Hazard Audit 2019 - Orica

Document number: 21356-RP-001 Sherpa Consulting Pty Ltd (ABN 40 110 961 898) Revision: 0 Phone: 61 2 9412 4555 Revision Date: 20-Dec-2019 Web: www.sherpaconsulting.com File name: 21356-RP-001 Rev 0

HAZARD AUDIT 2019

AMMONIUM NITRATE FACILITY

KOORAGANG ISLAND

ORICA AUSTRALIA PTY LTD

PREPARED FOR: Sherree Woodroffe

Senior Safety Specialist Kooragang Island

DOCUMENT NO: 21356-RP-001

REVISION: 0

DATE: 20-Dec-2019

http://www.sherpaconsulting.com/

Document: 21356-RP-001 Revision: 0 Revision Date: 20-Dec-2019 File name: 21356-RP-001 Rev 0

DOCUMENT REVISION RECORD

Rev Date Description Prepared Checked Approved Method of issue

DRAFT 28-Oct-19 Internal review J Polich - - -

A 11-Nov-19 Issued to client for comment

J Polich G Peach G Peach Email PDF

0 20-Dec-19 Final issue J Polich G Peach G Peach 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 2019

Ammonium Nitrate Facility

Kooragang Island

QA verified:

O Alim

Date: 19-Dec-2019


CONTENTS

ABBREVIATIONS ...................................................................................................................................... 5

1. SUMMARY AND RECOMMENDATIONS ......................................................................................... 7

1.1. Background ................................................................................................................................ 7

1.2. Summary of findings .................................................................................................................. 8

1.3. Recommendations ..................................................................................................................... 8

1.4. Closeout ..................................................................................................................................... 9

2. CONTEXT AND SCOPE OF HAZARD AUDIT ............................................................................... 20

2.1. Background .............................................................................................................................. 20

2.2. Audit context ............................................................................................................................ 20

2.3. Audit purpose and objectives .................................................................................................. 22

2.4. Scope ....................................................................................................................................... 22

2.5. Exclusions and limitations ....................................................................................................... 23

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 ............................................................ 31

3.6. Security .................................................................................................................................... 31

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

4. AUDIT OF SITE ............................................................................................................................... 34

4.1. Site inspections........................................................................................................................ 34

4.2. Check against industry standards for AN stores ..................................................................... 36

5. AUDIT OF SAFETY MANAGEMENT SYSTEMS ............................................................................ 38

5.1. Overview .................................................................................................................................. 38

5.2. Integrated management system, SHESMS ............................................................................. 38

5.3. Findings ................................................................................................................................... 38

6. SITE HISTORY ................................................................................................................................ 40

6.1. Previous studies ...................................................................................................................... 40

6.2. Incident history......................................................................................................................... 40


7. RECOMMENDATION SUMMARY .................................................................................................. 42

APPENDIX A. AUDITOR APPROVAL

APPENDIX B. EVIDENCE AND REFERENCE DOCUMENT SUMMARY

APPENDIX C. KI SITE ORGANISATION CHART AND INTERVIEWEES

APPENDIX D. AUDIT RECORD WORKSHEETS

APPENDIX E. SUMMARY OF CLOSEOUT OF 2016 HAZARD AUDIT RECOMMENDATIONS

TABLES

Table 1.1: 2019 Hazard Audit Management System Element Performance Summary .......... 10

Table 1.2: 2019 Orica Ki Site Hazard Audit Recommendations ............................................. 16

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

Table 3.1: Site changes since 2016 ....................................................................................... 31

Table 4.1: Assessment of AN against industry guidance ....................................................... 36

Table 6.1: ‘Serious’ SHES incident summary since 2016 ...................................................... 40

Table 7.1: 2019 Hazard audit recommendation summary...................................................... 42

FIGURES

Figure 3.1: Orica KI site location............................................................................................ 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

CBA Cost Benefit Analysis

CSB (US) Chemical Safety Board

DG Dangerous Goods

DMS Document Management System

DPIE (NSW) Department of Planning, Industry and Environment (formerly DPE)

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 Control

KCV Key Control Verification

KI Kooragang Island

KPI Key Performance Indicator

MDEA Methyl Diethyl Amine

MHF Major Hazard Facility

MOC Management of Change

NAP Nitric Acid Plant

NFPA National Fire Protection Association

NH3 Ammonia

NSW New South Wales

OEL Orica Enterprise Library

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


SHESMS (Orica) Safety, Health, Environment and Security Management System

SHECMS (Orica) Safety, Health, Environment and Community Management System (superseded by SHESMS)

SHES Safety, Health, Environment, Security

SIL Safety Integrity Level

SMS Safety Management System

SSAN Security Sensitive Ammonium Nitrate

TGAN Technical Grade Ammonium Nitrate

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, Industry and Environment (DPIE) for an expansion of the Kooragang Island

(KI) facility in 2009 (application no: 08_0129).

The development was 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 nitric acid (NAP4) and ammonium nitrate

manufacturing plants (AN3), however this was postponed indefinitely due to changes in

economic conditions.

The DPIE 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 most

recent audit was undertaken by Sherpa Consulting Pty Ltd (Sherpa) in 2016.

Orica retained Sherpa to conduct the 2019 Hazard Audit. This report contains the

findings of the Hazard Audit conducted in 2019.

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 ISO19011:2019 Guidelines for Auditing Management Systems by

auditors approved by DPIE prior to the audit.

The audit comprised:

• desktop documentation review to prepare for the audit visit.

• site visits in September 2019 which included observing site operations,

discussions with site personnel and a review of the Orica KI site documentation

and Orica’s integrated corporate Safety, Health, Environment and Security

management system (SHESMS) 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 2016 Hazard Audit and

included specific review of:

• Site and plant modifications since the 2016.

• Close out of actions arising from 2016 Hazard Audit and other safety studies that

have occurred since 2016.

• Continued 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.

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 Security Management System (SHESMS) as implemented 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. Further details are provided in the detailed audit worksheets for

each element (APPENDIX D).

The audit protocol adopted was the same as that adopted for the 2016 audit to allow

comparison with the previous audit. Table 1.1 identifies the system elements where

recommendations were made in the 2016 Hazard Audit together with a comparison of

the auditors’ judgement of system implementation for each management system

element for 2019. Note that all actions from the 2016 Hazard Audit have been closed.

The degree of implementation has either stayed the same as the 2016 audit or has

improved from ‘Mostly Implemented’ to ‘Fully Implemented’ for some elements.

Overall, the SHESMS 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 13 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. No items of this nature were identified in this audit.

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

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

2022 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 DPIE, 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: 2019 Hazard Audit Management System Element Performance Summary

Audit Element (HIPAP9)

Overall

Element

Compliance

2019

2016 for

comparison Comments

1. SHE Management

System Structure and

Administration

Fully

Implemented

Fully

Implemented

Orica's integrated corporate Safety, Health, Environment and Security Management System (SHESMS) covers

all the main requirements of a Safety Management System. This includes policy, vision, SHE 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

Fully

Implemented

SHES management is initiated at the corporate level and managed as an integrated part of site management

activities with the KI Site Manager having overall responsibility for implementation. The auditor observed a

visible commitment to safety management at KI in the form of integration of SHES items into daily meetings,

highly visible BoS and increased focus on KPI information since the last audit. A number of risk reduction

projects have been completed since the 2016 audit and the focus is now on structural inspection and

refurbishment programmes and business system improvements.

3. Organization,

Accountabilities and

Responsibilities

Fully

Implemented

Fully

Implemented

Organisation charts and position descriptions are available

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

Fully

Implemented

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

At an individual level all employees have documented personal SHE objectives that demonstrate the

employee’s contribution to SHES performance. Potential improvements in objectives or planning are identified

under the individual element headings where relevant.

5. Legal Requirements

and Codes

Fully

Implemented

Fully

Implemented

A compliance register is available in Enablon, supporting actions are also set up in Enablon

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.



Overall

Element

Compliance

2019

2016 for

comparison Comments

6. Documentation

Fully

Implemented

Fully

Implemented

There is an extensive document base covering the SHESMS and supporting procedures at corporate and KI

site level which are available within the OEL or accessible via the Orica Intranet (Globe).

Drawings are managed electronically via Vault.

Incident information is in Enablon

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

database, Lotus Notes SHE Risk Register), SAP for maintenance and PTW, and in some cases network drives.

It is noted that the DMS has been migrated into a new system (OEL). This could be refined (would need to

occur at a corporate level not KI level) to default to show only the current version of documents. All revisions of

a document appear which may result in mistaken use of an older version.

7. Hazard Identification

and Risk Control

Mostly

Implemented

Mostly

Implemented

Site specific modifications procedure developed from corporate procedure

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 yet 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 large number of open actions (this is reducing) arising from the

periodic hazard study and Process HIRAC processes that have not been resourced. 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. It is noted that this is planned to occur as part of the MHF relicencing process

over 2020 .

8. Operating Procedures

Fully

Implemented

Fully

Implemented

Operations for all plant areas appear to be covered by extensive procedures for normal operations and

abnormal conditions, available with the OEL.

9. Process Safety

Information

Fully

Implemented

Fully

Implemented

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 .



Overall

Element

Compliance

2019

2016 for

comparison Comments

10. Contractor

Management and

Procurement

Fully

Implemented

Fully

Implemented There are formal processes in place for contractor selection and management and contractors appear to be

well managed. The Track Easy system provides transparency of the status of licences, inductions and PTW

training

11. Pre Start-up Safety

Fully

Implemented

Fully

Implemented

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

and also in plant startup checklists.

12. Equipment Integrity

Fully

Implemented

Mostly

Implemented

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 largely complete. A structural integrity

inspection and refurbishment programme is being implemented. Major shutdowns appear to have been

completed in the required timeframe and a shutdown planning team is in place to prepare for the next major

turnaround.

13. Safe Work Practices

Fully

Implemented

Fully

Implemented

Permit to Work Systems are well developed and appear to be well implemented. Training records are

available.

14. Management of

Change

Mostly

Implemented

Mostly

Implemented

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

for engineering changes with supporting records available. An ongoing effort has been made to reduce the

number of open mods, Quality of closeout actions appeared to have improved since the previous 2016 audit.

There is an opportunity to provide greater transparency around organisational change management.

15. Accident/ Incident

Reporting and

Investigation

Fully

Implemented

Fully

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

investigation was comprehensive and transparent. KPIs are in place. A 'process safety event' definition and

flag in Enablon has been recently added (at corporate level) and is now being applied at KI to incident

recording.



Overall

Element

Compliance

2019

2016 for

comparison Comments

16. Training and

Education

Fully

Implemented

Fully

Implemented Training and Competency systems were well developed and covered induction, operations, safe work practices

and corporate requirements such as use of the OEL, modifications (in the Lotus Notes database) and incident

reporting in Enablon. Records were readily available in TrackEasy.

There is an opportunity to more clearly define the level of plant-specific process knowledge required for roles

such as shift superintendent and engineers in the Technical group and include this in position descriptions and

/or training plans.

17. Emergency Planning

and Response

Fully

Implemented

Mostly

Implemented

Emergency plan is in place and linked to MHF. The ERP was last reviewed in 2018 and updated to reflect

changes in site operations and neighbours, and drills / exercises completed to schedule. The next planned

review of the ERP will occur as part of the MHF licence update over 2020.

18. Security and Access

Control

Not reviewed

in audit

Not reviewed

in audit

Security was not reviewed in detail.

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

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

Fully

Implemented

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.

Key control verification (KCV) programme has been implemented at KI as per Orica corporate requirements.

20. Environmental

impacts / pollution

potential

Not reviewed

in audit

Not reviewed

in audit

Not in scope of Hazard Audit

21. Environmental

Performance

Compliance

Not reviewed

in audit

Not reviewed

in audit

Not in scope of Hazard Audit



Overall

Element

Compliance

2019

2016 for

comparison Comments

22. Condition of Consent

Compliance

Fully

Implemented

Fully

Implemented

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.

NOTE: 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.

23. Industry guideline

compliance (SAFEX)

Fully

Implemented

Fully

Implemented

A review of the AN areas against the guidance in SAFEX was carried out. The AN bulk and bag 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. There

has been no requirement to update the 2015 QRA since the 2016 audit as there have been no significant

changes in AN inventory or operating practices.

24. AS4326 Compliance

Fully

Implemented

Fully

Implemented

A review of compliance of the AN stores was 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 the basis of the actual

KI AN inventories and agreed by DPIE and Safework hence regulatory consultation requirement is regarded as

satisfied. There has been no requirement to update the 2015 QRA since the 2016 audit as there have been no

significant changes in AN inventory or operating practices.

25. CSB Investigation

into West Texas

(recommendations)

Fully

Implemented

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 continue to be well addressed at KI. Previous 2016 Hazard

Audit action relating to removal of redundant combustible building material had been addressed.



Overall

Element

Compliance

2019

2016 for

comparison Comments

26. Closeout of 2016

Hazard Audit

recommendations

Fully

Implemented

Mostly

Implemented

A review of the 2016 Hazard Audit action closeout was completed. Discrete actions have been addressed.

Ongoing actions eg labelling improvements to equipment are covered by ongoing programmes with a schedule

that is captured as a project run by piping group. The relevant actions had been entered into Enablon with

target dates. The status of Hazard Audit actions is reported 6 monthly to DPIE with the last report provided in

Sept 2019.

27. Closeout of other

study actions

Fully

Implemented

Mostly

Implemented

A review of actions from other studies was carried out. There were no identified new condition of consent

studies since the 2016 audit. Actions from some internal hazard studies and technical assessments were

reviewed and the completion status of actions is appropriate for the stage of the projects. The KI site FSS has

also been recently updated in June 2019. There are no open recommendations.


Table 1.2: 2019 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

Nothing specific

3

.

Organization, Accountabilities

and Responsibilities

Nothing specific

4. Objectives, Target and Plans

2. Observation: Progress has been made prioritising and

closing out PHS / HIRAC risk register actions (these are not in

Enablon but remain in Lotus Notes Risk Register) and

quarterly reviews are held. Consider implementing a KPI

around PHS / HIRAC action closeout and check progress in

next Hazard Audit.

Requirements :

4.1.4, 7.1.5,

26.1.16

5. Legal Requirements and

Codes

Nothing specific

6. Documentation

7. Observation: OEL Open Text has recently replaced

previous Lotus Notes DMS. OEL brings up all versions of

documents, with potential that the wrong version will be

selected. Review updating OEL configuration so that only

current version appears by default. It is recognised this needs

to be done at corporate level.

Requirements :

6.1.5, 8.1.1

7. Hazard Identification and

Risk Control

8. Observation: the corporate SMS appears to have deleted

the requirement for Periodic Hazard Studies / HIRACs. KI is

still using the PHS / HIRAC approach for MHF purposes.

Clarify how the PHS process fits into the corporate SMS risk

assessment and review process and ensure the KI specific

periodic review requirements are clearly explained in MHF

safety case update

Requirements :

7.1.1

1. Observation: MHF 2020 update process includes creating a

tool for showing an overall risk profile for the KI site and also

used to show risk reduction over time or effect of removal of

safeguards. Confirm progress in next Hazard Audit.

