfied and the risk reduction program will not be required.

1. The FHA was last updated in 2015 to reflect the AMI project and also changes in ammonia shipping frequency

19. 3 years after the commencement of Final Operations of the Project, or as otherwise agreed to by the Secretary, the Proponent shall undertake a Hazard Analysis of the Initial Operations and the Project to update the hazard analysis contained in the Preliminary Hazard Analysis and the Final Hazard Analysis.

Fully Implemented

6. # 08_0129 Schedule 4 Hazard Analysis Update

Hazard Audit Implementation plan update

1. Nothing specific identified. Orica have submitted period compliance reports to the DPE on:- status of project approval conditions - status of previous hazard audit actions and other actions

20A. The Proponent shall comply with all reasonable requirements of the Secretary in respect of the implementation of any measures arising from the hazard studies submitted in respect of conditions 14 to 20 inclusive, within such time as the Secretary may agree.

7. # 08_0129 Schedule 4 Further Requirements




Audit Element: Industry guideline compliance (SAFEX)


Requirements


SDS NITROPRIL Substance No: 000022017701

1. KI site manufactures and stores Technical Grade AN with density of 0.72 - 0.78 g/cm so SAFEX guidance is applicable

Confirm applicability of guidance to facility ie: - TGAN (UN1942, UN2067 only) but not FGAN, Class 1 AN mixtures, ANS / ANE, UN1942 AN with density > 0.9g/cc

1. Customer returns not accepted

2. Production process doesn't include any incompatible materials

3. Procedure for introduction of new chemicals or materials onto KI site to ensure compatibility with AN or that appropriate safeguards in place.

4. Procedures for spill cleanup, eg if hydraulic oil or diesel spill from FEL occurs in AN store, machine is removed from store ad clean up implemented

- Offspec product (from process, spillages or returns)

Fully Implemented

1. Section 2 of GPG02 Scope of GPG02

1. SHEC MS as per Hazard Audit elements includes all these items

SMS to include: - Safety policy- Plan Framework- Training - Procedures- Emergency Response

Fully Implemented

2. Section 4 of GPG02 Safety Management Systems


MHF Licence Conditions


1. SHEC MS as per Hazard Audit elements includes all these items

Includes:- licences- local regulations- separation distances

3. Section 5 of GPG02 Regulatory Requirements

Site walk around - AN bulk store and AN bag store

FEL Spec - AN Area Loader Build Specification - Kooragang Island (KIW-3000)

2. Confirm lightening protection is adequate for AN bulk store and AN bag store

4. Observation: The wooden walkways

1. All electrics on site comply with AS3000 and subject to periodic inspections

2. Lighting in AN bulk and bag store is to IP65 standard (ie has covers and bulb can't fall into product) and is elevated such as the AN pile could not reach the lighting based on store dimension and

6.1 General Requirements Electric: -Electrical devices which are used in a TGAN environment must conform to the relevant electrical codes - Ensure proper protection against electrical storms according to local codes

Fully Implemented

4. Section 6 of GPG02 Site Design, Construction and Management






Requirements




Orica KI Site FSS Report

between the disused building adjacent to the AN bulk store are the only identified combustible building materials in the vicinity of the Bulk Store. Whilst ignition and escalation are unlikely, removal is suggested which would eliminate all combustibles in the vicinity of the Bulk Store.

12. Observation: Overall reduction in combustibles in vicinity of AN can only be achieved by removal of wooden pallets and potentially change in AN bag material. It is suggested that Orica ensure that the current project investigating use of non-combustible pallets / bags include a formal SFARP demonstration that supports the project decision (as required under MHF regulations) and also that project outcomes be checked in next Hazard Audit (2019)

angle of repose

3. FELs used in AN store are dedicated to store, and are flameproof as per KI build spec

4. Palletising equipment in Bag store remains but has been decommissioned (Around 5 years ago, approx 2011)

and practices - Lighting should have additional safeguard to prevent it from falling onto the product

1. Dedicated AN stores, no other materials stored in vicinity, AS 4362 compliant separation distances, a full QRA has also been completed.

2. No wood or bitumen / asphalt inside AN bulk store or bag store, concrete flooring.

3. Freight containers usually loaded with AN bags. Occasional bulk, in that case a polyethylene liner is used inside shipping container.

4. Copper - controlled use at KI site, none in AN stores

5. Reactive ground not applicable at KI

Construction: - Storages should be built at appropriate distances from each other. Different classes of materials should be stored according to Dangerous Goods regulations and company policy. - Means of minimising confinement should be reviewed, including options of pressure relief where appropriate. - Any AN storage facility should not contain wood lining or an exposed wooden floor. In the case of freight containers wooden floors may be protected by sealing with mild steel, plastic sheet or a suitable coating such as polyurethane or epoxy paint. The coating option is not recommended if the seams are not tight and cannot be sealed properly as AN spillage can impregnate the wood resulting in a fire hazard. If the AN is stored in bags in the freight container, the bag will provide sufficient separation of the AN from the floor. - Galvanised steel should be protected from direct contact with TGAN (e.g. coat with epoxy tar or chlorinated rubber). - The use of exposed copper should be avoided, as copper is incompatible with TGAN. - Flooring should be constructed of non-combustible material (concrete, compacted road base, asphalt with low bitumen content 1






Requirements


- TGAN stores must not be erected on locations that have pyrites, hot or other reactive ground that can react violently with the TGAN.

1. AN bulk store and AN bag store each have dedicated drainage, running to open drains (loosely attached metal grate on top of drains.)

