Recommendation R20000119

Recommendation issued to: Mobil Oil Australia Pty Ltd

Recommendation details
Output No: R20000119
Date issued: 30 March 2001
Safety action status:

See report 'Systemic Investigation into Fuel Contamination'.

Output text

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.

Initial response
Date issued: 18 July 2001
Response from: Mobil Oil Australia Pty Ltd
Action status: Open
Response text:

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.

ATSB response:

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.

Further correspondence
Date issued: 24 December 2001
Response from: Mobil Oil Australia Pty Ltd
Response status: Open
Response text:

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).

ATSB comment:

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."

Further correspondence
Date issued: 09 December 2002
Response from: Mobil Oil Australia Pty Ltd
Response status: Closed - Accepted
Response text:

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.

Last update 05 April 2012