Requirements :

7.1.3, 26.1.15

9. Observation: it is not clear if HIRAC review process

explicitly identifies MODs that have occurred in the process

under review and ensures the effect of these is accounted for.

Confirm how the HIRAC review process accounts for

modifications and what documentation is required, eg list of

applicable mods could be included in HIRAC study description

or information list .

Requirements :

7.1.3



Place(s) Used

4. Observation: HIRAC for Fire in AN despatch area doesn't

identify wooden pallet elimination (MOD KI012189) as an

additional risk reduction measure. (see Lotus Notes doc ID

ANDES/ MHF 18/12031924 page 04002 last updated

19/8/2019). Revisit this HIRAC and ensure all control

measures adequately identified and risk ranking updated as

needed.

Requirements :

7.1.3, 14.1.11

See Observation 2. Requirements :

4.1.4, 7.1.5,

26.1.16

10. Observation: the corporate KCV programme may not

cover all 'critical' controls identified in 'MHF' or 'significant'

HIRACS. Confirm the definition of 'critical control' in the

HIRACs and how it relates to 'key' controls and ensure

relationship between the KCV and any other critical control

verification process is clearly defined, eg include as part of

MHF update

Requirements :

7.1.6

8. Operating Procedures


6.1.5, 8.1.1

3. Observation: Ammonia plant 'alarm help' summary is

available but not used and operators not clear if this is up to

date. Either update and train in its use or discontinue and

define alternative.

Requirements :

8.1.4

9. Process Safety Information

None identified

10. Contractor Management

and Procurement

None identified

11. Pre Start-up Safety

None identified

12. Equipment Integrity

None identified

13. Safe Work Practices

None identified

14. Management of Change

11. Observation: Some inconsistency in closeout of mod

actions in Hazard Study database (ie not closed) when MOD

SHE Acceptance had been completed. (Auditor was advised

that this is a problem with Lotus Notes ie the actions can't be

closed due to the way they have been set up and there is no

actual link to the SHE acceptance checklist in Mods

database). Review the link between closing out mod hazard

study actions and completion of MOD SHE acceptance form to

see if this can be improved once new Enablon mod system is

in use.

Requirements :

14.1.1

12. Observation: There is no overall register of organisational

changes. (Not included in Lotus Notes MOD database for Requirements :

14.1.3



Place(s) Used

confidentiality reasons). Review developing a register with at

least the organisational change title, method of review and

organisational change owner. Also review providing some

additional guidance in overall MoC procedure as to what level

of assessment / documentation is required for typical

examples of organisational change (Noted that this may be a

corporate change). This would assist with demonstrating in

MHF Safety Case that this area of change is adequately

addressed.


7.1.3, 14.1.11

15. Accident/ Incident Reporting

and Investigation

4. Observation: It may be useful for MHF reporting purposes to

include a category for material / fluid for SHES incidents in

Enablon. It is recognised that this would need to be done at a

corporate level.

Requirements :

15.1.1

16. Training and Education

6. Observation: It is not explicit in training or position

descriptions what level of process knowledge is required for

some roles. Clearly define required process specific

knowledge for roles such as Shift Superintendent, area

process engineer, eg 'Ammonia plant operations101' or

equivalent

Requirements :

16.1.6

17. Emergency Planning and

Response

5. Observation: As an MHF, the ESIP should also contain

Tactical Fire Plans as per FRNSW Fire Safety guideline

'Emergency services information package and tactical fire

plans'. Consult with the FRNSW to confirm scope and develop

these as part of next MHF / ERP update.

Requirements :

17.1.5

18. Security and Access Control

Not reviewed

19. Auditing and Management

Review

None identified

20. Environmental impacts /

pollution potential

Not reviewed

21. Environmental Performance

Compliance

Not reviewed

22. Condition of Consent

Compliance

None identified -

23. Industry guideline compliance

(SAFEX)

None identified -


None identified -

25. CSB Investigation into West

Texas (recommendations)

None identified -



Place(s) Used

26. Closeout of 2016 Hazard

Audit recommendations

None identified – all closed out or progressed as per APPENDIX E. Any follow-up recorded under SMS elements.

-

27. Closeout of other study

actions

None identified -


2. CONTEXT AND SCOPE OF HAZARD AUDIT

2.1. Background

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

Island, NSW. The facility comprises 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 subject to a number of development approvals with associated conditions of

consent. These typically include preparation of a series of safety and environmental

management studies in the design and commissioning stages, as well as the

requirement for periodic hazard and environmental audits in the operational stage of the

facility.

2.2. Audit context

This report is the 2019 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, Industry and Environment (DPIE) to conduct the

2019 Hazard Audit. The audit team approval is contained in APPENDIX A.

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

with the relevant conditions to the approval for the two main developments to the site:

• 08_0129 (2009) Orica Ammonium Nitrate Expansion Project

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

The previous 3 yearly Hazard Audit covering both approvals was undertaken by Sherpa

in 2016 (Ref: Hazard Audit 2016 Ammonium Nitrate Facility Kooragang Island doc ref

21065-RP-001 Rev 0 11-Nov-2016).

2.2.1. 2009 expansion condition 08_0129

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 nitric 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 was staged (as agreed with DPIE) with the first main stage

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

operation in 2012.


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

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

to changes in economic conditions.

As part of the expansion approval process, Orica also committed to a range of risk

reduction projects. These were referred to as the Ammonia Management Improvement

(AMI) Project. A significant proportion of this aspect of the expansion project has been

completed.

Hazard Audit Extract from 08_0129 Schedule 3 Item 20:

2.2.2. 1998 expansion N91/00593/003

Orica received development approval from the NSW Department of Urban Affairs and

Planning (now DPIE) 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 the condition of

consent requirements. As per HIPAP 5 this includes:

• Assessing whether the facility is being operated in accordance with its hazards-

related conditions of consent.

• Verifying that the integrity of safety systems is being managed and that the facility

is being operated in accordance with its SMS.

At a lower level 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 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 (ie identification, assessment of risk, tracking and

close-out of identified issues and actions) has been established as per consent

08_0129 Schedule 3 Item15k).

• Adequate safety management system documentation has been prepared by

Orica.

• Audit actions from the previous 2016 hazard audit and similar audits have been

closed.

• Orica has allocated sufficient resources for managing safety issues.

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

Where appropriate, recommendations to improve the overall safety of the facility are

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, NAP3/AN2 plants and AN stores.

• Documentation review and site inspection of changes at KI since the previous

2016 Hazard Audit was completed

Specific reviews were undertaken as follows:


• The site and plant modifications since 2016.

• Close out of actions arising from 2016 Hazard Audit and other studies that may

have occurred since 2016.

• Degree of ongoing implementation of recommendations from the CSB Texas

West 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

2.5.1. Environmental performance

The hazard audit does not cover environmental performance or environment-related

conditions of consent as this is covered in a separate Environmental Audit.

2.5.2. Security

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.

2.5.3. Projects

At the time of conducting this audit (September / October 2019), there were some major

projects in progress at different stages of advancement. In particular:

• A set of ammonia risk reduction projects (AMI Project). A significant proportion of

this project was complete and fully commissioned (including installation of the

ammonia storage and nitrates plant flares, consolidation of the ammonia supply to

the AN plants to a single smaller storage vessel and removal of No. 2 ammonia feed

tank, and connection of various ammonia vent streams to scrubbers) at the time of

the 2016 hazard audit. The 2016 audit included review of the AMI project as

operating at the time of the 2016 audit. Since 2016 the ammonia plant flare has been

installed and commissioned and upgrades to instrumentation and electrical

equipment has occurred at the ammonia storage facility. The one remaining aspect

of the AMI project is replacement of the liquid ammonia pumps in the ammonia

storage area and the subsequent decommissioning of the No. 1 ammonia feed tank.

Detailed design activities have been completed however the installation is scheduled

for February 2020. Therefore, this aspect of the AMI project was not covered in the

2019 hazard audit.

• A new boiler (Site Steam Upgrade project). This has been a long duration project

with the boiler largely installed and close to commissioning. The previous 2016 audit


covered review of closeout of the design stage safety studies. The 2019 hazard audit

briefly reviewed commissioning planning activities.

2.5.4. Site facilities

The Triella aqueous ammonia facility is covered by a Council approval with separate

conditions. This facility was not reviewed in the 2019 hazard audit.

AN is now exported through the No. 4 Mayfield berth, rather than the K2 Berth on

Kooragang Island. The wharf used for import / export of ammonia is a Port of Newcastle

asset. There were no operational activities at the berths at the time of the audit and this

area was not covered in the 2019 hazard audit.

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 system structures

including:

• AS/NZS ISO 19011: 2019 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 for desktop review

in early September 2019.

• Site visits were carried out in late September 2019.

• After the site visits, supplementary documentation was provided to the auditors

by Orica.

• The final information was reviewed over October / November 2019 and a draft

audit report prepared in November 2019.


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

December 2019 for provision to DPIE.

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

The organisational structure in place at KI at the time of the site visits and people

interviewed as part of the audit 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 (hrs) Description Leader

1. 11/09/2019

10.00 Audit kickoff

Interviews

Site tour – general areas, new ammonia

pipeline

Site tour – Ammonia Plant

Jenny Polich

2. 11/09/2019

10.00 Interviews

Site visit - AN / NAP plants

Jenny Polich

3. 23/09/2019

8.00 Site visit - AN Bulk and Bag stores, fire

protection equipment

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 and bulk products (fertiliser and ammonia,).

• South – Warehousing and Despatch Facility warehouse adjacent to the southern

boundary of the Orica KI site.

• East –strip of land between Greenleaf Road and the Orica KI site – diesel storage

and despatch facility operated by Park Pty Ltd and a magnesite storage and

despatch facility operated by Tasmania Mines.

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

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

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

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

AN solution, nitric acid

• Ancillary equipment such as steam boilers, cooling water, air and nitrogen.

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

the plant.

A layout showing the main plant locations and any significant new facilities since the

2016 audit is given in Figure 3.2.


Figure 3.1: Orica KI site location

Document: 21356-RP-001

Revision: 0

Revision Date: 20-Dec-2019

Document ID: 21356-RP-001 Rev 0

Figure 3.2: Site layout

NOTE: This figure has been reproduced from the inaugural post-operations Aecom 2013

Hazard Audit report and the approximate locations of major new equipment since the

2016 audit have been identified. In this case there has been minimal change in overall

facilities since 2016.

New boiler Replacement NH3

pipeline (similar

route) as previous

Nitrates flare

(AMI Project)

Ammonia storage flare

and ammonia plant

flare (AMI Project)


3.3. Organisation and staffing

There are approximately 180 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 2019 audit, the majority of site personnel reported through the

Manufacturing division including all Safety, Health, Environment and Security (SHES)

personnel.

The organisation chart in place at the time of the 2019 audit is shown in APPENDIX C.

The plant operational areas and associated personnel are divided into Ammonia Plant

(including storage) and Nitrates (all NAP and AN plants). The AN bulk and bag stores

are part of Supply Chain.

3.4. Process overview

A simplified, brief summary of the process is provided below.

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 in a 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.

The Ammonia Plant operates continuously. Major shutdowns occur every 6 years. The

last major shutdown was in 2017 (catalyst changes occurred) and the next major

shutdown is in 2023. Smaller mid-cycle shutdowns occur every 3 years (next planned in


August 2020) for activities such as rotating equipment maintenance, relief valve testing

and SIL loop testing.

3.4.2. Nitric acid

There are three similar Nitric Acid plants (NAP1 / NAP2 / NAP3):

• 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.

The acid plant run continuously between converter catalyst changes. Major

shutdowns are every 5 years

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 - producing ammonium nitrate in a solid form; (AN1 only, AN2

granulation section has been shut down for efficiency reasons).

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

AN is stored as bulk or bagged product before despatch.

The nitrates plants run on a batch basis with periodic shutdowns to clean the prill tower

and AN solids handling equipment. Major shutdowns are every 5 years.

The most recent shutdowns were:

• Combined NAP1/AN1 in 2018

• Combined NAP2 / NAP3 / AN2 between February and April 2019.


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 hazardous

substances register / 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

(ie all visitors must report to the Main Gatehouse) 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

Changes of potential relevance to safety and risk management since the last audit

(2016) were identified and have been summarised in Table 3.1.

It is noted that there have been relatively few major equipment changes since 2016 and

the focus has been on environmental improvements, asset integrity and improving IT

and business systems with a general migration away from Lotus Notes databases.

A major business wide organisational change has been implemented since 2016 which

has meant staff changes and many people in new roles at KI. Changes directly relevant

to Manufacturing division at KI are noted in Table 3.1.

Table 3.1: Site changes since 2016

Title Description

Plant and Equipment (major changes)

AMI Project – most project work (flares, scrubbers, ammonia inventory reduction) has been completed and was installed at time of 2016 audit.

Last remaining item is replacement of liquid ammonia pumps and removal of last pressurised ammonia storage bullet No 1. Design is complete however installation has not yet occurred, with the work scheduled for February 2020.

New Boiler (Site Steam Upgrade) – construction complete, pre-commissioning commenced but not yet operational.

Replacement ammonia pipeline to wharf. Constructed and operational.

A number of environmental improvement projects including:

- Use of tertiary treated recycled water (6ML/day) for demin water feed to significantly reduce town water use


Title Description

- Arsenic soil contamination remediation project

NOTE: These are not covered in the Hazard Audit

Asset integrity Major structures inspection and refurbishment programme, including:

- NAP stack

- Access platforms (all plants)

- Elevated equipment brackets (all plants)

- Roof sheeting

- Ammonia Plant pipebridge

Ammonia refrigerated storage (V101) acoustic emission integrity testing completed in 2018. No identified issues.

Safeguards / risk reduction

Upgrades to instrumentation, control system and safety shutdown system at ammonia storage.

Elimination of wooden pallets in AN store for 1.2 tonne bags. (Export AN bags are still handled on pallets)

Business Systems

Document management system (DMS) - OpenText system (Orica Enterprise Library, OEL) replaced Lotus Notes databases

Enablon rolled out for KPI tracking (at time of previous audit Enablon use has commenced for incident reporting only)

Enablon rolled out for all action tracking except Hazard Studies (at time of previous audit Enablon use has commenced for incident reporting only)

Chem Alert now used for all SDS, hazardous substances and WHS risk assessments (NOTE: health / hygiene monitoring still in Lotus Notes)

Lotus Notes Modification database will be phased out. From Q3 2019 all new mods will be in Enablon.

(NOTE: migration of old mods from Lotus Notes won’t occur so systems will run in parallel for a time).

Onsite Track Easy use has been expanded to cover additional training records such as Permit to Work as well as licences (at previous audit it was in use mostly for inductions and licences).

SMS The Safety, Health, Environment and Community Management System (SHECMS) in place at the corporate level has been replaced with the Safety, Health, Environment and Security Management System (SHESMS). The KI specific SMS has been updated accordingly.

