Catalyst for Improving the Environment 

Evaluation Report 

EPA Region 8 Needs to 

Better Manage the 

Risk Management Program for 

Airborne Chemical Releases 

 Report No. 09-P-0130 

 March 30, 2009 

U.S ENVIRONMENTAL PROTECTION AGENCY 

OFFICE OF INSPECTOR GENERAL 
 

Report Contributors: Rick Beusse 

 Bao Chuong 

Jim Hatfield 

Erica Hauck 

 Rebecca Matichuk 

 

Abbreviations 

CAA Clean Air Act 

CFR Code of Federal Regulations 

ECEJ Office of Enforcement, Compliance, and Environmental Justice 

EPA U.S. Environmental Protection Agency 

EPCRA Emergency Planning and Community Right-to-Know Act 

EPR Office of Ecosystems Protection and Remediation 

FY Fiscal Year 

MOU Memorandum of Understanding 

OECA Office of Enforcement and Compliance Assurance 

OEM Office of Emergency Management 

OIG Office of Inspector General 

RMP Risk Management Plan 

SEE Senior Environmental Employment 

Cover photo: Damage from a 2007 flash fire at an RMP-regulated natural gas processing 

facility in EPA Region 8. (EPA Region 8 photo) 
 

 

 09-P-0130 

March 30, 2009

Catalyst for Improving the Environment

Why We Did This Review

The purpose of the Clean Air 

Act (CAA) Risk Management 

Program is to reduce the 

likelihood of airborne 

chemical releases that could 

harm the public, and mitigate 

the consequences of releases 

that do occur. During our 

evaluation of U.S. 

Environmental Protection 

Agency (EPA) implementtation of this program, we 

identified concerns with EPA 

Region 8’s coordination and 

management of the Program 

that require the attention of 

Region 8 management.

Background

Under the CAA Section 112(r) 

Risk Management Program, 

stationary sources that contain 

more than the threshold 

quantity of any of the 

regulated substances on-site in 

a process must implement a 

risk management program. 

Within Region 8, the Office of 

Ecosystems Protection and 

Remediation (EPR) and the 

Office of Enforcement, 

Compliance, and 

Environmental Justice (ECEJ) 

are jointly responsible for 

implementing the Program.

For further information, 

contact our Office of 

Congressional, Public Affairs 

and Management at 

(202) 566-2391.

To view the full report, 

click on the following link: 

www.epa.gov/oig/reports/2009/

20090330-09-P-0130.pdf

EPA Region 8 Needs to Better Manage the Risk 

Management Program for Airborne Chemical Releases

 What We Found

The two Region 8 offices jointly responsible for implementing the CAA 112(r) 

Risk Management Program have not effectively planned or coordinated 

compliance assurance activities. Further, regional operating guidance for the 

Program is inconsistent concerning the roles and responsibilities of each office. 

Consequently, over half of the high-risk facilities have never been audited or 

inspected, while duplicative oversight activities have been performed at lower-risk 

facilities. Further, cases of identified noncompliance remain unresolved. 

Based on criteria such as amount of covered chemicals stored on-site and potential 

population exposed during a worst-case scenario, we identified 61 high-risk 

facilities in Region 8. The Region had never inspected or audited 38 of these 61 

high-risk facilities (62 percent) since the Program’s inception in 1999. 

Cumulatively, these 38 high-risk facilities could potentially impact over one 

million people during a worst-case chemical release. Although 38 high-risk 

facilities had never been audited or inspected, 59 lower-risk facilities received 

duplicative oversight by being both audited and inspected by the Region. 

We reviewed nine cases that EPR referred to ECEJ for possible enforcement 

action because the facilities failed to certify they came into compliance after a 

program audit found noncompliance. ECEJ concluded that no enforcement action 

could be taken and returned the cases. Two of the facilities eventually certified 

they had come into compliance. However, no follow-up actions were taken by 

either office for the remaining seven facilities, and their compliance status has 

been unresolved for over 2 years. Cumulatively, these seven facilities could 

impact over 10,000 people in a worst-case chemical release scenario. Compared 

to other regions, Region 8 has taken fewer CAA Section 112(r)-related 

enforcement actions, and none have been taken at high-risk facilities. 