2. No incompatible drainage (eg acidic effluent) in area

Drainage:Drainage systems must be constructed according to applicable environmental standards and should be designed to avoid the accumulation of any significant amount of TGAN in the event of a spillage. Such systems can include the following: - Open drains to prevent the possibility of molten TGAN becoming trapped and confined in drains - Other potential areas of confinement include drains and channels. - Prevention of the contamination of surface and ground. - A system for collecting and disposing of contaminated waters including fire water effluent - Isolation from other storage areas, buildings and combustible materials. - Separation from potentially incompatible effluent streams

1. Provided as per ADG and SSAN requirementsSignage

1. Not applicable6.2: Open Air compounds

1. Not applicable6.3 Freight Containers for Storage

1. Some hoppers for loading trucks and bagging

2. All metal construction, open top hoppers

3. No flammable liquids anywhere around the AN stores. Combustible liquids only diesel fuel / hydraulics in FELs, forklifts.

4. Stores drainage design prevents ingress of liquids

6.4 Silos or Bins:- Various requirements regarding materials of construction compatibility with AN, wind / seismic loading, design to prevent caking- Adequate venting must be provided to prevent pressure or vacuum build up during loading and unloading. - No combustible materials (including flammable liquids in tanks) should be underneath or in the vicinity of the silo.






Requirements


- The topography in the area of the silo should be taken into account to prevent spilled flammables running towards the silo.

1. Stores drainage design prevents ingress of liquids

2. AN bulk and bag stores single storey, natural ventilation in bag store, air conditioning at roof level of bulk store

3. Explosion vent door on AN Bulk store building

4. Concrete flooring for AN bulk and bag stores

5. FELs outside store when not is use

6.5 Buildings:-Well ventilated and single storey - Floors may be of concrete, compacted road base, low bitumen (less than 9%) asphalt or earth. Regulations may limit the choices for the storage of bulk TGAN in some countries - Water ingress, which will cake TGAN, must be avoided - Mobile haulage equipment should not be in the AN Store unless it is in use.

1. Not applicable6.6 Storage of Large Amounts of TGAN at Mine Sites

1. KI Site ERP includes AN fire and NOx response and evac to far end of Greenleaf Rd (1km from bulk AN store)

2. Minimal combustibles in vicinity of AN stores. Small amount of wooden walkway between AN bulk store and disused office / shed adjacent to AN bulk store observed in walkaround.

3. KI Site FSS details fire protection (seen in site inspection) : - Sprinkler system in AN bulk and bag stores, remotely operable from outside stores- Automatically activated fire water sprays in AN conveyors- Sprinklers at AN truck loadout areas

6.7 Fire Fighting Fires involving Ammonium Nitrate should never be fought. If the fire involves Ammonium Nitrate the facility must be evacuated. (. 1km evac distance > 1000 tonne storage) - Only those employees on the site who are trained in the hazards of ammonium nitrate should provide support and guidance to the fire fighters during the evacuation. - Appropriate PPE including self-contained breathing apparatus (SCBA) should be made available should there be a fire that does not involve Ammonium Nitrate and needs to be fought. - Fire protection strategies should be based on minimising the presence (both potential and actual) of combustibles around TGAN. - For a fire involving TGAN, the prompt remote application of water is the most






Requirements


effective means of control. It is the cooling effect of water that controls the fire. - Water from hoses and fixed monitors must be able to reach all parts of the store. - Foam and/or dry chemical extinguishers must be available to deal with vehicle or electrical fires. - Fire fighting systems for incipient fires or fires not involving Ammonium Nitrate should be capable of single person operation - The SERP should provide guidance for scenarios which involve the release of NOx.

1. Not applicable6.8 Contaminated TGAN Storage

Kooragang Island Phase 1 Uprate Final Hazard Analysis (31/24733/172898)

2015 Model Shipping Update Results (QRA risk contours)

1. Full QRA was prepared including AN explosions for Bulk Store, Bag Store and other inventories in yard areas. Shipping containers not specifically included but similar inventories are.

QRA was according to NSW DPE HIPAP requirements as part of Trident and has been updated to reflect changes in project scope (related to ammonia not AN).

The siting and layout of TGAN storage is based on minimising the risk from an event within the storage facility. Owners and operators of TGAN stores should adhere to the Quantified Risk Assessment (QRA) method mandated by their relevant regulatory authority(ies).

Fully Implemented

5. Section 7 of GPG02 Location of Storage Facilities



1. FELs (Bulk store) and forklifts (Bag store) have parking areas outside stores

2. FELs and specific forklifts are dedicated to AN storage area. They have KI specific build specs which include extinguishers, water scrubbed exhausts and other measures to minimise ignition potential

3. Operating procedures require attendance in store with vehicle at all times

8.1. General Considerations :The following requirements are applicable to all stores (in- and off- specification AN whether stored in bulk, bulk bags or packaged AN):- Internal combustion power operated vehicles and machinery shall not be left unattended within any TGAN store if the engine is running. - Internal combustion and electrically powered vehicles and machinery should be: - provided with a readily accessible dry chemical fire extinguisher rated for fighting electrical and vehicle fires only.

Fully Implemented

6. Section 8 of GPG02 Operation of Stores






Requirements


- located outside the TGAN store when not in use. - attended at all times while the engine is running inside the store - free of any leaks of fuel, lubricating oil and hydraulic fluid. - fitted with a spark arrestor or similar device.