Key control verification (KCV) process has been implemented. This is a corporately driven programme and not specifically driven by MHF (though there are some overlaps)

Organisation and staffing

Site environment, risk and safety personnel re-integrated into Manufacturing reporting to Manufacturing Centre Manager (not through Australia Pacific Asia SHES)

Manufacturing restructure all reporting to Manufacturing Centre Manager:

- Dedicated production manager and shift superintendent for each of Ammonia and Nitrates

- Dedicated maintenance team for each main plant area, ie Ammonia and Nitrates (previously common maintenance team over whole site)


Title Description

- Dedicated superintendent roles under Engineering for each of Reliability, Integrity, Planning, Turnaround Projects and Shutdown Planning

Neighbours Incitec Pivot - has removed all AN fertiliser and is no longer an MHF.

Consent for expansion will lapse in 2019

Sawmillers – woodchips in port area to west have gone

Tasmania Mines – a magnesite storage and despatch facility has been constructed to the south-east of the site.

Agriproducts storage and despatch facility to the south-west of the site is no longer operational.


4. AUDIT OF SITE

This section provides a summary of the site inspection of the KI site activities and

associated equipment.

Additional details of items reviewed is provided in the audit checksheets in APPENDIX

D.

The inspection was executed with a number of different site personnel co-ordinated by

the Senior Safety Specialist over several days in September 2019. Supporting

maintenance records from SAP, various Enablon reports and other supporting

documentation were provided 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. No leaks

observed. Minimal odours.

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

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

• Hoses inspected all had tagging and were within test dates.

• 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), the shift superintendent and a new operator (less than 1 year in the role)

indicated:

• Good understanding of plants and its hazards

• Understanding of training and procedures. Good knowledge of abnormal

conditions, controlled shutdown screen.

• Understanding of emergency response requirements

• Good understanding of the SAP based PTW system and documentation in

control room correct.


• Knowledgeable about proposed boiler changes (however not directly involved

currently as being primarily coordinated by dedicated project / commissioning

team).

4.1.2. Nitrates

A walkaround of the NAP /AN plants indicated the following

• Equipment was generally in good condition. No leaks observed. Minimal odours.

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

consistent over the whole plant.

• Hoses inspected all had tagging and were within test date.

• Housekeeping standard was very high particularly in NAP2. Minimal rubbish or

redundant equipment, bunds clear.

Discussions in the control room involving an operator (experienced, 9 years) indicated:

• Good understanding of plants and its hazards.

• Knowledgeable about proposed boiler changes

• Good understanding of the SAP based PTW system and documentation in

control room correct.

4.1.3. New projects

• AMI Project. No operational or maintenance issues with the AMI project flares

(now operating for several years) were identified by the operators or

maintenance personnel at the Ammonia or Nitrates plants.

• Ammonia pipeline. No identified issues, minimal direct interface with operations

– mechanical upgrade – no significant operating / instrumentation changes.

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,

ceiling and AN product, and between stacks of AN product

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

• Dedicated offspec / contaminated AN area had minimal product in it.

4.1.5. Other facilities

Fire protection equipment appeared to be tagged and within test.

Temporary skid-mounted firewater pump in place. Will be replaced by new pump by end

of 2019.

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:

• Degree of implementation of recommendations from the CSB Texas West

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 as per the

findings of the 2016 audit, the KI site continues to address the recommendations and

guidance. Refer to audit checksheets in APPENDIX D for additional details and any

actions and observations.

Table 4.1: Assessment of AN against industry guidance

Audit Element (HIPAP9) Overall Element

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. There has been no requirement to update

the 2015 QRA since the 2016 audit as there have been no

significant changes in AN inventory or operating practices.


(Note: AS4326:

2008 is ‘under

revision’ but no draft

Fully Implemented A review of compliance of the AN stores was 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


Audit Element (HIPAP9) Overall Element

Compliance

Comments

available at tine of

audit)

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

and agreed by DPIE and SafeWork hence regulatory

consultation requirement is regarded as satisfied.

There has been no requirement to update the 2015 QRA

since the 2016 audit as there have been no significant

changes in AN inventory or operating practices.

25. CSB Investigation

into West Texas

(recommendations)

Fully 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.

Previous 2016 Hazard Audit action relating to removal of

redundant combustible building material had been

addressed.


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, SHESMS

Orica’s corporate policies as outlined in the SHESMS overview and supporting

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 and 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 SHESMS 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 and are

available in the OEL or SAP as relevant.

5.3. Findings

Details of the assessment against each element of the audit protocol are 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 at time of audit

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


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

be well covered by the SHESMS 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 assist on-going improvements in process safety

management.

Key findings organised 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 2016 hazard audit actions

All 28 recommendations from the 2016 Hazard Audit had been closed with supporting

evidence available, or a process has been put in place and work is ongoing (such as

Item 19 pipe labelling upgrades, Item 15 development of overall site risk profile). All had

been entered in Enablon. Records of review, priority, target dates, actions taken and

status of each action were available.

APPENDIX E summarises the 2016 Hazard Audit recommendation status and evidence

of closure.

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.

No other conditions of consent studies have been carried out. Actions have been entered

into Enablon from internally conducted studies, eg actions from AS1768 Lightning

Review of AN stores are in Enablon.

6.2. Incident history

All incidents and near misses are reported and entered into Enablon. Details of

investigation and closeout of action status and supporting evidence is also in Enablon.

A flag identifying ‘process safety events’ has also been included in Enablon (ie at the

corporate level since mid 2019) and is being used at KI.

The SHES incidents in Table 6.1 were summarised from Enablon that have occurred at

KI since 2016 and had a potential safety impact of “3. serious” or “4. very serious”. This

list does not include OHS type incidents.

Note these incidents were localised and contained on site hence did not have an actual

impact outside the site. There was also no identified potential for offsite effects

Table 6.1: ‘Serious’ SHES incident summary since 2016

Event ID Event Date (LT) Short Description Severity

2019-00048726 19/07/19 08:00 am

MDEA leak on semi-lean line to absorber 3 - Serious

2019-00045490 23/04/19 11:00 am

Failure of pigtail on 101B catalyst tube 3 - Serious

2019-00043326 21/02/19 08:00 pm

Pin hole leak on CO2 Absorber Semi-Lean MDEA inlet nozzle

3 - Serious


Event ID Event Date (LT) Short Description Severity

2018-00030319 14/01/18 04:33 am

C. RBLO steel brace fell from height 3 - Serious

2017-00028104 31/10/17 03:00 pm

C. Structural beam in pipe rack found to be unsupported at one end

3 - Serious

2017-00028071 31/10/17 12:00 am

101C tube leak due to transport baffle being left in place 3 - Serious

2017-00027829 21/10/17 08:00 am

Failure of top pigtail of catalyst tube B18 resulting in a release of process feed gas

3 - Serious

2017-00027131 27/09/17 07:00 am

Secondary reformer was operated slightly above the design pressure

3 - Serious

2017-00027049 25/09/17 08:30 am

C. Angle iron brace dislodged from NAP1 stack but did not fall to ground

3 - Serious

2017-00026884 19/09/17 11:50 am

C. An access stair tread fell from height at K2 wharf 3 - Serious

2017-00022530 26/02/17 11:00 am

C. Discovery of Asbestos Containing Material within radiant section of reformer

4 - Very Serious


7. RECOMMENDATION SUMMARY

A total of 12 recommendations to further improve safety management at the KI site were

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

These recommendations are divided into two categories:

3. 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. No items of this nature were identified in this audit.

4. Observations: Recommendations have been provided that could enhance existing

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

2022 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 DPIE, Orica will enter the recommendations

and required completion dates into the Enablon tracking system to ensure actions are

closed out and evidence provided.

Table 7.1: 2019 Hazard audit recommendation summary

Recommendations Audit Protocol

Place(s) Used

1. Observation: MHF 2020 update process includes creating a tool for showing an overall

risk profile for the KI site and also used to show risk reduction over time or effect of removal

of safeguards. Confirm progress in next Hazard Audit.

Requirements:

7.1.3, 26.1.15

2. Observation: Progress has been made prioritising and closing out PHS / HIRAC risk

register actions (these are not in Enablon but remain in Lotus Notes Risk Register) and

quarterly reviews are held. Consider implementing a KPI around PHS / HIRAC action

closeout and check progress in next Hazard Audit.

Requirements:

4.1.4, 7.1.5,

26.1.16

3. Observation: Ammonia plant 'alarm help' summary is available but not used and

operators not clear if this is up to date. Either update and train in its use or discontinue and

define alternative.

Requirements:

8.1.4

4. Observation: HIRAC for Fire in AN despatch area doesn't identify wooden pallet

elimination (MOD KI012189) as an additional risk reduction measure. (see Lotus Notes doc

ID ANDES/ MHF 18/12031924 page 04002 last updated 19/8/2019). Revisit this HIRAC

and ensure all control measures adequately identified and risk ranking updated as needed.

Requirements:

7.1.3, 14.1.11

5. Observation: As an MHF, the ESIP should also contain Tactical Fire Plans as per

FRNSW Fire Safety guideline 'Emergency services information package and tactical fire

plans'. Consult with the FRNSW to confirm scope and develop these as part of next MHF /

ERP update.

Requirements:

17.1.5

6. Observation: It is not explicit in training or position descriptions what level of process

knowledge is required for some roles. Clearly define required process specific knowledge

for roles such as Shift Superintendent, area process engineer, eg 'Ammonia plant

operations101' or equivalent

Requirements:

16.1.6


Recommendations Audit Protocol

Place(s) Used

7. Observation: OEL Open Text has recently replaced previous Lotus Notes DMS. OEL

brings up all versions of documents, with potential that the wrong version will be selected.

Review updating OEL configuration so that only current version appears by default. It is

recognised this needs to be done at corporate level.

Requirements:

6.1.5, 8.1.1

8. Observation: the corporate SMS appears to have deleted the requirement for Periodic

Hazard Studies / HIRACs. KI is still using the PHS / HIRAC approach for MHF purposes.

Clarify how the PHS process fits into the corporate SMS risk assessment and review

process and ensure the KI specific periodic review requirements are clearly explained in

MHF safety case update

Requirements:

7.1.1

9. Observation: it is not clear if HIRAC review process explicitly identifies MODs that have

occurred in the process under review and ensures the effect of these is accounted for.

Confirm how the HIRAC review process accounts for modifications and what

documentation is required, eg list of applicable mods could be included in HIRAC study

description or information list.

Requirements:

7.1.3

10. Observation: the corporate KCV programme may not cover all 'critical' controls

identified in 'MHF' or 'significant' HIRACS. Confirm the definition of 'critical control' in the

HIRACs and how it relates to 'key' controls and ensure relationship between the KCV and

any other critical control verification process is clearly defined, eg include as part of MHF

update

Requirements:

7.1.6

11. Observation: Some inconsistency in closeout of mod actions in Hazard Study database

(ie not closed) when MOD SHE Acceptance had been completed. (Auditor was advised that

this is a problem with Lotus Notes ie the actions can't be closed due to the way they have

been set up and there is no actual link to the SHE acceptance checklist in Mods database).

Review the link between closing out mod hazard study actions and completion of MOD

SHE acceptance form to see if this can be improved once new Enablon mod system is in

use.

Requirements:

14.1.1

12. Observation: There is no overall register of organisational changes. (Not included in

Lotus Notes MOD database for confidentiality reasons). Review developing a register with

at least the organisational change title, method of review and organisational change owner.

Also review providing some additional guidance in overall MoC procedure as to what level

of assessment / documentation is required for typical examples of organisational change

(Noted that this may be a corporate change). This would assist with demonstrating in MHF

Safety Case that this area of change is adequately addressed.

Requirements:

14.1.3

Document number: 21356-RP-001 Revision: 0 Revision Date: 20-Dec-2019 File name: 21356-RP-001 Rev 0 APPENDIX A

APPENDIX A. AUDITOR APPROVAL

Document number: 21356-RP-001 Revision: 0 Revision Date: 20-Dec-2019 File name: 21356-RP-001 Rev 0 APPENDIX B

APPENDIX B. EVIDENCE AND REFERENCE DOCUMENT SUMMARY

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

10-20000-01.dwg (1).pdf Site Layout 4/6/2009 Orica Site Layout drawing (all)

2015 Model Shipping Update Results (QRA

risk contours)

3/6/2015 AECOM QRA - revised risk contours for MOD3.

No significant changes to ops or inventories since 2016

audit - QRA not updated

Requirements: 22.1.3,

23.1.5, 26.1.3

2020 Midrun Scope Development report

(Ammonia turnaround planning)

2020 ammonia s/d scope example Hardness testing

first 50106974


15.1.2

Actions - DoP Hazard Audit-20092019-6.xlsx Sept 2019 Orica Enablon report: summary of all 2016 hazard audit

actions, status, review history etc.

Requirements: 26.1.1

Agency notification record doc 0044706 2019 Orica Notification to Safework of MDEA leak Requirements: 15.1.2

Ammonia plant abnormal operation

procedures.msg

Sept 2019 Orica OEL - List of all ammonia plant procedures dealing with

abnormal ops (covers loss of utilities, relief events,

equipment failure etc)


16.1.3, 26.1.17

Annual production.xlsx Sept 2019 Orica 2017 / 2018/ 2019 (to date) annual production

summary for NH3, NA, AN


AS4326 Storage and Handling of Oxidising

Agents.

2008 AS committee Australian Standard

Good practice - not statutory

Pending revision - though a new draft is not yet

available

Brad Maybury OSTE competencies.PNG Sept 2019 Orica Onsite Track Easy - example report of training status Requirements: 13.1.1,

16.1.2, 16.1.4

Compliance register. Enablon compliance

tasks report.xlsx

Sept 2019 Orica Enablon report. Lists all KI licences / permits and expiry

dates that site must comply with, regulatory an

authority etc


5.1.6, 26.1.14

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

Good practice - not statutory

Dangerous Goods and Pollutants Register

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

Orica DG Manifest Requirements: 5.1.2,

23.1.3



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

Development Consent - Notice of Modification

(1)

7/11/2012 DPE Approvals # 08_0129


(2)

17/12/2014 DPE Approvals # 08_0129 MOD 2


(3)

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

(minor word changes only compared to MOD2)

DMS training matrix Orica as part of EBA being updated for operators etc.

