See report 'Systemic Investigation into Fuel Contamination'.
The Australian Transport Safety Bureau recommends that Mobil Oil
Australia establish as a part of its management of change process a
mechanism for systematically identifying undesirable outcomes that
should be considered in hazard or risk assessment processes.
As part of its program of continuous improvement and as a result
of the introduction of the enhanced Product Quality Management
System, Altona Refinery has reviewed and enhanced its Management of
Change Procedure. The enhanced Product Quality Management System
provides further procedural protection across the various elements
of product manufacture. In addition, quality mapping at the
refinery has been used to identify those points in the
manufacturing process where changes to the process or equipment may
detrimentally impact on product quality.
The following letter was sent to Mobil on 24 September
2001:
I refer to your letter of 13 July 2001 regarding Mobil's response
to the ATSB's recommendations published in our report Systemic
Investigation into Fuel Contamination.
It is standard practise for the ATSB to review and categorise
responses to recommendations. The Bureau bases its classification
of responses to recommendations on available evidence.
Unfortunately we are unable to close the loop with respect to the
recommendations issued to Mobil Oil Australia earlier this year
until we are satisfied that the enhancements you have mentioned
address the intent of the recommendations and have been
implemented.
Consequently, the ATSB requests that Mobil provide further details
of the nature of the enhancements to which your letter refers and
evidence of implementation.
Responses to recommendations are made public through the Bureau's
Quarterly Summary of Safety Deficiencies report.
Mobil writes in response to the ATSB's letter of 24 September
2001 in which the ATSB indicated it sought more information on the
status of Mobil Altona's actions since the avgas incident in
November 1999.
Following receipt of this letter, Mobil's [name supplied] has had
discussions with yourself and [name supplied] to seek further
clarification on what information the ATSB is seeking.
As you will recall, in July this year Mobil Oil Australia responded
to the ATSB's investigation report titled "Systemic Investigation
into Fuel Contamination". In that response Mobil described some of
the improvement initiatives implemented at its Altona Refinery
which were of relevance to the ATSB recommendations.
In Attachment One to this letter is a table which provides a
breakdown of the major improvement initiatives actions taken at the
Altona refinery that are of relevance to the ATSB investigation
into the avgas incident. The table provides further information on
the nature of the improvement initiatives. In addition, each of the
improvement initiatives has been mapped to the relevant
recommendations in the ATSB investigation report into the avgas
incident. Finally the table documents the status of the
implementation of each of the improvement initiatives.
Mobil is pleased to report that all of these initiatives are now
complete or well progressed.
If you require further information on this matter please contact
[name supplied] on [number supplied].
Attachment 1 Extract
1. Update Unit Operating Boundaries
- The refinery's TDC Operating System alarms when operating
conditions move outside preset limits. Alarms are logged and
require action by operating staff to bring operations back into the
desired range.
- Any actual unit operations that exceed these boundaries will
trigger an automated alarm. Any planned unit operations that exceed
these boundaries will trigger the refinery Management of Change
procedure.
- As part of its program of continuous improvement, Altona Refinery
has reviewed the boundaries for each process unit with a specific
emphasis on product quality related issues, as well as, operational
safety and environmental performance.
- In addition to this review, the refinery is presently developing
an enhanced system (MRAA-SHED-10002 Operating Limits System) which
extends beyond the TDC system, to monitor operations versus a more
broadly defined set of Operating boundaries, and to generate
exception reports. The reports will be reviewed by Operations
personnel and management. The boundaries define the limits for key
operational parameters at which the unit can be operated eg
pressure, temperature, rate etc. The enhanced system will be
operational by March 2002 on a trial basis.
2. Enhance Product Quality System
- The Altona Quality System (MRAA-QAB-10214) has been enhanced and
provides quality assurance for the entire operation from product
development, planning manufacture, feed stock selection, chemical
selection and use, product manufacture, blending, certification and
release to the customer.
- The system demands technical and marketing review/approach of
proposed changes ensuring international experience is taken into
consideration.
- The Quality System is subject to regular local and international
audit with the continuing ISO accreditation providing independent
confirmation of the system health.
3. Employ additional PQ staff
- Mobil created a new permanent Refinery Product Quality Advisor
position and filled it in June 2000.
- As part of the enhancement program for the Altona Quality System,
Altona refinery engaged an ExxonMobil European quality expert with
extensive experience in product quality systems on an 18-month
assignment.
4. Conducted Product Quality Reviews/Audits
- To ensure continuing effectiveness of the Refinery's Product
Quality System a number of Product Quality audits have been
conducted and more are scheduled on an on-going basis.
- Followups arising from these audits are documented and then
tracked in the refinery Corrective Actions Request System
(CARS).
On 10 October 2002, the ATSB sent an email to Mobil that
included the following text:
"As discussed, please find following the ATSB's current
classification of the recommendations issued to Mobil as part of
the Fuel Contamination report. I have also included our thinking on
what we would like to see and/or clarify in order to close the
recommendations that remain open."
Following our meeting on November 11th, Mobil has now finalised
a set of documents that should enable the remaining recommendations
related to Mobil in the Report of Fuel Contamination to be
closed.
The enclosed document set contains all relevant documents discussed
at the meeting on November 11th. As discussed and confirmed by you
these documents will be treated as an Air Safety Record
Investigation Note under the Air Navigation Act.
ATSB Note: The ATSB have assessed the documentation provided by
Mobil and consider that the intent of the recommendation has been
complied with.