1. KI is a no smoking site and all hot work or intruduction of energy sources to AN stores (apart from FELS/ forklifts) controlled under PTW system (as covered in site Induction)

2. Lighting in AN bulk and bag store is to IP65 standard (ie has covers and bulb can't fall into product) and is elevated such as the AN pile could not reach the lighting based on store dimension and angle of repose

- Smoking and open flames shall not be permitted inside the TGAN store and notices to this effect shall be displayed. - Unguarded electrical lights shall not be permitted inside the TGAN store and notices to this effect shall be displayed. - In areas where there are electrical storms, proper protection against lightning strikes must be provided and maintained. - Lighting should have additional safeguard to prevent it from falling onto the product.

1. Site inspection indicated clear entry / exit routes, good housekeeping in both stores. Minimal evidence of spills

- The open floor of every store, including any vehicle access area should be kept clean of any spilled TGAN or other material spillages at all times. Spills must be cleaned up immediately.

1. Site inspection indicated clear entry / exit routes, good housekeeping in both stores

- Store layouts must ensure unimpeded exits for personnel and vehicles.

1. not checked specifically but KI manage lifting equipment, cranes etc as per NSW WHS regulations

- Lifting equipment shall conform to the local codes

1. SSAN site - not reviewed in detail - Security systems should be in place to prevent unauthorized access and to enable early detection of, and appropriate response to, unexplained loss of product (Refer Appendix C on p.50).

1. Site inspection indicated clear entry / exit routes, Housekeeping






Requirements


good housekeeping in both stores. Minimal evidence of spills

2. Bags on bagged product looked to be in good condition (no evidence of rips, tears, rodents chewing)

3. Floor in good condition and flat / smooth

4. No vegetation for 100s of meters

- Storages should be kept clean at all times and inspected regularly and particularly when maintenance is being carried out • Housekeeping standards should prevent contamination of TGAN and accumulation of combustible and/or flammable materials in proximity to TGAN. - Floors, walls, pallets and equipment must be clean and spillages cleaned promptly. Spilt AN must be stored in the offspec AN area if it cannot be recovered in a clean state. - Organic materials (e.g. sawdust) must not be used to clean floors. - Necessary precautions must be taken to prevent the ingress of TGAN into areas out of view (e.g. hollow tubes). - It is recommended that all floor and ground surfaces should be level and free from sharp objects which might tear or puncture bags. - Rats and other rodents should be controlled to avoid damage to bags (open air compounds and buildings). - AN storage area must not be used for any other purpose (storage of cleaning products, tools, consumables, etc). - Vegetation (and combustible materials such as empty pallets) must be cleared according to local regulations. A minimum distance of 8 metres around the store is recommended as a guideline. - Haulage/reclaim equipment used in the building should be well maintained with particular focus on oil and grease leaks/contamination.

1. Wooden pallets are used to store bagged product on.

2. Polypropylene bags for AN

- The use of combustible materials (e.g. pallets for storing AN) should be avoided as far as reasonably possible






Requirements


3. Shipping containers are steel with wooden floors

1. Bag store - mostly 2 high block stacked with offset (SAFEX term is "normally stacked") at time of visit

2. Each bag about 1.2 tonne including pallet

3. Painted lines showing limit of bag storage areas > 1m from store walls. This was clear

4. Distance to roof from 2- 3 high stack >> 1m

8.2. Packaged Stores Key points: - Stacking of pallets and IBCs shall be limited to three high, with each pallet containing no more than 1.3 tonnes. - Stack stability must be maintained in all stack configurations - A free air space of a least one meter (1m) should be maintained between stacks of packaged TGAN and the outer walls of the buildings. - A minimum clearance of one meter (1m) shall be maintained between the top of the stack and the roof or lowest support beam of the building, or to the lowest lighting fixture.

1. Total capacity of Bag store is 2,500 tonnes. Currently arranged in 8 x 150 te piles with 8m separation between piles

2. Shipping containers (outside) are either loaded with bags or occasionally bulk. 4 x 500te blocks of containers, 4m separation between block

- For packages and IBCs, individual stacks should be separated by the distance determined by the QRA. - For packages and IBCs stacked on wooden pallets, storage should be in maximum stack sizes of 200 tonnes, or as determined by the QRA. - For packages and IBCs stored on either non-combustible (steel) pallets OR without any pallets, the maximum stack size will be determined by the QRA.

1. Lighting in AN bulk and bag store is to IP65 standard (ie has covers and bulb can't fall into product) and is elevated such that the AN pile could not reach the lighting based on store dimension and angle of repose

8.3. Bulk Stores Key points: - A minimum clearance of one meter (1m) shall be maintained between the top of the pile and the roof or lowest support beam of the building, or to the lowest lighting fixture. - Lighting should be positioned or protected so that it cannot fall into the bulk pile.

1. Not covered - security plan in place as per SSAN requirements - not reviewed in detail


7. Section 9 and Appendix B of GPG02 Security Requirements






Requirements



3. Observation: The QRA (in FHA) appears to use the total inventory of the Bag Store (Table AV-5) in the consequence assessment. Given the storage configuration with 8m between stacks there may be scope to reduce this to a single stack basis in future revision of the QRA. Orica to review QRA AN bag store basis when QRA update is next required

1. Total capacity of store is 2,500 tonnes. Currently arranged in 8 x 150 te piles with 8m separation between piles

2. Total AN Bag Store inventory used (2320 tonnes, Table AV-5) in consequence assessment as single pile

A.1.1. Bags and IBCs The gap separation distances between each stack shall be maintained as follows for the various densities of TGAN: • Low density (less than 750 kg/m3 or 0.75 g/cc), high porosity TGAN stacks that are “normally” configured (i.e. set back by ½ bag at each layer) should be separated by 16 metres 6. For a “pyramidal” stack, the separation can be reduced to 9 metres. • Medium density (between 0.75 and 0.85 g/cc) TGAN stacks should be separated by 9 metres for a normal configuration and reduced to 7 metres for a pyramidal configuration • High density (greater than 0.85 and less than 0.90 g/cc) TGAN should have a separation gap between stacks of 1 metre (The basis of which is still to be confirmed by field tests).