Includes links to Skill manual


16.1.1

Enablon action ID 2017-AP00044751 Orica Requirements: 26.1.6

Enablon action ID 2017-AP00044755 Orica Requirements: 26.1.9

Enablon event ID 2019-00044414 22 March 2019 Orica Example of minor ammonia release -worker exposure Requirements: 15.1.1

Events - 2019 Hazard Audit - Process Safety

tag.xlsx

Orica Enablon report export - process safety events Requirements: 4.1.3,

15.1.2

Events - 2019 Hazard Audit.xlsx Orica Enablon report export - 'serious’ SHES Incident events Requirements: 15.1.1,

15.1.2

Evidence for Plant Mod KI012636 - thrust

component material change.msg

Orica Requirements: 14.1.11

Examples of completed SIF test sheets Orica Integrity

Finance Stream - APA.pdf Orica Finance org chart - no direct relevance to Hazard Audit

Fire water diesel engine driver replacement

WO

Orica SAP - breakdown - Replace diesel fire water prime

mover - Order Type GM01 Order No 60245207

Flowchart for pressure equipment inspection

deferral (flowchart)

Orica Flowchart documenting required process for deferral of

pressure equipment inspection (Contained in OEL see

doc no. 1957573 ‘Pressure systems inspection deferral

process’


26.1.20

FRONT END PART 3 LU SIGNED.pdf Orica SOPs- example ammonia plant training module Requirements: 16.1.3

FRONT END PART 5 LU SIGNED.pdf Orica SOPs- example ammonia plant training module Requirements: 16.1.3



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

HAZCHEM audit - stock holdings - laboratory -

57-cylinder store.pdf

Orica Chem Alert report Requirements: 26.1.11

HR Stream - APA.pdf Orica HR org chart - no direct relevance to Hazard Audit

ICI ANZ Automatic extinguishing plant for

Eastern Nitrogen Limited Walsh Island.pdf

ICI original basis of AN store fire protection systems. Noted

in FSS June 2019


Independent Hazard Audit Action Plan Update

(January – June 2019) (190903 DPIE IHA

update.pdf)

3 Sept 2019 Orica Periodic update to DPE - 2016 Hazard Audit actions.

Includes status in Appendix A


26.1.1

JSEA example - Fire pump flow test 15/5/2018 Wormald Example JSEA attached to PTW

Kevin Tatton OSTE competencies.PNG Orica Requirements: 16.1.2,

16.1.4

KI Organisation chart Orica Manufacturing KI Org chart Requirements: 1.1.2,

2.1.1, 3.1.1

KI, SHE Risk Register HIRACs (MHF and

Significant scenarios)

Orica SHE Risk register stays in Lotus Notes Requirements: 7.1.2

KI Status of Noel Hsu’s recommendations

relating to CSB’s West, Texas report

2016 Orica KI Industry info

Self-audit by KI in 2016 - see 2016 Info

No changes or updates to this


KIW-1020: KI Emergency Response Plan

17 16/04/2018 Orica ERP Requirements: 17.1.1,

22.1.4, 23.1.4, 25.1.1,

26.1.26

KIW-1103-B-PI-08-Pressure_Systems

(Critical_Procedural_Control) -8-1960293.pdf

Release 8 21 Dec 2018 Orica Pressure Systems (Critical Procedural Control) as

identified under MHF


26.1.23

KIW/2601 Fire Water Pump Performance Test 0 31/1/2013 Orica Defines test method and performance requirements for

fire water pumps




KOORAGANG ISLAND AMMONIA

OPERATIONS HAZARDOUS AREA

VERIFICATION DOSSIER Doc no E-10031-

HD-0001

A 15/12/2015 EEHA Engineers Hazardous area Requirements: 26.1.7

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

KPI Screen shot.docx Sept 2019 Orica Requirements: 2.1.1,

4.1.2, 4.1.3, 7.1.6, 12.1.1,

16.1.4, 26.1.25

Lightning Study AN Bulk & Bag Store Report -

Revision 2.docx

2017 Orica AS1768 compliance review Requirements: 23.1.4,

26.1.2

List of modifications since 160701.xlsx Sept 2019 Orica Requirements: 14.1.1,

14.1.11, 26.1.25

Lotus Notes Mods database - see list of mods Sept 2019 Orica Requirements: 14.1.1,

26.1.25

MOD KI012189 Orica "Modify dispatch doors". This MOD covers elimination

of pallets for AN 1.2 tonne bags and associated AN

bag materials handling changes required


26.1.12

NH3 Permit Issuer OSTE competencies.png Sept 2019 Orica Onsite Track Easy report Requirements: 13.1.1

ORICA KI EMERGENCY RESPONSE PLAN

Revision 17.docx

Orica

Orica KI FW Boosters SFAIRP Report Rev

C.pdf

C 24/09/2019 Pinnacle SFARP / CBA of booster upgrade to match max

demand case (ie AN store)


Orica KI Site FSS Report E June 2019 Pinnacle FSS updated Requirements: 9.1.9,

23.1.4, 24.1.6, 25.1.1,

26.1.5, 26.1.10, 26.1.18

Orica Kooragang Island, Ammonia Production

Limit Increase, Modification of Project

Approval 08_0129

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



RE Additional info for the hazard audit .msg

Relative community distance – Orica KI vs

West Fertilizers

Safety, Health and Environment Policy March 2017 Orica (board) SHESMS - included in SMS doc Appendix 1, available

on the Globe and various noticeboards


26.1.1

Safety Management System Kooragang

Island

2 August 2019 Orica SHESMS

Safety Management Sizemore 2.pdf


1.1.2, 1.1.3, 1.1.4, 2.1.1,

3.1.1, 3.1.2, 6.1.5, 7.1.1,

26.1.13

Schedule 11 Hazardous Chemicals Register

Rev 11.xlsx

11 24/07/2019 Orica HAZARDOUS CHEMICALS REGISTER (manifest)

Periodic updates from March 2010 to July 2019


9.1.1, 23.1.3, 24.1.7,

24.1.8

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

Site organisation chart.pdf Orica KI manufacturing org structure

Site walk around - Ammonia Plant Attended by Jenny Polich, Murray Poole Requirements: 12.1.12

Site walk around - AN bulk store and AN bag

store

Attended by Jenny Polich, Sherree Woodroffe, Scott

Andrews


23.1.4, 23.1.6, 24.1.1,

24.1.5, 24.1.6, 25.1.1,

26.1.12

Site walk around - general plant areas

including gatehouse, pipe bridges, manifest

box

Attended by Jenny Polich, Sherree Woodroffe Requirements: 12.1.12

SN#4110018634_021; Parts List_R02.pdf Orica MODs - supporting info Requirements: 14.1.11

SOD - 30001031 Production Superintendent

position description

Orica Position description Production Superintendent Requirements: 3.1.2,

16.1.6

Standard isolation sheets (Nitrates) 2018 Orica Requirements: 26.1.21

Strategy Plan 000000706738 - piping 4 yearly

inspection, Ammonia Area - *LOCK* -

redundant piping

Orica SAP - integrity - example PM task - piping inspection -

task locked out and no frequency - piping was

redundant and has been removed




Strategy Plan 000000710061 - Ammonia

liquid piping 4 yearly inspection, Ammonia

Area

Orica SAP - integrity - example PM task - piping inspection Requirements: 12.1.2

Test records sprinklers and fire pump flow SAP records 2017/ 2018 fire pump and sprinkler tests Requirements: 26.1.8,

26.1.10

Document number: 21356-RP-001 Revision: 0 Revision Date: 20-Dec-2019 File name: 21356-RP-001 Rev 0 APPENDIX C

APPENDIX C. KI SITE ORGANISATION CHART AND INTERVIEWEES

The attached charts show the KI site organisational structure in place at KI at the time of the 2019 audit.

✓ Indicates the people interviewed as part of the audit with a complete list of all auditees following the charts.


Audit Participants:

Name Title Company Role Comment

Andre Hoffman Senior Manager - Maintenance

Engineering

Orica Auditee Integrity

Andrew Man ditch Senior Manager - Technical Orica Auditee Process / technical

Annie Lacombe Senior Manager - Product Line AN Orica Auditee Manufacturing

Experienced - Ops - AN

in role since Jan 2019

Antony Taylor Senior Manager - SHES Orica Auditee SHES

Ashley SHES Advisor Orica Auditee SHES

Enablon expert

Ben Toby Shift Superintendent - Ammonia Orica Auditee

Brad Maybury Operator - Ammonia Plant Orica Auditee 9 years (process coordinator, control room operator, field operator)

Brett Galloway Maintenance Superintendent AN

(Acting)

Orica Auditee 15+ years in maintenance role

Acting super while Matt Anstey on leave

Clinton Jacobsen Operator - AN plant Orica Auditee 9 years (process coordinator, control room operator / field operator)

Daniel Allen Senior Manager - Product Line

Ammonia

Orica Auditee Manufacturing

Experienced - ops - a number of roles at Ammonia Plant

Daniel Page Team leader – Product Warehouse Orica Auditee 9 years, team leader AN Bulk Stores, bagging etc

Kevin Tatton Operator - Ammonia Plant Orica Auditee New to operator role (< 1 year), trades background at KI (4-year apprentice, 3 years

maintenance)

Laxmi Kant Jahangir Senior Engineer - Electrical and

Control

Orica Auditee Technical (E&I, SIL), came from Yara - NH3 / AN experience

Replaced Les Willis (some gap)

Luke (Simon) Pelf Shift Superintendent - AN Orica Auditee < 1 year (previously from Origin)

Murray Poole Maintenance Superintendent NH3 Orica Auditee Ammonia plant maintenance

15+ years at KI

Paul Gallagher Senior Superintendent - Reliability Orica Auditee Reliability

20+ years at Orica various sites, at KI since 2012

Electrical background

Paul Hastie Manufacturing Centre Manager Orica Auditee Manufacturing (site manager)


Name Title Company Role Comment

Scott Andrews Superintendent - Product

warehouse

Orica Auditee Manufacturing

Facilities Maintenance including AN store

Scott Petersen Senior Superintendent - Integrity Orica Auditee Integrity

Responsible Mechanical Engineer

10+ years at KI in mechanical roles

Scott Send-off Risk Specialist Orica Auditee Technical Risk registers / Hazard studies / MHF

Very experienced - 20+ years at Orica in technical roles

(Seconded to cover Belinda Moss - maternity leave)

Sherree Woodroffe Senior Safety Specialist Orica Auditee SHES

Jenny Polich Principal Engineer Sherpa Lead Auditor Approved as auditor by DPE

Stuart Chia Principal Engineer Sherpa Audit reviewer Approved as auditor by DPE

Giles Peach Principal Engineer Sherpa Audit reviewer Approved as auditor by DPE

Document number: 21356-RP-001 Revision: 0 Revision Date: 20-Dec-2019 File name: 21356-RP-001 Rev 0 APPENDIX D

APPENDIX D. AUDIT RECORD WORKSHEETS

2019 Hazard Audit Orica KI Site

21356 Orica KI 2019 Haz Audit FINALPage 1 of 44

Print Date: 20/12/2019

GeneralAdministration

Facility InformationCompany: Orica Australia Pty Ltd

Business Unit: Manufacturing

Facility: Kooragang Island Ammonium Nitrate Facility

Project ID: 21356

Project Name: 2019 Hazard Audit

Study DurationStart Date: 01/09/2019

End Date: 20/12/2019

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 (2019) 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 DPIE, 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 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 including AN stores, Ammonia Plant and AN / NAP Plants. 2. The focus was on the site and plant modifications since prevous Hazard Audit in 2016. There have been relatively few equipment changes since the 2016 audit . 3. The closeout of any actions arising from the 2016 Hazard Audit or other studies that may have occurred since 2016 4. The continued 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.

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 3 cl 15k))

Job is intended to: Satisfy NSW DPIE 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 SHESMS, 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 an emergency occurs?11. Job specific questions - eg maintenance, mods, compliance, operations procedures etc




1. Audit Elements

Audit Element (HIPAP9)Overall Element

ComplianceHIPAP Ref Comments Personnel Interviewed

Sherree Woodruffe

Paul Hastie

Fully Implemented1. SHE Management System Structure and Administration

3 Orica's integrated corporate Safety, Health, Environment and Security Management System (SHESMS) covers all the main requirements of a Safety Management System. This includes policy, vision, SHE 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.

Sherree Woodruffe

Paul Hastie

Antony Taylor

Fully Implemented2. Commitment and Leadership 2.1 SHES management is initiated at the corporate level and managed as an integrated part of site management activities with the KI Site Manager having overall responsibility for implementation. The auditor observed a visible commitment to safety management at KI in the form of integration of SHES items into daily meetings, highly visible BoS and increased focus on KPI information since the last audit. A number of risk reduction projects have been completed since the 2016 audit and the focus is now on structural inspection and refurbishment programmes and business system improvements.

Sherree Woodruffe

Paul Hastie

Fully Implemented3. Organization, Accountabilities and Responsibilities

3.3.1 Organisation charts and position descriptions are availablePotential improvements in resourcing, definition or responsibility for a specific element are identified under the individual element headings where relevant.

Sherree WoodruffeFully Implemented4. Objectives, Target and Plans 3.2.3 At the site level a SHES improvement plan is developed annually. At an individual level all employees have documented personal SHE objectives that demonstrate the employee’s contribution to SHES performance. Potential improvements in objectives or planning are identified under the individual element headings where relevant.

Scott Sandhoff

Sherree Woodruffe

Antony Taylor

Andre Hoffman

Fully Implemented5. Legal Requirements and Codes 3.2.1 A compliance register is available in Enablon, supporting actions are also set up in Enablon 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.

Sherree Woodruffe

Ashley Russell

Fully Implemented6. Documentation 3.3.5 There is an extensive document base covering the SHESMS and supporting procedures at corporate and KI site level which are available within the OEL or accessible via the Orica Intranet (Globe). Drawings are managed electronically via Vault. Incident information is in EnablonSite specific records are available either within the relevant site databases (eg Modifications Lotus Notes database, Lotus Notes SHE Risk Register), SAP for maintenance and PTW, and in some cases network drives. It is noted that the DMS has been migrated into a new system (OEL). This could be refined (would need to occur at a corporate level not KI level) to default to show only the current version of documents. All revisions of a document appear which may result in mistaken use of an older version.

Scott Sandhoff

Sherree Woodruffe

Mostly Implemented

7. Hazard Identification and Risk Control 4.2 Site specific modifications procedure developed from corporate procedure 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 yet 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 large number of open actions (this is reducing) arising from the periodic hazard study and Process HIRAC processes that have not been resourced. 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. It is noted that this is planned to occur as part of the MHF relicencing process over 2020 .

Paul Hastie

Daniel Allen

Annie Lacombe

Sherree Woodruffe

Fully Implemented8. Operating Procedures 4.3 Operations for all plant areas appear to be covered by extensive procedures for normal operations and abnormal conditions, available with the OEL.

Scott Petersen

Andrew Manditch

Paul Gallagher

Fully Implemented9. 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 .

Sherree Woodruffe

Andrew Manditch

Andre Hoffman

Fully Implemented10. Contractor Management and Procurement

4.54.12

There are formal processes in place for contractor selection and management and contractors appear to be well managed. The Track Easy system provides transparency of the status of licences, inductions and PTW training

Annie Lacombe

Daniel Allen

Andrew Manditch

Sherree Woodruffe

Fully Implemented11. Pre Start-up Safety 4.6 Pre-startup safety checks are well covered in the modification acceptance and handover certificates system and also in plant startup checklists.

Scott Petersen

Andre Hoffman

Paul Gallagher

Fully Implemented12. Equipment Integrity 4.7 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 largely complete. A structural integrity inspection and refurbishment programme is being implemented. Major shutdowns appear to have been completed in the required timeframe and a shutdown planning team is in place to prepare for the next major turnaround.

Sherree WoodruffeFully Implemented13. Safe Work Practices 4.8 Permit to Work Systems are well developed and appear to be well implemented. Training records are available.




Audit Element (HIPAP9)Overall Element

ComplianceHIPAP Ref Comments Personnel Interviewed

Ben Toby

Luke (Simon) Pelc

Annie Lacombe

Daniel Allen

Paul Hastie

Andrew Manditch

Mostly Implemented

14. Management of Change 4.9 There is a formal control of modification and change management process in place which is extensively used for engineering changes with supporting records available. An ongoing effort has been made to reduce the number of open mods, Quality of closeout actions appeared to have improved since the previous 2016 audit. There is an opportunity to provide greater transparency around organisational change management.