Region 8 has partnered with North Dakota to gain assistance in oversight activities 

at RMP facilities. Since 2004, North Dakota has assisted Region 8 by conducting 

40 audits at agricultural ammonia facilities. 

 What We Recommended

We recommended that the Regional Administrator develop (1) a strategy for 

implementing the Risk Management Program in Region 8 that defines program 

goals, performance measures, and organizational responsibilities; and (2) an 

oversight process to evaluate the Region’s success in implementing the strategy. 

Region 8 agreed with our findings and recommendations, and has already 

completed the recommended actions. 

U.S. Environmental Protection Agency 

Office of Inspector General 

At a Glance 
 

March 30, 2009 

MEMORANDUM

SUBJECT: EPA Region 8 Needs to Better Manage the Risk Management Program for 

Airborne Chemical Releases 

 Report No. 09-P-0130 

FROM: Wade T. Najjum 

 Assistant Inspector General for Program Evaluation 

TO: Carol A. Rushin 

 Acting Regional Administrator, EPA Region 8 

This is our report on the subject evaluation conducted by the Office of Inspector General (OIG) 

of the U.S. Environmental Protection Agency (EPA). This report contains findings that describe 

the problems the OIG has identified and corrective actions the OIG recommends. This report 

represents the opinion of the OIG and does not necessarily represent the final EPA position. 

Final determinations on matters in this report will be made by EPA managers in accordance with 

established audit resolution procedures. 

The estimated cost of this report – calculated by multiplying the project’s staff days by the 

applicable daily full cost billing rates in effect at the time – is $157,141. 

Action Required 

In accordance with EPA Manual 2750, we are closing this report upon issuance in our tracking 

system since your response to the draft report provided corrective actions that meet the intent of 

the draft report’s recommendations. In accordance with OIG policy, we will periodically follow 

up to determine how well the Agency's corrective actions have addressed the report’s 

recommendations. We have no objections to the further release of this report to the public. 

This report will be available at http://www.epa.gov/oig. 

If you or your staff have any questions regarding this report, please contact me at (202) 566-0832 

or najjum.wade@epa.gov, or Rick Beusse at (919) 541-5747 or beusse.rick@epa.gov. 

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

WASHINGTON, D.C. 20460

OFFICE OF 

INSPECTOR GENERAL
EPA Region 8 Needs to Better Manage the Risk 09-P-0130 

Management Program for Airborne Chemical Releases 

 

Table of Contents 

Purpose........................................................................................................................ 1 

Background ................................................................................................................. 1 

Noteworthy Achievements......................................................................................... 3 

Scope and Methodology............................................................................................. 3 

Results of Review ....................................................................................................... 4 

Conclusions................................................................................................................. 8 

Recommendations...................................................................................................... 8 

Region 8 Comments and OIG Evaluation ................................................................. 8 

Status of Recommendations and Potential Monetary Benefits.............................. 9 

Appendices 

A Details on Scope and Methodology.................................................................. 10 

B Region 8 Response to Draft Report.................................................................. 12 

C Distribution ......................................................................................................... 21 
 09-P-0130 

1 

Purpose 

In November 2007, the Office of the Inspector General began an evaluation of the U.S. 

Environmental Protection Agency’s (EPA’s) implementation of the Clean Air Act (CAA) 

Section 112(r) Risk Management Program. The purpose of the Risk Management Program is to 

reduce the likelihood of airborne chemical releases that could harm the public, and mitigate the 

consequences of releases that do occur. The objectives of our evaluation were to determine 

whether (1) procedures are in place to ensure that facilities subject to the Risk Management 

Program regulations have submitted risk management plans (RMPs), and (2) the inspection 

process provides reasonable assurance that covered facilities comply with Risk Management 

Program requirements. Although we issued our report on EPA’s overall Program performance in 

February 2009,1 we are issuing this separate evaluation report due to specific concerns we 

identified in Region 8. 