Fully Implemented

8. Appendix A of GPG02 Separation Distances


1. The QRA in the FHA generally uses a similar approach and parameters for AN explosion risk assessment as described in GPG02 guidance

2. Average AN Bulk Store inventory used (9200 tonnes, Table AV-5) in consequence assessment as single pile (which it is).

This appendix describes the TNT equivalence parameters an frequency approach for including in a QRA

Fully Implemented

9. Appendix B of GPG02 Risk Assessment and Consequence Modeling




Audit Element: AS4326 Compliance


Requirements



1. DPE and Safework have accepted risk profile as per QRA

(a) The separation distances to protected places and boundaries given in the relevant State or Territory regulations shall apply.

1. No vegetation for 100s of meters(b) Every store for ammonium nitrate shall have a clear area at least 5 m wide around it. Such an area shall be cleared of any vegetation or combustible material and any equipment that is not necessary for the operation of the store. Any standing trees should be cleared for at least 15 m, or a distance equivalent to 1.5 times the height of the trees, whichever is the greater.

1. Within overall secure site as per SSAN security plan

(c) Stores shall be surrounded by a security fence, being — (i) at least 2.45 m high; (ii) galvanized or plastic-coated, with selvedges twisted and barbed; (iii) capped with three rows of barbed wire; and (iv) located at least 3m from the ammonium nitrate store.

1. not applicable (d) Where ammonium nitrate is stored in conjunction with explosives, the store shall be separated in accordance with AS 2187.1.

1. AN bulk store and AN bag store single store and ventilated

(e) Buildings in which ammonium nitrate is stored shall be well ventilated and singlestorey.

(f) Buildings and structures shall be dry and free from any water seepage through the roof, walls or floor.

(g) Where a drainage system is provided, there shall not be any traps, tunnels or pits under the floor of a storage area, or any space where molten or liquid ammonium

Fully Implemented

1. AS4326 clause 9.3.1 Location, design and construction of stores for ammonium nitrate






Requirements


nitrate may collect and be confined.

(h) Kerbing or grading shall be provided such that, in the event of fire, molten ammonium nitrate will flow clear of all other storage areas, buildings and combustible materials, and be retained on the premises.

(i) The store layout shall be such as to permit the unimpeded exit of personnel and vehicles.

(j) Where there is a risk of corrosion from the ammonium nitrate, all electrical equipment inside the store shall have a rating of not less than IP 65 in accordance with AS 60529.

(k) The use of hollow sections, including pipes, shall be avoided. NOTE: This is in order to prevent the build-up of gases and residues.

(l) Any galvanized steel shall be protected from direct contact with the ammonium nitrate, e.g. by coating with epoxy tar or chlorinated rubber.

(m) Exposed copper shall not be used in the store. NOTE: Copper can react with ammonium nitrate to form sensitive explosive compounds.

1. DPE and Safework have accepted risk profile as per QRA

The regulatory authority shall be consulted with regard to any separation distances relating to stores for ammonium nitrate.

Fully Implemented

2. 9.3.2 Separation distances to vulnerable facilities and critical infrastructure


1. FEl and FL design issues a) to e) are all included in the relevant KI specs.

2. Site visit did not identify any unsuitable vehicles in store areas or unattended vehicles inside store areas.

Vehicles and machinery powered by internal combustion engines and operated within the store shall— (a) be diesel-powered; (b) be provided with a battery isolation

Fully Implemented

3. 9.3.3 Internal combustion engines






Requirements


3. Procedures are in place for vehicle use within stores, response to spills

4. FEL parking area is more than 10m from Stores

5. Store Egress / Exit is clear and unobstructed

switch and an insulated cover over the battery terminals; (c) be free of any leaks of fuel, lubricating oils and hydraulic fluid; (d) be provided with a dry-powder fire extinguisher having a rating of not less than 40(B) (to be used only in the event of a vehicle fire); (e) be fitted with a spark arrester; (f) be started outside the store; (g) be kept outside the store when not in use; (h) be garaged at least 10 m from the store; (i) be attended at all times whilst inside the store; and (j) have unhindered egress from the store at all times.

1. Not applicable - no other DGs in AN stores Not Applicable

4. 9.3.4 Co-storage of other materials and dangerous goods within the ammonium nitrate store


1. KI is a no smoking site and all hot work or introduction of energy sources to AN stores (apart from FELS/ forklifts) controlled under PTW system (as covered in site Induction)

2. Housekeeping standard was observed to be high

3. Sawdust not used

4. No unused packaging observed in AN bag store. Separate storage area for pallets and bags

The following specific operational requirements apply to the storage of solid ammonium nitrate: (a) Smoking and naked lights shall not be permitted within the ammonium nitrate store. (b) Floors and walls shall be kept clean and any spillages cleaned up promptly. Organic materials such as sawdust shall not be used to clean floors. (c) Unused timber pallets and empty bags and packaging shall be promptly removed from the store. (d) Pallets, ropes, covers, and any other equipment shall not be allowed to become impregnated with ammonium nitrate.