Sherree Woodruffe

Antony Taylor

Ashley Russell

Fully Implemented15. Accident/ Incident Reporting and Investigation

4.105.3

Enablon is used to record all incidents and track associated investigations / actions. Data entry and investigation was comprehensive and transparent. KPIs are in place. A 'process safety event' definition and flag in Enablon has been recently added (at corporate level) and is now being applied at KI to incident recording.

Sherree Woodruffe

Annie Lacombe

Daniel Allen

Paul Hastie

Mostly Implemented

16. Training and Education 4.113.3.33.3.4

Training and Competency systems were well developed and covered induction, operations, safe work practices and corporate requirements such as use of the OEL, modifications (in the Lotus Notes database) and incident reporting in Enablon. Records were readily available in TrackEasy. There is an opportunity to more clearly define the level of plant-specific process knowledge required for roles such as shift superintendent and engineers in the Technical group and include this in position descriptions and /or training plans.

Sherree WoodruffeFully Implemented17. Emergency Planning and Response 4.13 Emergency plan is in place and linked to MHF. The ERP was last reviewed in 2018 and updated to reflect changes in site operations and neighbours, and drills / exercises completed to schedule. The next planned review of the ERP will occur as part of the MHF licence update over 2020.

Sherree WoodruffeNot reviewed in audit

18. Security and Access Control 4.14 Security was not reviewed in detail. KI is a secure site and has an SSAN security plan in place. The auditor was accompanied by SSAN licensed personnel to areas handling AN. Locks were observed on AN stores and AN shipping containers.

Sherree Woodruffe

Ashley Russell

Annie Lacombe

Paul Hastie

Fully Implemented19. Auditing and Management Review 4.15, 5.4, 5.5 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. Key control verification (KCV) programme has been implemented at KI as per Orica corporate requirements.

Not reviewed in audit

20. Environmental impacts / pollution potential

n/a Not in scope of Hazard Audit

Not reviewed in audit

21. Environmental Performance Compliance

n/a Not in scope of Hazard Audit

Sherree Woodruffe

Antony Taylor

Fully Implemented22. 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 were found to be complied with.

NOTE: 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

Sherree Woodruffe

Scott Sandhoff

Fully Implemented23. Industry guideline compliance (SAFEX)

06_0089 A review of the AN areas against the guidance in SAFEX was carried out. The AN bulk and bag 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. There has been no requirement to update the 2015 QRA since the 2016 audit as there have been no significant changes in AN inventory or operating practices.

Scott Andrews

Sherree Woodruffe

Fully Implemented24. AS4326 Compliance 06_0089 A review of compliance of the AN stores was 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 the basis of the actual KI AN inventories and agreed by DPIE and Safework hence regulatory consultation requirement is regarded as satisfied. There has been no requirement to update the 2015 QRA since the 2016 audit as there have been no significant changes in AN inventory or operating practices.

Scott Andrews

Sherree Woodruffe

Fully Implemented25. 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 continue to be well addressed at KI. Previous 2016 Hazard Audit action relating to removal of redundant combustible building material had been addressed.

Sherree WoodruffeFully Implemented26. Closeout of 2016 Hazard Audit recommendations

Hazard Audit - 2016

A review of the 2016 Hazard Audit action closeout was completed. Discrete actions have been addressed. Ongoing actions eg labelling improvements to equipment are covered by ongoing programmes with a schedule that is captured as a project run by piping group. The relevant actions had been entered into Enablon with target dates. The status of Hazard Audit actions is reported 6 monthly to DPIE with the last report provided in Sept 2019.

Sherree Woodruffe

Antony Taylor

Fully Implemented27. Closeout of other study actions Site FSS Rev F (2019)

A review of actions from other studies was carried out. There were no identified new condition of consent studies since the 2016 audit. Actions from some internal hazard studies and technical assessments were reviewed and the completion status of actions is appropriate for the stage of the projects. The KI site FSS has also been recently updated in June 2019. There are no 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

Safety Management System Kooragang Island

1. SHES MS includes general SHE Standards and Major Hazard Standards. They apply to all Orica sites where Orica controls engagement of contractors, suppliers etc (such as KI). The standards include some mandatory requirements and are the basis for the development and application of SHESMS Procedures, Guidance Documents and Work Instructions at all levels of Orica

2. SHESMS overview includes governance structure and management framework. SHES is integrated into other management functions . Specific SHES Committees established at the Board and site level which includes representatives from management and SHES functional groups. This is in place at KI which has site SHES committee and site specific safety and environment personnel who report through Manufacturing

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 Implemented1. SHE management structure

KI Organisation chart


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

2. Site specific dedicated Safety lead updated KI SMS in accordance with corporate SHESMS changes

Who was involved in developing SMSWho updates it?

1. Overall 2 yearly review cycle for SHESMS overall.

2. Via KI site SHES committees

How is feedback provided?

Fully Implemented2. Participation/consultation


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

Fully Implemented3. Links to other systems (OHS/QA/EMS)


1. Corporate SHESMS system applicable globally Fully Implemented4. Maintaining continuity of safety management systems (making SMS system dependent and not individual dependent)

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

Being Developed5. Maintaining continuity of responsibility for process safety / environmental management under organisational change




Audit Element: Commitment and Leadership



Finding

Safety, Heath and Environment Policy



KPI Screen shot.docx

1. SHE Policy signed in March 2017 part of KI SMS

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

Commitment from senior executive management

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

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

1. Statement included in SHE policy and SMSCommitment to compliance with legislation / codes/ standards

1. SHES Group standards include Process Safety, supported by SHES group procedures

Explicit reference to Major Hazards / Prevention of MIs

1. Included in roles and responsibilities

2. Safety leadership interaction (SLI) programme with improvements tracking in Enablon and associated KPIs

Communication and training requirements

1. Yes - includes reference to nature of operations / industryClear definition of scope with respect to nature , scale and risks of activities

1. Overall vision includes "Safety is our priority always" Long term objectives

1. SHESMS values includes: "we find ways to minimise our impact on the environment in all our actions"

Commitment to prevention of pollution

1. Not knownCommunication and consultation during development

1. SHE Policy signed in March 2017 - included as part of KI SMSPolicy maintenance and review - typically once per year

Fully Implemented1. SHE Policy - clear, concise statement of commitment that sets the goal as to the performance standards to be achieved

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

2. Included in Induction package

3. SHES committee meetings occur

4. Daily meetings include SHES issues

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

Fully Implemented2. Communications re policy(internal/external)

1. The SHESMS 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 SHESMS documents are made available to the partner

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

3. SLI programme

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 Implemented3. Commitment demonstrated - resourcing (people / budget), language, working environment




Audit Element: Organization, Accountabilities and Responsibilities



Finding



1. Communication requirements / roles are covered in SMS Is there a management and/or organizational structure highlighting communication and safety interfaces at a Corporate and Business Function Level?

1. Corporate SHES Systems Manager role

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

3. Site specific dedicated KI Environment and Safety leads who report through Manufacturing

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

Fully Implemented1. Organisational structure

SOD - 30001031 Production Superintendent position description


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 SHES MS governance framework

2. KCV programme

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

Fully Implemented2. Definition of accountabilities / responsibilities

1. Site specific dedicated KI Environment and Safety leads who report through Manufacturing

Fully Implemented3. Accessibility of persons of responsibility and accountability to staff




Audit Element: Objectives, Target and Plans



Finding

1. KI overall objectives in Annual SHES Improvement Plan.

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

3. Visible KPIs tracked via Enablon dashboards include incident rates, SLIs completed, overdue action closeout etc

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

Fully Implemented1. Safety / environment objectives setting and monitoring

KPI Screen shot.docx1. Yes. KPIs discussed on a daily basis at morning meetings

2. Different roles have different Enablon dashboards (can be customised to suit the role) that show relevant KPIs

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 Implemented2. Setting KPI's


Events - 2019 Hazard Audit - Process Safety tag.xlsx

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

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

Fully Implemented3. Process safety and environmental performance monitoring and reporting mechanism

2. Observation: Progress has been made prioritising and closing out PHS / HIRAC risk register actions (these are not in Enablon but remain in Lotus Notes Risk Register) and quarterly reviews are held. Consider implementing a KPI around PHS / HIRAC action closeout and check progress in next Hazard Audit.

1. Risk reduction improvement projects have been implemented over 2014 - 2016 such as installation of scrubber and flare systems to capture ammonia emissions (vent and pressure relief cases) and consolidation ammonia supply storage to AN plants from several large ammonia bullets to a single smaller capacity ammonia storage vessel This is largely complete - still need to replace NH3 pumps and then can decommission last pressurised NH3 storage bullet.

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

3. 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 which is being refreshed to prepare for the 2020 MHF licence update. Whilst the number of open actions has significantly reduced from over 1000 open actions , 783 have been prioritised, dates and resources allocated . There are still 404 left. Quarterly review meetings have been implemented

Plan should: - Designate responsibility - Resources Required - Timeframe

Mostly Implemented4. 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: Legal Requirements and Codes



Finding

Compliance register. Enablon compliance tasks report.xlsx

1. sites must have a SHE Legal and regulatory requirements register that is reviewed annually

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

Fully Implemented1. Applicable safety legislation (Planning approvals, MHF regulation, DG regulation, OHS regulation etc)

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

Schedule 11 Hazardous Chemicals Register Rev 11.xlsx

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. HIRAC review update work has commenced

MHF - up to date and available

Fully Implemented2. 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 Implemented3. Applicable standards - AS, API, NFPA etc

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

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

Fully Implemented4. Industry code of practice

1. Technical panels within Orica to provide advice to the sites on best practices for the various technologies.

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

1. Corporate Audits (company auditor), insurance audits. Also regulator audits as required

2. Audit actions tracked in Enablon

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

Not reviewed in audit 5. Corporate standards/procedures


1. Global Mark audits for ISO accreditation - management system compliance. Actions go into Enablon for closeout

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

1. Compliance register includes hazard audit etc Areas of non-compliance?

Fully Implemented6. Compliance review

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

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

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

Mostly Implemented7. Awareness/training

1. OEL, the GlobeDo personnel have access to codes, standards? (intranet, manuals etc)

Fully Implemented8. Documentation/accessibility

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

Mostly Implemented9. KPI's




Audit Element: Documentation



Finding

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

These should be controlled documents (eg SOP) Fully Implemented1. 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 assessments / 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 Implemented2. Site be able to demonstrate that effective records are kept

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

Fully Implemented3. 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.


7. Observation: OEL Open Text has recently replaced previous Lotus Notes DMS. OEL brings up all versions of documents, with potential that the wrong version will be selected. Review updating OEL configuration so that only current version appears by default. It is recognised this needs to be done at corporate level.

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

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

Where is SMS documented?Who has access?How?

Fully Implemented5. Document control system/ accessibility of information




Audit Element: Hazard Identification and Risk Control

Overall Element ComplianceMostly Implemented


Finding


8. Observation: the corporate SMS appears to have deleted the requirement for Periodic Hazard Studies / HIRACs. KI is still using the PHS / HIRAC approach for MHF purposes. Clarify how the PHS process fits into the corporate SMS risk assessment and review process and ensure the KI specific periodic review requirements are clearly explained in MHF safety case update

1. KI is still using the Orica Hazard Study process for hazard identification and associated Process HIRAC method for Major Hazard risk assessment and also to identify Significant scenario HIRAC. (ie HIRACS are 'MHF or Significant') 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 personnel with the PHS / HIRAC process, KI management has decided to stay with the existing methodology. KI is still not using CRMI.

2. This HS process has been 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 Implemented1. Hazid, Risk assessment and control process

KI SHE Risk Register HIRACs (MHF and Signifcant scenarios)

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. Ammonia BOS being updated

3. SDS access via ChemAlert.

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) have been carried out for all areas. Current focus is HIRAC review for MHF licence renewal

4. Recognised techniques HAZID / HAZOP used for Hazard studies and MHF Safety Case HAZID. The HAZID info is then used to populate the risk assessment (HIRAC) inputs for high consequence scenarios

Uses appropriate and recognised techniques, eg HAZID, HAZOP

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. No changes since 2016, except Incitec no longer an MHF

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. Technical panels within Orica to provide advice to the sites on best practices for the various technologies.

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

Fully Implemented2. Hazard identification - process safety

1. Observation: MHF 2020 update process includes creating a tool for showing an overall risk profile for the KI site and also used to show risk reduction over time or effect of removal of safeguards. Confirm progress in next Hazard Audit.

9. Observation: it is not clear if HIRAC review process explicitly identifies MODs that have occurred in the process under review and ensures the effect of these is accounted for. Confirm how the HIRAC review process accounts for modifications and what documentation is required, eg list of applicable mods could be included in HIRAC study description or information list .

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 - no need to further update

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

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 example an overall list of all "High" risks, or all Process Safety Risks with a consequence level of high (eg single fatality) or greater.

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)

is the HAZID/ Risk Assessment/ Risk Register - recent - reflects current operations/ configuration

Mostly Implemented3. Risk Assessments of existing operations (qualitative or quantitative, risk tolerability criteria)




Audit Element: Hazard Identification and Risk Control



Finding

4. Observation: HIRAC for Fire in AN despatch area doesn't identify wooden pallet elimination (MOD KI012189) as an additional risk reduction measure. (see Lotus Notes doc ID ANDES/ MHF 18/12031924 page 04002 last updated 19/8/2019). Revisit this HIRAC and ensure all control measures adequately identified and risk ranking updated as needed.

2. Standard 4 of SHESMS 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 SHESMS 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 the 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 privilege) 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

1. Some consideration of human factors evident in Process HIRACs.

2. Significant project implementing control system upgrade and best practice Alarm Management completed in 2013 / 2014 to reduce load on operators

Evidence of consideration of staffing level, response times, ergonomics, human error assessment, attitudes, operator/ process interface adequacy and complexity

Mostly Implemented4. Human factors in managing risks


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 ignition 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, control system / safety PLC upgrade at ammonia storage and software tracking process excursions, trips etc.

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. PHS3 actions have been prioritised and are gradually being closed out. These are not in Enablon

Management and prioritisation of actions arising from HAZID / Risk Assessment

Mostly Implemented5. Ongoing risk reduction (adequacy of control measures for major hazards control in terms of redundancy, effectiveness, reliability, availability and survivability)

KPI Screen shot.docx 10. Observation: the corporate KCV programme may not cover all 'critical' controls identified in 'MHF' or 'significant' HIRACS. Confirm the definition of 'critical control' in the HIRACs and how it relates to 'key' controls and ensure relationship between the KCV and any other critical control verification process is clearly defined, eg include as part of MHF update

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 ammonia and NAP / AN plants to allow tracking of process excursions and process trips. KPIs around this

3. Process Safety Event category introduced into Enablon around June 2019

For hazard control measures - pressure/ vacuum, high/ low temperature, overfill, pump suction, dead head, load sensing, leak detection

1. KCV programme introduced that involves a detailed verification of Key Controls as defined at corporate level. Schedule has been developed and is being implemented. Some overlap - not entirely clear if this covers all MHF critical controls. (SIFs, statutory inspections etc are well covered).

Monitoring of critical controls

Fully Implemented6. Performance Standards

1. Yes, 5 yearly process as per MHF. HIRACS currently being revisited for 2020 licence renewal

2. All Level I risks have been reduced to Level II or less . Eg NRVs fitted for unidentified high pressure backflow case around 106E

Does the hazard identification, risk assessment & control process allow for periodic evaluation of effectiveness of controls?

Fully Implemented7. Continual improvement

1. Personnel are very aware of MHF and major hazards and key control measures via KCV programme

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 Implemented8. Communications and awareness




Audit Element: Operating Procedures



Finding

7. Observation: OEL Open Text has recently replaced previous Lotus Notes DMS. OEL brings up all versions of documents, with potential that the wrong version will be selected. Review updating OEL configuration so that only current version appears by default. It is recognised this needs to be done at corporate level.

1. Documented operating procedures for most tasks can be found on OEL. 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 safety requirements for:- Special Hazards- Physical and chemical properties- Precautions to take during normal operations/ maintenance/ emergencies

Fully Implemented1. 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 Implemented3. What is the procedure for assigning personnel not trained or not familiar with a particular operation?

Ammonia plant abnormal operation procedures.msg

DMS training matrix

3. Observation: Ammonia plant 'alarm help' summary is available but not used and operators not clear if this is up to date. Either update and train in its use or discontinue and define alternative.

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 existing Safety Case Report appendix. Technical department doing ongoing work for Safe Operating Envelope (SOE)

2. The Nitrates area operating procedures include specific WI guidance for responding to abnormal process situations,. Nh3 has abnormal ops procedures

3. Ammonia plant 'alarm help' summary is available but not used. Not clear if its up to date

4. Alarms are manageable at Nitrates an NH3 plants - critical alarm pages comes up first, ongoing work on rationalisation

5. The MHF Process HIRACs identify "critical controls", in some cases these are operating procedures (though an overall list was not available at time of audit). "Critical procedures" are differentiated from other procedures by a tag on the document.

How are 'critical operating parameters COP' defined? Are they documented in terms of a) consequence and b) actions required to correct deviations?

Mostly Implemented4. Safe Operating limits / Critical Operating Parameters

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 Implemented5. Temporary unavailability of equipment - impact on operations




Audit Element: Process Safety Information



Finding


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 Hazardous materials - SDS

1. All drawings in Vault. Generally PIDs appear to be updated as part of mods and close 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 engineersPFDs and mass and energy balances

1. All drawings in Vault . Dossiers on network and up to dateHazardous 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 Implemented1. Current process safety information

1. Covered in BoS and corporate standards for specific items eg AN pumping Does it exist? Fully Implemented2. Design safety philosophy

1. Process and functional descriptions, equipment datasheets are generally available

Fully Implemented3. Design basis

1. All drawings in Vault Fully Implemented4. Drawings showing underground utilities and services

1. All drawings in Vault Fully Implemented5. PV / mechanical Drawings

1. Process and functional descriptions, equipment datasheets are generally available

Fully Implemented6. Equipment data sheets

1. Electrical and loop drawings generally available Fully Implemented7. Valve and instrumentation data sheets including PSV's, control loop set points

1. Ammonia leak detection in various areas..Layouts available. SAP system includes maintenance tasks

Fully Implemented8. Fire & Gas system (flame/ smoke detectors, flammable/ toxic gas detectors)

Orica KI Site FSS Report 1. Fire system drawings and FSS exist and recent site wide FSS . Includes hydraulic calcs and demand cases. Design basis and codes referred to in 2019 FSS.

Drawings

1. covered in FSS (last update 2019)Sizing case, max water demand

1. FSS approved by FB for last MHF and will be resubmitted as part of MHF 2020 update

FB approval

Fully Implemented9. Fire protection systems (firewater system, deluge/ spray system, fixed/ portable foam system)

1. Drawings not sighted. Not reviewed in audit 10. Computer control system documentation

1. Confined space register and risk assessments as per WHS requirements Fully Implemented11. Register of formally classified confined spaces

Not reviewed in audit 12. Emergency system services (emergency power, UPS, backup instrument air)

1. With maintenance department Fully Implemented13. Vendor operation/ maintenance manuals




Audit Element: Contractor Management and Procurement



Finding

1. Contractual plus certificatesQA / ITP process Fully Implemented1. Quality assurance of procurement (spares, equipment, raw materials, reagents)

1. Design sign off, ITPs, examples from boiler project sighted

2. Spec includes details of any required certifications

Check who signs off Fully Implemented2. Equipment fit for purpose

1. Prequalification process in place

2. Contractor injuries / incidents / near misses included in Enablon, can be reported separately

Is there a formal selection process? Fully Implemented3. Contractor selection/criteria/procedures

1. Inductions, SHE plans , JSEAs, Orica specific PTW training for contractors who are Permit Receivers,. On Track Easy

Management of contractors on site Fully Implemented4. 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 boiler project sighted

Fully Implemented5. 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 Implemented6. Continuity of services




Audit Element: Pre Start-up Safety



Finding

1. Covered in checklist that is part of Mod process - examples of completed form sighted for Boiler 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 Implemented1. Pre Start-up safety review




Audit Element: Equipment Integrity



Finding

KPI Screen shot.docx1. SAP system in place. 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 < 15% of total maintenance task hours (which it is) and also around overdue inspections for critical items (none currently overdue). KPI around this

Review PM system for current status and OUTSTANDING / OVERDUE items (especially statutory or company requirements).

Fully Implemented1. PM system exists

Strategy Plan 000000706738 - piping 4 yearly inspection, Ammonia Area - *LOCK* - redundant piping

Strategy Plan 000000710061 - Ammonia liquid piping 4 yearly inspection, Ammonia Area

1. Identify "SHE 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 in SAP associated with any critical function as well as regulatory requirements such as PV inspections)

Definition and process for identifying "critical" equipment Fully Implemented2. Critical items have been identified

Flowchart for pressure equipment inspection deferral (flowchart)

KIW-1103-B-PI-08-Pressure_Systems (Critical_Procedural_Control)-8-1960293.pdf

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

2. Capstone software (a quantitative approach based on API 580/581) for assessing failure likelihood / criticality based on actual inspection history has been implemented for pressure vessels in NAP and ammonia plants. Software is used by global integrity and approval to defer based on Capstone risk ranking. Any deferral is signed off and registered. KPI around deferrals

3. RCM process for rotating machinery

4. FMECA for other equipment

5. 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). "

6. Shutdown tasks are planned based on statutory requirements / 'critical controls' and upgrade factors - dedicated shutdown / turnaround planning role in engineering team. Examples for last Ammonia Plant s/d in 2017 include NRVs for 106E (backflow/ overpressure protection arising from PHS3), catalyst change, feed coil replacement, NH3 refrigerator 105 HP rotor replacement (to achieve a smoother startup), lot of elec cabling upgrades, V101 acoustic emission testing/ Nitrates s/d: NH3 pumps thrust material back to CS - see MOD KI012636, replace pipe reactor AN2, repair Waste Heat boiler fatigue issues

7. plants track reasons for loss of production and use this to inform works required

8. Theme of minor leaks in Nitrates plant around cooling water treatment. Maintenance tasks not clear between contractor and Orica personnel - now working out scope and entering into SAP

Fully Implemented3. Reliability data to determine maintenance schedules

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 Implemented4. 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,

Not reviewed in audit 5. Pollution control equipment included in PM system







Finding

1. In SAP as statutory inspections -as per Capstone and RMS Fully Implemented6. 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 Implemented7. Hardware integrity inspections included (intrusive, NDT, corrosion loops, inspection schedules, documentation)

1. Not reviewedCheck pipelines - Insulating Flanges, cathodic protection records, action taken if issues detected

Not reviewed in audit 8. Cathodic protection monitoring

1. In SAP as statutory inspectionsConfirm all PSVs in PM systemNot overduerecords of pass / fail and any fixes available

Fully Implemented9. PSV servicing

SIF test records - L: drive1. 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. SIF registers available

4. Logic tests for SIF loops planned in 2020 shutdown

Identify critical instruments / loops - bow ties, MHF work etc Fully Implemented10. Instrument calibrations / critical instrumented protection functions (IPFs)

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. work was largely included in 2017 shutdown for ammonia plant

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 Implemented11. Hazardous area classification integrity

Site walk around - Ammonia Plant

Site walk around - general plant areas including gatehouse, pipebridges, manifest box

Site walk around - AN bulk store and AN bag store

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 - ongoing - being managed by piping group

2. sample of hoses inspected during walk arounds - all clearly tagged

Fully Implemented12. Equipment labeling and identification in field

1. Shift log, half hour handover period. Quite detailed records for last 6 months.

Fully Implemented13. Shift hand-over procedures

1. Site is generally very tidy, no obvious housekeeping issues. Fully Implemented14. Housekeeping standards and monitoring housekeeping integrity

1. Password protected

2. Various SIL rated PLCs

Fully Implemented15. Software/ programmable control systems security

1. part of inspection regime Fully Implemented16. Corrosion underneath insulation

1. in place for major rotating machinery Fully Implemented17. Vibration monitoring

1. Not explicitly covered in audit.Minimum pipe size of 25mm was adopted for ammonia piping in AMI project

Not reviewed in audit 18. Small bore pipework integrity

1. ongoing structures inspection and refurbishment programme.including: -NAP stacks-Access platforms (all plants) -Elevated equipment brackets (all plants)-Roof sheeting NH3 Plant pipebridge

Piping supportsTank floorsPlinthsStacksColumn supportsRoofed areas

Mostly Implemented19. 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 Implemented21. Critical spares

1. Three flares installed as part of AMI project (installed at time of 2016 audit). Access appears adequate and no reported ops or maintenance issues with flares.

Fully Implemented22. Access to flare







Finding

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 Implemented23. 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 similar

Ability to identify integrity issues from incident tracking / near miss system (leaks, mechanical, instrument etc)

Fully Implemented24. Incident History




Audit Element: Safe Work Practices



Finding

Brad Maybury OSTE competencies.PNG

NH3 Permit Issuer OSTE competencies.png

1. A new PTW module in SAP was 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 - 2 yearly refresher required ) was defined and 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

(hot work, confined spaces, excavation work, heavy equipment, lock out/ tag out, isolation)

Fully Implemented1. Check the PTW system and status of records

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 historically developed on a job by job basis Nitrates s/d March 2018 trialled standard isolation sheets - successful continue with rollout. 2016 Hazard Audit action 2017-AP0044766 closed in Enablon and new action created.

3. Did not check LOTO in field

4. If work is associated with a MOD, their is a WO field that can be used to add MOD number and this triggers permit issuer to confirm there is a Mod approved.

Link between PTW, isolation plans, approval of Mods Fully Implemented2. Check the PTW system / isolation against procedure

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 Implemented3. Determine handover between shifts




Audit Element: Management of Change



Finding

Lotus Notes Mods database - see list of mods

List of modifications since 160701.xlsx

11. Observation: Some inconsistency in closeout of mod actions in Hazard Study database (ie not closed) when MOD SHE Acceptance had been completed. (Auditor was advised that this is a problem with Lotus Notes ie the actions can't be closed due to the way they have been set up and there is no actual link to the SHE acceptance checklist in Mods database). Review the link between closing out mod hazard study actions and completion of MOD SHE acceptance form to see if this can be improved once new Enablon mod system is in use.

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. NOTE: this will be replaced by Enablon mods system form Q3 2019 but old mods won't be migrated

3. Lotus Notes Mod database will very shortly replaced by Enablon Mods module - existing Mods won't be migrated

4. Audit focused on mods since 2016. There has been a concerted effort at reducing the number of open mods using Mod Tracker - and KPIs have been implemented to track the number of open mods (peaked in May at 310, down to 180 in Sept 2019) as well as various other indicators

5. 8 mods checked as part of Mod review. Closeout records well completed. Experienced process engineer (Stuart Monroe) has a role to do a weekly check of mod closeout quality

6. No temporary mods open past due date - all "removed" status

7. Some inconsistency in closeout of mod actions in Hazard Study database (ie not closed) when SHE acceptance had been completed eg KI012698 - this is a problem with Lotus Notes ie the actions can't be closed due to the way they have been set up and there is no actual link to the SHE acceptance checklist in Mods database .

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 Implemented1. 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 Implemented2. Like for like / replacement in kind

12. Observation: There is no overall register of organisational changes. (Not included in Lotus Notes MOD database for confidentiality reasons). Review developing a register with at least the organistional change title, method of review and organisational change owner. Also review providing some additional guidance in overall MoC procedure as to what level of assessment / documentation is required for typical examples of organisational change (Noted that this may be a corporate change). This would assist with demonstrating in MHF Safety Case that this area of change is adequately addressed.

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. Discussed with Manufacturing Centre Manager. Org changes are assessed 'as needed'. records are available of some individual org change assessments but there is no overall list / register or specific guidance on how to assess organisational changes

3. No records of where it is decide a formal assessment is not needed . eg temporary role coverage by a more experienced person (eg Scott Sandhoff replacing Belinda Moss as MHF role when on mat leave)

4. Actions re Org change assessment are not in Enablon or risk register

Mostly Implemented3. 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 Implemented4. Forms

1. Electronic workflow in MOD database includes all review and approval steps Fully Implemented5. Approval levels

1. Defined in procedure. Action lists for Mods are generally filled in and closed out

Fully Implemented6. 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 Implemented7. Records maintenance (P&ID update, operating procedures/maintenance procedures update)

1. Very good awareness of when to use the procedure for engineering changes. Not well known for organisational change

Fully Implemented8. Awareness when to use the procedure

1. Mod database shows a relatively low number of temporary mods with short timeframes to closure

Check that there are not a lot of long duration open temporary mods

Fully Implemented9. Temporary changes (sunset clause), return to initial condition




Audit Element: Management of Change



Finding

2. Definition of temporary modification and maximum timeframe in procedure (max allowable is 6 months)

3. KI has a specific step to the corporate workflow standard for temporary mods - final step is REMOVED

Confirm definition of temporary

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 Implemented10. KPI's

MOD KI012189


Evidence for Plant Mod KI012636 - thrust component material change.msg

SN#4110018634_021; Parts List_R02.pdf

4. Observation: HIRAC for Fire in AN despatch area doesn't identify wooden pallet elimination (MOD KI012189) as an additional risk reduction measure. (see Lotus Notes doc ID ANDES/ MHF 18/12031924 page 04002 last updated 19/8/2019). Revisit this HIRAC and ensure all control measures adequately identified and risk ranking updated as needed.

1. Sample MODs reviewed; 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 selected MODs and associated Hazard studies Looked at MODs and various supporting information such as Commissioning check sheets, ITPs, PID revisions

3. There is a delay in closing some 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.

4. MOD KI012189 covers elimination of wooden pallets for 1.2 tonne AN bag handling. The relevant HIRAC has not been updated to capture this risk reduction measures

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 packages) - Start-up or shutdown procedures - Preventative Maintenance - Equipment Registers - Emergency Plans

Mostly Implemented11. Example reviews




Audit Element: Accident/ Incident Reporting and Investigation



Finding

Events - 2019 Hazard Audit.xlsx

Enablon event ID 2019-00044414

1. Definition is in corporate procedure and Enablon drop downs. Classified by severity actual and potential. Near miss is entered as potential severity (eg 3 serious) and included in reports as severity level - 1 (eg 2)

2. Anyone with Orica logon can enter and initially classify incident ('contributor'), then it is i validated, then goes live

3. Process safety events are defined (definition worked up by Mick Gill - formerly KI but no Global Technical Manager - consistent with industry definitions) and now included as a category in Enablon.