Fully Implemented

5. 9.3.5 Operational requirements specific to ammonium nitrate

Site walk around - AN bulk 1. Design standard for AN conveyors covering The following requirements and Fully 6. 9.3.7 Conveyor belts






Requirements


store and AN bag store


materials of construction, including FRAS (fire resistant anti-static) belts

2. All AN conveyors have fire suppression systems (fusible bulb as per FSS)

recommendations shall apply to any conveyor belts in the ammonium nitrate store: (a) The conveyer belt shall be designed to move on rollers and remain within the confines of the conveyer framework. (b) The materials used in the conveyer belt and rollers should be fireproof so that they do not contribute to a fire. (c) The area around the conveyer belt shall be kept free of flammable materials (see also Clause 10.5). (d) The conveyer system shall be maintained to prevent spills, heat spots and rubbing.

Implemented


12. Observation: Overall reduction in combustibles in vicinity of AN can only be achieved by removal of wooden pallets and potentially change in AN bag material. It is suggested that Orica ensure that the current project investigating use of non-combustible pallets / bags include a formal SFARP demonstration that supports the project decision (as required under MHF regulations) and also that project outcomes be checked in next Hazard Audit (2019)

1. AN bag store stores up to 2500 tonne . In stacks of up to 150 tonnes on combustible (wooden) pallets, 8m between stacks up to 3 high. Table 9.3 states 2000 tonnes as the maximum capacity of a store with bags on combustible pallets (5000 tonnes for non-combustible pallets) hence capacity exceeds AS4326 requirement. QRA and MHF work has been undertaken on basis of 2320 tonnes and agreed by DPE and Safework - hence regulatory consultation requirement satisfied.

2. Painted lines showing limit of bag storage areas > 1m from store walls. This was clear and unobstructed

3. Distance to roof from 2- 3 high stack > 1.5m

4. NOTE: Auditor was advised that Orica is currently investigating options for non-combustible pallets or storage without pallets for AN bags

(a) Where packages or IBCs of ammonium nitrate are stored in stacks, the capacities of such stacks and the distances between them shall comply with Table 9.3. The maximum capacity of any individual store of packaged ammonium nitrate is also given in Table 9.3. NOTES: 1 The relevant regulatory authority may need to be consulted regarding the manner of stacking and the maximum capacity of the ammonium nitrate store. 2 Where a licence is required, it is necessary to consult with the regulatory authority. (b) When not on combustible (e.g. timber or plastic) pallets, packages and IBCs shall be stored such that the maximum stack size is 500 t. Such stacks shall be separated from each other by an air space of at least 3 m or a concrete wall at least 200 mm thick. (c) Stacks of pallets or IBCs shall be configured so that stability is maintained. NOTE: A maximum stack height of 3 m is

Fully Implemented

7. 9.4 SPECIFIC REQUIREMENTS FOR THE STORAGE OF AMMONIUM NITRATE IN PACKAGES AND IBCs






Requirements


recommended. (d) Stacks of packages of ammonium nitrate shall be separated by an air space of at least 1.2 m— (i) between each stack; (ii) from the outer walls of the building; and (iii) from the lowest support beams of the roof.



1. Maximum capacity of 15,500 tonnes. Some separation walls within store but quantity in a pile significantly exceeds 500t. QRA and MHF licence work has been undertaken on basis of single pile of 9,200 tonnes and agreed by DPE and Safework - hence regulatory consultation requirement satisfied.

9.5.2 Storage of ammonium nitrate in bunkers Loose bulk ammonium nitrate shall be kept in piles, in a bunker system, each pile having a capacity not exceeding 500 t. Piles of ammonium nitrate shall be separated from each other by concrete walls of at least 200 mm thickness. NOTES: 1 For storage of larger quantities, or where a bunker system is not used, it may be necessary to consult with the relevant regulatory authority. 2 Where a licence is required, the relevant regulatory authority needs to be consulted.

Fully Implemented

8. 9.5 SPECIFIC REQUIREMENTS FOR THE BULK STORAGE OF SOLID AMMONIUM NITRATE




Audit Element: CSB Investigation into West Texas (recommendations)


Requirements


KI Status of Noel Hsu’s recommendations relating to CSB’s West, Texas report



4. Observation: The wooden walkways between the disused building adjacent to the AN bulk store are the only identified combustible building materials in the vicinity of the Bulk Store. Whilst ignition and escalation are unlikely, removal is suggested which would eliminate all combustibles in the vicinity of the Bulk Store.

5. Confirm the design fire / suppression basis for the fire protection systems in the AN Bulk and Bag Stores to ensure they are "adequate", eg meet relevant codes or control measure adequacy tests adopted in MHF risk assessments.

6. Observation: It is not clear what "adequate" ventilation is for the AN storage buildings. It is suggested that this be clarified ie is it to meet relevant codes or control measure adequacy tests adopted in MHF risk assessments and whether provided systems achieve this

1. Orica KI have undertaken a self audit against an internally developed summary (by Noel Hsu) of the CSB's West Texas recommendations and found that the AN storage areas are generally compliant, also that the recommendations relating to regulations, emergency response and training are already largely covered by the WHS and MHF regulatory requirements in NSW.

West Texas report deals with FGAN but TGAN has very siimlar properties and learnings regarded as applicable.

Recommendation R1 to R4 - deal with regulatory changes in US - not relevant in NSW as MHF, HIPAP planning hazard studies and associated ERP largely covers this

1. AN Bulk Store and Bag Store are non-combustible building materials except for small area of wooden walkway near Bulk Store

2. Automatic sprinkler systems are provided in parts of the Bulk Store (air conditioning unit, plenum and road tanker loadout)

3. Manually operated sprinklers provided in Bag Store

4. Air conditioning in AN Bulk Store and natural ventilation in Bag Store. "adequate" ventilation does not appear to be defined - thought to be worker comfort levels

5. Separation distances to any incompatibles are very large

6. The Site FSS summarises the available water for each of the sprinkler systems but does not identify the design fire / sizing case / confirm adequacy of the systems in the AN stores

Recommendation R5 and R6 deal with ensuring good engineering practices are followed including: - Non-combustible materials for buildings storing AN - Automatic sprinklers / fire protection systems- Define adequate ventilation for FGAN for indoor storage areas. - Require all FGAN storage areas to be isolated from the storage of combustible, flammable, and other contaminating materials. - Establish separation distances between FGAN storage areas and other hazardous chemicals, processes, and facility boundaries.

1. Site ERP and NSW FB has reviewed ERP and the FSS and is periodically on site for exercises. Already covered.

Recommendation R7 to R16 deal with knowledge and training for emergency responders

1. Orica KI have undertaken a self audit against an internally developed summary (by Noel Hsu) of the CSB's West Texas recommendation and believe insurance is adequate

Recommendation R18 covers insurance

1. Outside scope of Hazard AuditRecommendation R19 Customer

Mostly Implemented

1. Recommendations 1 -19 of CSB West Texas Incident Investigation Report




Audit Element: CSB Investigation into West Texas (recommendations)


Requirements


knowledge




Audit Element: Closeout of 2013 Hazard Audit recommendations


Requirements


MOD KI011126 (Chlorguard Installation)


1. Chlorguard is physically installed Physically inspect in field and check for updated documents / reports / calculations as relevant / MOD in system and is closed

1. SAP PMs for chlorine sensor calibration and function tests - Maintenance Items 66031 to 66034 inclusive

2. PID updated and in Vault

Check closeout was appropriate, eg PM tasks defined, PIDS updated, SOPs updated etc

Fully Implemented

1. (2013 Hazard Audit Rec 1) A review of the recommendations from the previous audit and other hazard studies identified that it was recommended to review the potential to use less hazardous biocide than the current chlorine system. The investigation identified that due to the quantity of biocide required, chlorine was the only effective material. Hence, to reduce the risks associated with the use of chlorine, a “Chlorguard” system will be installed. This has been approved but not yet installed. Hence, it is recommended that the installation of the “Chlorguard” system be reviewed at the next audit (2016).

KOORAGANG ISLAND AMMONIA OPERATIONS HAZARDOUS AREA VERIFICATION DOSSIER Doc no E-10031-HD-0001

HAC Report Orica KI Nitrates Plant doc ref KIW-2515_1

Ammonia Operations 2015 HA Inspections doc ref E-10031

7. Develop implementation plan for improving HA compliance with gaps identifies in HA inspection activities (which were completed Dec 2015) and verify progress in next Hazard Audit (2019)

1. Comprehensive HA dossier has been prepared covering all operational areas

2. HA visual inspections have been carried out in AN areas (2013/2014) and Ammonia areas (2015)

Physically inspect in field and check for updated documents / reports / calculations as relevant / MOD in system and is closed

1. Prioritisation of identified items has been completed. Not scheduled at time of audit though some work may be included in 2017 shutdown


Mostly Implemented

2. (2013 Hazard Audit Rec 2) It was identified that the site has developed a number of documents related to the Hazardous Areas, however, some of the details required by AS60079.14-2009 (Section 4.2, Ref.5) in relation to the verification dossier are not included in this documentation. It is therefore recommended that Orica KI develop a Hazardous Area Verification Dossier and include the requirements of Section 4.2 in AS60079.14-2009 (Ref.5).



1. A sample of hydrants was inspected. All had test tags. Hoses were in boxes with boxes cabled tied closed. SAP inspection tasks in place.



Fully Implemented

3. (2013 Hazard Audit Rec 3) During the site inspection it was identified that a number of fire main hydrants were not fitted with inspection tags indicating currency of hydrant tests. It is therefore recommended that hydrants at the site be checked to ensure test tags are installed on each hydrant.

KI Fire pump system testing results

FW Routines.XLS - SAP

8. Observation: (2013 Hazard Audit Rec 4) Fire pump test log results are available in electronic

1. SAP contains records of planned and completed FW pump tests.


Fully Implemented

4. (2013 Hazard Audit Rec 4) The testing of the site fire pump (diesel) is required under the provisions of AS1851-2005 (Ref.6). This standard requires a test log to be






Requirements


task summary form but not in pump house. If hard copy local records are not preferred by Orica, it is suggested that information be provided in the Pump house as to where to find the records.