4. LOC will be raised as an environmental impact in Enablon, This includes identofying a particalar chemical from the drop down list, quantity eg event 2019-00044414, 22 March 2019. Can run a query / filter to get all events for a particular material

Check:- incident definition exists- understanding of personnel of incident definition?- near misses included

Fully Implemented1. Definition of incident

Events - 2019 Hazard Audit - Process Safety tag.xlsx

Events - 2019 Hazard Audit.xlsx

Agency notification record doc 0044706

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. All actions from audits and other studies, incident investigations etc entered into Enablon.

4. Actions completed prior to closure of an investigation are not in Enablon action tracking - need to refer to Incident Investigation records

5. Overdue actions- daily report - goes to Site Manager or Group Manager - high focus on this. Very few - KPI shows clear downward trend.

6. To close action must add a comment or attach files - can't leave blank

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 - easy to retrieve. Report for SHES incidents with potentially "serious" or worse incident (excluding Injury /illness category) retrieved since 2016. 11 incidents in this periods (33 if injury/illness included) . Some small leaks - a couple of catalyst tube leaks (natural gas) in Ammonia plant. To be addressed by changeout of tubes - is included in next 2020 shutdown task list. One MDEA leak at ammonia plant (2019-00048726, July 2019) - investigation is occurring . A pattern of items falling from structures - being addressed by structural inspection and refurbishment programme.

2. Incidents reported weekly, monthly by type and severity, KPIs tracked - on dashboards

Are records easily accessible

1. defined in procedures, flowchart for reporting available and also included in ERP. DMS no 2001904. SHES Event manager in EOL generates report and provides records of which authority ('agency notifications') it was sent to

2. One incident with severity 4 - asbestos found in reformer - notified EPA.

Is reporting to external authorities required - when / how/ who

Fully Implemented2. Reporting system (incidents, accidents, near misses, loss of containment)

1. Investigation triggers (based on potential severity), team requirements and competencies are defined in corporate procedures. Collective decision.

2. Methodology is ICAMS for severity 3 and above, 5 Why for lesser severity

Minimum competencies for incident investigation Who should be on the team?

Fully Implemented3. Investigation system (who does team composition, external specialist involvement)

1. Outcomes of incident investigations and action 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)

4. Action learnings - "awareness programme" - typically in monthly meetings eg topic Repairs - reinstating integrity

Outstanding incident investigations or incidents not investigated ?

Fully Implemented4. Follow up and close out of actions arising

1. Yes - eg audit or other actions that require a risk reduction hardware change. Example MOD KI013019 upgrade of neutraliser drain valves initiated by SLI process

Do changes as outcomes of incident investigation make it into Mod system ?

Fully Implemented5. Relationship to change management for actions implemented




Audit Element: Accident/ Incident Reporting and Investigation



Finding

1. Numerous examples of lessons learned from in SHE 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 Implemented6. Communication of lessons learned




Audit Element: Training and Education



Finding

DMS training matrix1. 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 Implemented1. Training philosophy (who, what level, how often) and identification of training needs

Kevin Tutton OSTE competencies.PNG


1. Competency requirement are recognised at operator level eg Tier 1/2 /3. and Tier 4 supervisor. Also 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 Implemented2. Competency requirements


FRONT END PART 3 LU SIGNED.pdf

FRONT END PART 5 LU SIGNED.pdf

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) - start with tasks in plant and work up to panel over several year

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 Implemented3. Training programs (new employees, contractors, refresher for existing employees)


Kevin Tutton OSTE competencies.PNG


1. Training matrix indicates that a lot of required training has not been completed - ie blank / no 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

Is training to personnel up to date and as per training matrix ? Are there KPIs associated with overall training programme?

Fully Implemented4. Measuring performance and effectiveness

1. Combination of hard copy records for each employee (operations personnel) and - now mostly electronic records (Track Easy, licences etc)

Evidence of training and competency (test and assessment results, certificates etc) - all roles (contractors, drivers, employees)

Fully Implemented5. Records management

SOD - 30001031 Production Superintendent position description

6. Observation: It is not explicit in training or position descriptions what level of process knowledge is required for some roles. Clearly define required process specific knowledge for roles such as Shift Superintendent, area process engineer, eg 'Ammonia plant operations101' or equivalent

1. Overall there was good knowledge of site operations, hazards, MHF type activities, incidents reporting requirements, responsibilities with respect to SHE

2. Knowledge of required training is good amongst new operations staff.

3. knowledge of hazards is good, MHF recognised, BOS known about, range of chemical (NH3, Cl2 for water treatment, AN etc) and physical hazards (high pressure, steam) identified by all personnel interviewed

4. May be a gap in process specific knowledge in some roles - not clear what is required knowledge for AN or ammonia process for example for shift super etc. Tends to be self-taught / on the job learning

Knowledge of requirements eg chemical hazards, MHF scenarios, emergencies, reporting requirements

Fully Implemented6. Knowledge within organisation




Audit Element: Emergency Planning and Response



Finding

KIW-1020: KI Emergency Response Plan1. ERP in place. Table of contents indicates this is consistent with HIPAP. Has been reviewed and accepted by FB and Safework as part of previous MHF licence application. Most recent ERP update was Rev 17, 2018.

2. Covers scenarios for all areas on the KI site as well as pipelines to DG wharf

3. Last enacted in a real incident in 2017 (catalyst tube leak at ammonia plant inc ID 2017-00027829)

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 Implemented1. 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 late Sept 2019 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 interviewed appear familiar with requirements and have participated in drills and in some case real events.

2. SHES role covering emergency response vacant for a few months due to retirement. New starter in late Sept 2019

3. All operators are part of ER team (minimum requirement in role), trained in SCBA, confined space rescue, use of fire equipment - fog nozzles, monitors, hoses, extinguishers.

Knowledge of requirements of emergency plan by ops and other personnel

Fully Implemented2. 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 Implemented3. Emergency definition

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. ERP includes:- recent changes such as flares installed by AMI project- identification of Pacific Oils biodiesel facility, - drawings updated to show new Boiler / chemicals location

Changes in surrounding neighbours/ contacts - Changes resulting from MOCsChanges as a result of exercisesChanges in roles / responsibilities

1. Notes from debriefs are kept however suggested actions are not formally prioritised or completion tracked.

Debrief and learnings

Fully Implemented4. Review and Update

5. Observation: As an MHF, the ESIP should also contain Tactical Fire Plans as per FRNSW Fire Safety guideline 'Emergency services information package and tactical fire plans'. Consult with the FRNSW to confirm scope and develop these as part of next MHF / ERP update.

1. Plan developed in coordination with em services and neighbours

2. 12 x role cards for relevant ER team roles (RECEO - located in ECC)

3. Person in Command (PIC) for each Safe House. All operators trained to fill this role

4. Manifest and ESIP at Gate 3 and security gatehouse. Drawings recently updated to show new boiler depot and new substation.

5. SDS in ESIP are up to date

Defined roles & responsibilities for emergencies with offsite impact Providing assistance to emergency services - Offsite actions to mitigate the impact of the accidentESIP required and if so available / appropriately located

1. Not mentioned in ERPMutual Aid provisions

Fully Implemented5. 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 Implemented6. Communications (internal, external, current)




Audit Element: Security and Access Control

Overall Element ComplianceNot reviewed in audit


Finding

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 Not reviewed in audit 3. How are documents, computer software and hardware protected?

1. Not covered - security plan as part of MHF - not reviewed in detail Not reviewed in audit 4. What is the security of material and inventory control?




Audit Element: Auditing and Management Review



Finding

1. Combination of internal and external audits. Actions in Enablon

2. Enablon used for audit frequency and action tracking

3. Hazard Audit implementation plan status last reported to DPE in Sept 2019

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 Implemented1. Types of audits (electrical, process safety, OHS, insurance, hazardous area integrity, workforce inspections)

1. Orica Corporate sets frequency of SHESMS audits Who (and how does the company) establishes the scope of SMS audits and timeframe?

Fully Implemented2. 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 Implemented3. 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 Implemented4. Follow up and close out

1. SHE 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 Implemented5. Feedback and continual improvement




Audit Element: Environmental impacts / pollution potential



Finding

What can end up in stormwater, is containment adequate? Not reviewed in audit 1. Liquid wastes - Stormwater

Containment sufficient for credible fire scenarios?Basis documented?

Not reviewed in audit 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?

Not reviewed in audit 3. Liquid wastes - process areas / spill containment

What are the loads, are they consistent with best practice, could they be reduced?

Not reviewed in audit 4. Liquid wastes - effluent / reduction potential


Not reviewed in audit 5. Solid wastes / reduction potential


Not reviewed in audit 6. Groundwater / soil contamination


Not reviewed in audit 7. Air emissions - odour


Not reviewed in audit 8. Air emissions - eg VOCs, NOX / SOx ? CO2 etc




Audit Element: Environmental Performance Compliance



Finding

Not reviewed in audit 1.




Audit Element: Condition of Consent Compliance



Finding

Annual production.xlsx1. NH3 annual production 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 Implemented1. # 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

2015 Model Shipping Update Results (QRA risk contours)

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:1. AMI - only NH3 pump replacement and No 1 bullet removal to go. Everything else completed 2. New KI Boiler. Construction completed but not yet 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. No new HAZOPS have been carried out for any parts of this project since 2016.

Projects already covered by HAZOPs as follows: - AMI Project .- Site Steam Upgrade Project (New Boiler). The HAZOPs were submitted to and approved by the DPE pre- 2016 .

2. Status of any hazop mod 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 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. No requirement to update this since then

2. The FHA did not include an evaluation of all relevant findings and recommendations from the official investigation report(s), as available, 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. Projects already covered by CSS as follows: 1.CSS AMI Rev C (dated 2 April 2015). 2.CSS Boiler Rev B (dated 15 June 2015). These studies were submitted to and approved by the DPE pre- 2016 .

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.

Fully Implemented3. # 08_0129 Schedule 3 Pre-construction


Independent Hazard Audit Action Plan Update (January – June 2019) (190903 DPIE IHA update.pdf)

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 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

Fully Implemented4. # 08_0129 Schedule 3 Pre-commissioning




Audit Element: Condition of Consent Compliance



Finding

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 ERP in 2018 covers all aspects of project installed to date.

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. SHESMS 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. Spot checks indicate these are consistent with SIL ratings assumed in PHA. Test records available on network

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 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 which is largely completed - only NH3 pump replacement and No 1 bullet removal still to go.

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 the risk; andu) include an implementation schedule with due dates and a person responsible for the implementation of each measure.Note: In the case that the propagation risk from the Project is reduced earlier than anticipated in the EA, and it meets the NSW criteria, this condition will be satisfied and the risk reduction program will not be required.

Fully Implemented5. # 08_0129 Schedule 4 Risk Reduction Program

1. The FHA was last updated in 2015 to reflect the AMI project and also changes in ammonia shipping frequency. No requirement to update this since then. NOTE: The FINAL Operations stage as shown in Appendix B of the DA has not been reached due to postponement of further stages (NAP3/ AN4) of the project .

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 Implemented6. # 08_0129 Schedule 4 Hazard Analysis 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.

Fully Implemented7. # 08_0129 Schedule 4 Further Requirements




Audit Element: Industry guideline compliance (SAFEX)



Finding

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

5. Dedicated area for off spec / dirty product - segregated from main store - typically just dirty. Mixed into WANS. Minimal product there when site inspection done

- Offspec product (from process, spillages or returns)

Fully Implemented1. Section 2 of GPG02 Scope of GPG02

1. SHES MS as per Hazard Audit elements includes all these itemsSMS to include: - Safety policy- Plan Framework- Training - Procedures- Emergency Response

Fully Implemented2. Section 4 of GPG02 Safety Management Systems

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


1. SHES MS as per Hazard Audit elements includes all these itemIncludes:- licences- local regulations- separation distances

3. Section 5 of GPG02 Regulatory Requirements



Orica KI Site FSS Report

Lightning Study AN Bulk & Bag Store Report - Revision 2.docx

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 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)

5. Lightning protection / earhing study has been completed as per AS1768 . Risk found to be acceptable. Two actions and these are in Enablon.

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 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. Wooden pallets have been discontinued for most AN bags

5. Copper - controlled use at KI site, none in AN stores

6. Reactive ground not applicable at KI

7. Redundant combustible building materials have been removed.

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- TGAN stores must not be erected on locations that have

Fully Implemented4. Section 6 of GPG02 Site Design, Construction and Management







Finding

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. - 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.

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- monitors into Bulk store - externally activated

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 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.







Finding

- 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


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). No QRA updates required since 2015

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 Implemented5. 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. - 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 introduction 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, 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

Housekeeping - 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).

Fully Implemented6. Section 8 of GPG02 Operation of Stores







Finding

- 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 have been discontinued for most AN bags

2. Polypropylene bags for AN

3. Shipping containers are steel with wooden floors

- The use of combustible materials (e.g. pallets for storing AN) should be avoided as far as reasonably possible

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

Not reviewed in audit 7. Section 9 and Appendix B of GPG02 Security Requirements

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 Implemented8. 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

This appendix describes the TNT equivalence parameters an frequency approach for including in a QRA

Fully Implemented9. Appendix B of GPG02 Risk Assessment and Consequence Modeling







Finding

2. Average AN Bulk Store inventory used (9200 tonnes, Table AV-5) in consequence assessment as single pile (which it is).




Audit Element: AS4326 Compliance



Finding


1. DPIE 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 storey and ventilated - cross flow and roof vents

(e) Buildings in which ammonium nitrate is stored shall be well ventilated and single storey.

1. No identified water seepage (f) Buildings and structures shall be dry and free from any water seepage through the roof, walls or floor.

1. No identified low points(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 nitrate may collect and be confined.

1. Would be retained in store(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.

1. Store Egress / Exit is clear and unobstructed (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.

1. KI does not use copper materials(m) Exposed copper shall not be used in the store. NOTE: Copper can react with ammonium nitrate to form sensitive explosive compounds.

Fully Implemented1. AS4326 clause 9.3.1 Location, design and construction of stores for ammonium nitrate

1. DIPE 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 Implemented2. 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.

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

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 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;

Fully Implemented3. 9.3.3 Internal combustion engines




Audit Element: AS4326 Compliance



Finding

(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 Applicable4. 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. Pallet use largely eliminated

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 Implemented5. 9.3.5 Operational requirements specific to ammonium nitrate



1. Design standard for AN conveyors covering materials of construction, including FRAS (fire resistant anti-static) belts

2. All AN conveyors have fire suppression systems (fusible bulb as per FSS)

The following requirements and 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.