1. Box has been installed in fire pump house but only old records present

2. Last test was in April 2016 by Wormald and records scanned into SAP records so it is current


available on site with test sheets produced in triplicate (Section 3.2.6 of the standard). During the site inspection, a copy of the test log could not be located. It is therefore recommended that consideration be given to the installation of a weather resistant box in the pump house area to hold the test log so that it can remain in close proximity to the pumps. The test log should include all test requirements from AS1851, Section 3.2.6.5



1. DG notification reflected IBC package description. Physically inspect in field and check for updated documents / reports / calculations as relevant / MOD in system and is closed

1. Depot 50 shown as IBCs

2. Other updates have also been made to cover new inventories as part of AMI project such LPG for flares


Fully Implemented

5. (2013 Hazard Audit Rec 5)A review of the Dangerous Goods Notification document indicated that Depot 50 was an above ground tank. However, four separate materials were listed for this depot. It was identified that the depot holds Intermediate Bulk Containers (IBCs) which may either be classified as tanks or packages, depending on the depot configuration. It is recommended that the storage details associated with Depot 50 be reviewed to ensure the IBCs can be stored as “packages”. Otherwise, it may be necessary to update the DG Notification to cater for individual depot storage for each IBC.

Ammonia Management Improvement Project Kooragang Island HAZOP Report (20632-001)

Kooragang Island Facility Site Steam System Upgrade Project HAZOP Report (20932-RP-001)

1. A number of hazard studies teams recorded in the Risk Register were reviewed. They appeared to have operations representation. Ammonia plant periodic HS3 was being carried out at time of audit. Ops representatives were present.



Fully Implemented

6. (2013 Hazard Audit Rec 6) It was identified that in establishing the hazard and risk assessment programme at Orica KI, operations staff had been included in the studies, but risk management staff were of the opinion that more involvement from operations staff would assist in a more robust process. Whilst it was recognised that a programme for inclusion of more operations staff in the risk assessment process was commencing, it is recommended that this be reviewed at the next audit to confirm the programme






Requirements


continues, as input from operations staff is critical in ensuring the appropriate and realistic information is included in the assessment process.

9. (2013 Hazard Audit Rec 7) Clarify the process for providing feedback on completion of a job completed under a WO, ie if there is an issue with completion of work confirm how is this captured and how any patterns are identified over time.

1. There does not appear to be a signoff or feedback component to completing a WO.

2. The responsible engineer will “teco” the WO in SAP to close it off and indicate that it is complete . The date in which this happens is the only sign in SAP that the WO is complete and there is not detail of work completed.



Being Developed

7. (2013 Hazard Audit Rec 7) It was identified that the current work order forms do not have a formal area for feedback from personnel conducting the required work order actions. Currently any comments or feedback is being written on the back of the work order or in empty spaces between the lines. It is recommended that the work order forms be reviewed to determine whether it is possible to include a section for feedback and signature from the maintenance team so that any issues may be raised and recorded within the SAP system. It is also recommended that the maintenance team “sign” the completed works so that the planners/schedulers can be confident that the work is completed. This will provide valuable information on equipment history and assist ongoing maintenance to be as effective as possible.

1. Maintenance Manager advised that all equipment has now been migrated to SAP.

2. The auditor reviewed various items in SAP for the AN plants, NH3 areas and miscellaneous items such as fire systems. All plant areas and types of equipment (vessels, instrumentation, pumps, tanks, valves, relief systems, flares, hoses etc) appear to be in SAP.



Fully Implemented

8. (2013 Hazard Audit Rec 8) It was identified that the majority of plants, systems and equipment at Orica KI has been included in the SAP maintenance system, however, equipment in the AN Plant still requires inclusion in the SAP system. In discussion with the maintenance management team it was apparent that a project is underway to incorporate the AN Plant components into SAP, however, this is not yet complete. it is recommended that this be completed and reviewed at the next audit.


1. A number of PTWs and the SAP templates were reviewed. The PTW section for Work Authorisation, Acceptance and Return now has space for up to 5


Fully Implemented

9. (2013 Hazard Audit Rec 9) It was identified that the current Permit to Work (PTW) form does not contain a section for all personnel






Requirements


PTW #60062300 Ammonia plant (TSV NPT Thermal)

PTW #60063503 Ammonia Plant (Tank;MDEA Storage)

people. Separate sign on to JSERA and Process Risk Assessment is still required


working on the job to sign on to the form. Whilst the JSERA is provided with a multiple sign-on facility, the PTW form does not have sufficient space, hence, multiple sign-on is performed by using the back of the form. It is therefore recommended that the PTW form be reviewed for the inclusion of a formal sign-on section for all personnel.


1. A new PTW module in SAP has been rolled out over 2015. There are now two separate risk assessments - the JSERA and a Process Risk Assessment (PRA). These are separate forms that are linked to the Permit by the WO number. The PRA and the JSERA both display the risk matrix.



Fully Implemented

10. (2013 Hazard Audit Rec 10) It was identified that each PTW must be accompanied by a JSERA, which requires the use of the risk matrix to assess risks associated with the task. However, the JSERA form provided with the PTW, does not have a risk matrix attached. It is recommended that the PTW form be reviewed to include a risk matrix along with the JSERA forms

1. Not reviewed in detail . Since 2013 perimeter fence disturbance monitoring has been implemented that alarms to gatehouse.




11. (2013 Hazard Audit Rec 11) It was identified that the site security system is currently being upgraded to include motion detectors along the fence line with alarms and closed circuit television (CCTV). Whilst this system has been approved, it is not yet installed. It is therefore recommended that the security system upgrades be reviewed at the next audit (2016).

1. Orica Kooragang Island DMS documents have the following info in the footer which clearly identifies whether a document is within its review period:Uncontrolled document, Printed on 02/08/2016. Ref No : KIW-2563 Rev No : 6 Next Review Date : 25/05/2018



Fully Implemented

12. (2013 Hazard Audit Rec 12) A number of documents were reviewed (see Appendices D, J, L & M) and it was identified that the document review dates and currency were provided in the footer of documents to indicate their currency when being used by staff. However, there is no date indicating when the next revision is due. Hence, it is not immediately evident that he document in






Requirements


use is current. It is recommended that Orica KI consider adding a date on each document (e.g. in the footer) indicating the next due revision date.


Site Emergency Data - Substations and Switchrooms Distributed Control Systems Location Plan (DWG no. 10-20000-08)

1. No 2 Substation (T10, T11. T12) and No 3 Switchroom (T7 and T8) have been decommissioned and replaced in 2015 by a new modern transformer bay (Transformers T1 and T2) with containment and fire walls



Fully Implemented

13. (2013 Hazard Audit Rec 13) The No. 2 Substation and No. 3 Switchroom are currently being upgraded, including replacement/ relocation of a number of transformers. Measures to prevent propagation will be completed –by June 2014. It is recommended that this work be reviewed to ensure successful completion at the next audit (2016).



10. (2013 Hazard Audit Rec 14) The installed pressure / flow capability of the modified fire water system at the AN Bag store needs to be confirmed to ensure that it meets the required design basis. Confirmation the velocities in firewater piping do not exceed AS requirements is also required

1. MOD KI011787 for changing the fire water configuration at the AN bag store. This MOD status is COMPLETED. However could not find evidence in mod database or commissioning records that the revised design met the pressure / flow targets that were previously not met and that it was tested to perform to target flow / pressure.

2. The system is physically in place and labelled at the AN bag store



Mostly Implemented

14. (2013 Hazard Audit Rec 14) The AN Bag Store Zone 4 fire water demand currently exceeds the existing fire water system supply capability (in terms of available pressure and flow) as determined from the hydraulic modeling. Wormald’s have recommended two possible solutions for this situation for Orica to consider and resolve. A review of the options to address this issue shall be undertaken, dependent upon the timing of the demolition of the bag warehouse. It is recommended that Orica review the implementation timeframe as the demolition of the warehouse has been delayed. The final action for this FSS recommendation should be reviewed at the next audit


MOD KI009696 (H2 cylinder relocation)

11. Confirm that the separation distance between the H2 cylinders and the adjacent oxidising gas cylinders is adequate, for example meets

1. H2 cylinders have been relocated to behind block wall next to oxidising gas cylinders. MOD KI009696 and KI009697 was in system. Included a risk assessment but this did not cover separation between flammable and oxidising gases.


Check closeout was appropriate, eg PM tasks defined, PIDS updated, SOPs

Mostly Implemented

15. (2013 Hazard Audit Rec 15) It was identified from the recommendations made in the Fire Safety Study that at Transformer T14, the cylinder currently located to the immediate south of the transformer should be relocated to an area where potential propagation risk is






Requirements


requirements in AS 4332 The storage and handling of gases in cylinders

updated etc lowered (note also that an air conditioner is located above the transformer which will be damaged in the event of a transformer fire and/or explosion). A review of the progress of this recommendation indicated that a plant modification request had been raised and that the project is currently progressing through the change management process. It is therefore recommended that this action be reviewed at the next audit (2016) to confirm completion

1. No leaks were observed in AN2/NAP3 and general site walkaround. Bunds were clean and tidy

2. NAP1 starting up and very noisy didn't visit the area

3. Leaking valve observed in ammonia plant near flash drums - Ammonia was being absrbed by water from hose. Confirmed that this is included in scope of 2017 Shutdown work WO 60013340

4. Enablon incidents and WO summaries reviewed - very few leak issues identified (around 10 minor leaks in total since 2014)

Fully Implemented

16. 2009 Recommendation 1 - 2013 Hazard Audit Further recommendation:All leaks are reported and managed in the Maintenance Management System (MMS). Repairs are prioritised, based on personnel safety & environmental impact (ground, stormwater, effluent) followed by recovery & reclaim The ammonia & nitric acid systems were visited during the 2013 audit with leaks observed to have been addressed. The inclusion of leak reporting and repair appears to be successful. It is recommended that a further site inspection during the 2016 audit should be undertaken, to ensure the MMS continues to be successful.




Audit Element: Closeout of other study actions


Requirements


28. Check progress on compliance with site firewater booster arrangements against AS2419 in next Hazard Audit (2019)

1. Booster capacity has not been upgraded and an improvement project has not been developed or scoped.

Being Developed

1. FSS Rev E (Feb 2016) It is recommended that Orica review AS 2419 and AS 2941 to determine if any pumpset and pump piping design non-compliances are deemed necessary for retrospective improvements and compliance with current standards. For example, provide the feed booster connections for Fire and Rescue NSW for the fire water pumps


10. (2013 Hazard Audit Rec 14) The installed pressure / flow capability of the modified fire water system at the AN Bag store needs to be confirmed to ensure that it meets the required design basis. Confirmation the velocities in firewater piping do not exceed AS requirements is also required

1. MOD KI011787 for changing the fire water configuration at the AN bag store. This MOD status is COMPLETED. However could not find evidence in mod database or commissioning records that the revised design met the pressure / flow targets that were previously not met and that it was tested to perform to target flow / pressure. Also not clear whether high velocities in piping was addressed in MOD for AN bag store FW system

Mostly Implemented

2. FSS Rev E (Feb 2016) notes that hydrauilc modeling shows inadeqate capacity in AN bag store to supply water to two fire zones and also that velocities in AN bag store firewater piping exceed AS2419 recommended velocity limits in some areas

Hazard Audit 2016 - Orica

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Transcript of Hazard Audit 2016 - Orica