Fully Implemented6. 9.3.7 Conveyor belts


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. Orica has implemented storage without pallets for AN 1.2 tonne bags. Pallets still in use for export AN bagged material Refer to MOD KI012189

(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 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.

Fully Implemented7. 9.4 SPECIFIC REQUIREMENTS FOR THE STORAGE OF AMMONIUM NITRATE IN PACKAGES AND IBCs


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 Implemented8. 9.5 SPECIFIC REQUIREMENTS FOR THE BULK STORAGE OF SOLID AMMONIUM NITRATE




Audit Element: CSB Investigation into West Texas (recommendations)



Finding

KI Status of Noel Hsu’s recommendations relating to CSB’s West, Texas report




1. Orica KI undertook a self audit against an internally developed summary (by Noel Hsu) of the CSB's West Texas recommendations in 2016 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. There have been no identified changes to this and KI has not revisited the self-assessment.

West Texas report deals with FGAN but TGAN has very similar properties and learnings regarded as applicable.

Recommendation R1 to R4 - deal with regulatory changes in US - not relevant in NSW as MHF regulations, HIPAP planning hazard studies and associated ERP largely covers this

1. AN Bulk Store and Bag Store are non-combustible building materials

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 system

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 FRNSW has reviewed ERP and the FSS and is periodically on site for exercises. ERP is reviewed annually and will be updated as part of MHF license renewal application in 2020 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 knowledge

Fully Implemented1. Recommendations 1 -19 of CSB West Texas Incident Investigation Report




Audit Element: Closeout of 2016 Hazard Audit recommendations



Finding

Safety, Heath and Environment Policy

Actions - DoP Hazard Audit-20092019-6.xlsx

Independent Hazard Audit Action Plan Update (January – June 2019) (190903 DPIE IHA update.pdf)

1. Closed Fully Implemented1. 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. Closed Review against AS1768 completed. 2 resulting actions - included in Enablon

Fully Implemented2. 2. Confirm lightening protection is adequate for AN bulk store and AN bag store


1. Closed QRA update has not been required. Basis is conservative and can be reviewed as part of any further QRA updates

Fully Implemented3. 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. ClosedRedundant combustible building materials have been removed

HIRACs are being updated for AN areas

Fully Implemented4. 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.

Orica KI Site FSS Report 1. Closed

Reviewed against NFPA400 and NFPA13

Fully Implemented5. 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.

Enablon action ID 2017-AP000447511. Closed

2. Reviewed against standards – primarily for hygiene

Fully Implemented6. 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

KOORAGANG ISLAND AMMONIA OPERATIONS HAZARDOUS AREA VERIFICATION DOSSIER Doc no E-10031-HD-0001

1. Closed. Most completed in 2017 shutdown SAP tasks setup for periodic HA equipment inspection maintenance or turnaround tasks set up to address identified issues Closed 2017 / 2018 records available. 2019 scheduled for Oct 2019

Fully Implemented7. 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)

KIW/2601 Fire Water Pump Performance Test

Test records sprinklers and fire pump flow

1. Closed 2017 / 2018 records available. 2019 scheduled for Oct 2019 Fully Implemented8. 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.

Enablon action ID 2017-AP000447551. ClosedENG/10000036395/000/00 explains to responsible engineers how to audit the SI process. SAP DMS records OEL: ENG/10000036393/000/00 details the requirements for SI inspections

Fully Implemented9. 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.

ICI ANZ Automatic extinguishing plant for Eastern Nitrogen Limited Walsh Island.pdf


Test records sprinklers and fire pump flow

1. Closed

Original design basis found and covered in updated FSSDeluge test conducted and records available

Fully Implemented10. 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

HAZCHEM audit - stock holdings - laboratory - 57 cylinder store.pdf

1. Closed No observed oxidisers next Class 2.1 cylinders. Chem Alert report now includes cylinders / lab inventories

Fully Implemented11. 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

MOD KI012189


1. ClosedMOD covers elimination of pallets for AN 1.2 tonne bags

Fully Implemented12. 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)







Finding


1. ClosedTechnical panels in place Updates to Ammonia BOS in progress

Fully Implemented13. 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.


1. Closed Compliance register information is in Enablon (ie tasks) and in OEL for legislative SHE requirements

Fully Implemented14. 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). Orica will ensure that this recommendation is included in the 2019 Hazard Audit Scope. See DMS Doc KIW 2647 for further details

1. Observation: MHF 2020 update process includes creating a tool for showing an overall risk profile for the KI site and also used to show risk reduction over time or effect of removal of safeguards. Confirm progress in next Hazard Audit.

1. OngoingMHF risk assessment updates in preparation for the 2020 submission of the Safety Case. The assessment will include the development of a comparative risk assessment, using Orica corporate risk standard and will enable comparison within the site and also across the other operations within Orica. Process includes MIs as well as other ’Significant Risks’ not associated with Schedule 15 materials

Mostly Implemented15. 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)


1. Ongoing - Quarterly review of prioritisation of periodic hazard study actions (including HIRAC which is a subset of PHS2). Documentation of the above reviews in the KI Risk Register All Reports area

Evidence of implementation of actions to reduce all Level I Hiracs to Level II

Mostly Implemented16. 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. ClosedNumerous procedures to abnormal situations (covering loss of utilities, equipment failure, relief events etc) developed for NH3 plant and operators aware of them

Fully Implemented17. 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)

Orica KI Site FSS Report 1. Closed NFPA13 for AN store,

Fully Implemented18. 18. Observation: The FSS has been updated (Feb 2016) 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. Ongoing Maintenance plans include periodic labelling programmes - being managed by piping team.

Fully Implemented19. 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) Continue to progress equipment labelling in older areas of plant. Orica will ensure that this recommendation is included in the 2019 Hazard Audit Scope. See DMS Doc KIW 2647 for further details

Flowchart for pressure equipment inspection deferral (flowchart)

1. ClosedCapstone used for pressure vessels risk assessment. Deferral process captured in flowchart including authorisation by corporate integrity based on Capstone risk ranking then approval by site responsible engineer. KPI around deferred inspection / statutory PM tasks . Any deferral is signed off and registered.

Fully Implemented20. 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.

Standard isolation sheets (Nitrates)1. Closed Trial was conducted as part of the AN1/NAP1 turnaround in March 2018. A further action has been created (2018-AP0096372) to implement the use of standard isolation sheets in Nitrates following this trial

Fully Implemented21. 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







Finding

for all process isolations.

1. Closed The ability to manually add a modification number to a work order exists in SAP and is currently used.

Fully Implemented22. 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.

KIW-1103-B-PI-08-Pressure_Systems (Critical_Procedural_Control)-8-1960293.pdf

1. Closed Procedure KIW-03701 has been updated to include information / review required when a procedure is a critical control.

Fully Implemented23. 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)

1. Closed -Review carried out in 2019 audit - refer to audit Element 14 for findings

Fully Implemented24. 24. Observation: Organisational change assessment was not reviewed in 2016 audit. Ensure this is covered in 2019 Hazard Audit


Lotus Notes Mods database - see list of mods


1. ClosedKPI has been set up around mods completion -reduced from 310 to 180in Sept. Experienced process engineer allocated to check closeout quality - weekly review.

Fully Implemented25. 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.

KIW-1020: KI Emergency Response Plan1. Closed.Rev 17 ERP contains requirement to track actions in Enablon Actions in Enablon for last few exercises

Fully Implemented26. 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)

Orica KI FW Boosters SFAIRP Report Rev C.pdf

1. Closed. Formal SFAIRP review and CBA conclude insufficient benefit to justify booster upgrade

Fully Implemented27. 28. Check progress on compliance with site firewater booster arrangements against AS2419 in next Hazard Audit (2019)




Audit Element: Closeout of other study actions



Finding

1. 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.

2. No other conditions of consent studies. Various other actions entered in Enablon eg actions from Lightning review of AN stores.

Fully Implemented1. Identify actions from other studies

Document number: 21356-RP-001 Revision: 0 Revision Date: 20-Dec-2019 File name: 21356-RP-001 Rev 0 APPENDIX E

APPENDIX E. SUMMARY OF CLOSEOUT OF 2016 HAZARD AUDIT RECOMMENDATIONS

All 2016 hazard audit recommendations had been entered in Enablon. Records of review and

actions taken and status of each action were available. Refer to Enablon summary report

generated: Actions - DoP Hazard Audit 2016.xls.

All 28 recommendations had been closed with supporting evidence available, or a process has

been put in place and work is ongoing (such as pipe labelling upgrades, development of overall

site risk profile). These are noted as ‘ongoing’ in the table below which summarises the 2016

Hazard Audit recommendation status and evidence of closure.


ID (Enablon) Priority Owner Actual Due Date

2016 ID

Detailed Description 2019 Auditor comments

Evidence

2017-AP00044744

Low Sherree Woodroffe

30/06/19 1 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).

Closed March 2017 SHE policy

2017-AP00044745

Medium Paul Gallagher

15/12/17 2 2. Confirm lightening protection is adequate for AN bulk store and AN bag store

Closed Review against AS1768 completed. 2 resulting actions – included in Enablon


n/a - - 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

Closed QRA update has not been required. Basis is conservative and can be reviewed as part of any further QRA updates

-

2017-AP00044748

Low Paul Hastie 30/06/17 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.

Closed Redundant combustible building materials have been removed HIRACs generally updated for AN area

Site walkaround

2017-AP00044749

Medium Yasmine Vosper

15/12/17 5 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.

Closed Reviewed against NFPA400 and NFPA13

Pinnacle FSS June 2019



2016 ID


Evidence

2017-AP00044751


15/12/17 6 6. Observation: It is not clear what "adequate" ventilation is for the AN storage building. 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

Closed Reviewed against standards – primarily for hygiene

Refer to Enablon closeout details in ID 2017-AP00044751

2017-AP00044753

Medium Sherree Woodroffe

30/06/19 7 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)

Closed. Most completed in 2017 shutdown SAP tasks setup for periodic HA equipment inspection maintenance or turnaround tasks set up to address identified issues

SAP history

2017-AP00044754

Medium Bruce Tolkien

30/06/17 8 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.

Closed 2017 / 2018 records available. 2019 scheduled for Oct 2019

SAP records

2017-AP00044755

Medium Bruce Tolkien

15/12/17 9 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.

Closed ENG/10000036395/000/00 explains to responsible engineers how to audit the SI process OEL: ENG/10000036393/000/00 details the requirements for SI inspections

SAP DMS records



2016 ID


Evidence

2017-AP00044756


15/12/17 10 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

Closed Original design basis found and covered in updated FSS Deluge test conducted and records available

Pinnacle FSS June 2019 ICI ANZ Automatic extinguishing plant for Eastern Nitrogen Limited Walsh Island.pdf KI Fire pump system and sprinkler flow testing results SAP records 2017, 2018

2017-AP00044757


30/09/17 11 11. Confirm that the separation distance between the H2 cylinders and the adjacent oxidizing gas cylinders is adequate, for example meets requirements in AS 4332 The storage and handling of gases in cylinders

Closed No observed oxidizers next Class 2.1 cylinders. Chem Alert report now includes cylinders / lab inventories

Site walkaround HAZCHEM audit - stock holdings - laboratory - 57-cylinder store.pdf

2017-AP00044758

Medium Tim Armitstead

30/04/18 12 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)

Closed MOD covers elimination of pallets for AN 1.2 tonne bags

MOD KI012189 Site walkaround



2016 ID


Evidence

2017-AP00044759


30/06/19 13 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.

Closed Technical panels in place Updates to Ammonia BOS in progress

SMS Rev 2

2017-AP00044759


30/06/19 14 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). Orica will ensure that this recommendation is included in the 2019 Hazard Audit Scope. See DMS Doc KIW 2647 for further details

Closed Compliance register information is in Enablon (ie tasks) and in OEL for legislative SHE requirements

Compliance register Enablon report

2017-AP00044760

Medium Steve Hessel

30/06/18 15 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)

Ongoing MHF risk assessment updates in preparation for the 2020 submission of the Safety Case. The assessment will include the development of a comparative risk assessment, using Orica corporate risk standard and will enable comparison within the site and also across the other operations within Orica. Process includes MIs as well as other ’Significant Risks’ not associated with Schedule 15 materials

Lotus Notes SHE Risk Register



2016 ID


Evidence

2017-AP00044761


30/09/17 16 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.

Ongoing Ongoing - Quarterly review of prioritisation of periodic hazard study actions (including HIRAC which is a subset of PHS2). Documentation of the above reviews in the KI Risk Register All Reports area

Excel summary of status Evidence of implementation of actions to reduce all Level I Hiracs to Level II

2017-AP00044762


30/04/18 17 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)

Closed Numerous procedures to abnormal situations (covering loss of utilities, equipment failure, relief events etc) developed for NH3 plant and operators aware of them

Ammonia plant abnormal operations procedures summary list from OEL

2017-AP00044763


31/12/19 18 18. Observation: The FSS has been updated (Feb 2016) 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

Closed NFPA13 for AN store,

Pinnacle FSS June 2019 ,



2016 ID


Evidence

2017-AP00044764

Low Paul Hastie 30/06/19 19 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) Continue to progress equipment labelling in older areas of plant. Orica will ensure that this recommendation is included in the 2019 Hazard Audit Scope. See DMS Doc KIW 2647 for further details

Ongoing Maintenance plans include periodic labelling programmes – being managed by piping team.

Site walkarounds

2017-AP00044765

Medium Bruce Volkiene

30/06/17 20 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.

Closed Capstone used for pressure vessels risk assessment. Deferral process captured in flowchart including authorisation. KPI around deferred tasks

Flowchart for pressure equipment inspection deferral (flowchart).PDF

2017-AP00044766


30/04/18 21 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.

Closed Trial was conducted as part of the AN1/NAP1 turnaround in March 2018. A further action has been created (2018-AP0096372) to implement the use of standard isolation sheets in Nitrates following this trial

Standard isolation sheets (Nitrates)

2017-AP00044767


30/04/18 22 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.

Closed The ability to manually add a modification number to a work order exists in SAP and is currently used.

Sample WOs



2016 ID


Evidence

2017-AP00044768


15/12/17 23 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)

Closed Procedure KIW-03701 has been updated to include information required when a procedure is a critical control.

Example of critical procedures identified as such

2017-AP00044769

Low Sherree Woodroffe

30/06/19 24 24. Observation: Organisational change assessment was not reviewed in 2016 audit. Ensure this is covered in 2019 Hazard Audit

Closed Review carried out in 2019 audit refer to audit Element 14 for findings

Refer to audit checksheets in Appendix D

2017-AP00044770

Medium Michael Gill 30/09/17 25 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.

Closed KPI has been set up around mods completion. Experienced process engineer allocated to check closeout quality – weekly review.

Mods database KPI

2017-AP00044771


30/09/17 27 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)

Closed. Actions in Enablon for last few exercises

Rev 17 ERP Enablon records

2017-AP00044773

Medium Antony Taylor

31/07/19 28 28. Check progress on compliance with site firewater booster arrangements against AS2419 in next Hazard Audit (2019)

Closed. Formal SFAIRP review and CBA conclude insufficient benefit to justify booster upgrade

Pinnacle report: Orica KI FW Boosters SFAIRP Report Rev C.pdf

Hazard Audit 2019 - Orica

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