 

Background 

In 1990, Congress amended CAA Section 112 to enact a program to prevent releases of certain 

hazardous chemicals and to mitigate the consequences of releases to the surrounding community. 

EPA promulgated the Risk Management Program rule (40 Code of Federal Regulations Part 68) 

in 1996 to meet the requirements of CAA Section 112(r)(7). Under the Program, stationary 

sources that contain more than the threshold quantity of any of 140 regulated substances 

(77 toxic and 63 flammable substances) in a process are required to conduct a worst-case release 

assessment, and to prepare and submit a risk management plan (RMP) to EPA. Facilities were 

required to submit their first RMPs by June 21, 1999, and update them at least every 5 years or 

when on-site regulated substances or processes change. The Program regulations (40 CFR 

68.220) also require implementing agencies to periodically audit facility RMPs and require 

revisions when necessary to ensure compliance with the requirements for RMPs. These audits 

are referred to as 68.220 audits. 

Since very few States and local agencies have requested delegation of the Program, EPA is 

responsible for implementing the Program in most areas. None of the States in Region 8 have 

taken delegation, so the Region is directly responsible for all RMP facilities in the Region. 

EPA’s Office of Emergency Management (OEM) in the Office of Solid Waste and Emergency 

Response is primarily responsible for managing the Program on a national level. OEM provides 

funding to the regions to assist in implementing the Program. Implementation activities include 

conducting audits and inspections, and providing technical assistance, outreach, and training. 

OEM also provides guidance to the regions regarding the Program’s priorities and inspection 

strategies. In 2007, OEM distributed a list of high-risk facilities to the regions to encourage 

more effective use of the Program’s resources and to help the regions better prioritize their 

inspection efforts. However, the regions are not required to inspect these higher-risk facilities 

before lower-risk facilities. Depending on the facility, the population potentially impacted in a 

worst-case release scenario ranges from zero to over 1.7 million for a single facility in Region 8, 

as reported in facility RMPs contained in the RMP National Database. 

 

1 EPA Can Improve Implementation of the Risk Management Program for Airborne Chemical Releases, Report No. 

09-P-0092, February 10, 2009. 
 09-P-0130 

2 

The Office of Enforcement and Compliance Assurance (OECA) sets performance expectations 

for Risk Management Program compliance assurance activities. OECA’s National Program 

Manager Guidance for Fiscal Year (FY) 2009 states that regions should conduct Risk 

Management Program inspections at 5 percent of the total number of regulated facilities in the 

Region each fiscal year, and may include periodic 68.220 audits as part of their compliance 

program. According to OECA and OEM staff, RMP inspections conducted under CAA section 

1142 authority are more comprehensive than 68.220 audits and can result directly in enforcement 

actions. As the Program matured, EPA’s oversight emphasis has moved from 68.220 audits to 

federally-enforceable inspections. OECA includes only on-site inspections – not 68.220 audits – 

in its performance measure for the Risk Management Program, while OEM includes both on-site 

inspections and on-site 68.220 audits in its performance measures. 

Risk Management Program Organization and Responsibilities in Region 8 

In Region 8, two separate offices jointly implement the Risk Management Program under a 

Memorandum of Understanding (MOU) issued in 1997. According to the MOU, the Office of 

Ecosystems Protection and Remediation (EPR) is responsible for conducting Risk Management 

Program audits (i.e., 68.220 audits) and the Office of Enforcement, Compliance, and 

Environmental Justice (ECEJ) is responsible for conducting all Section 112(r) inspections in the 

Region. The 1997 MOU also states that: 

• EPR will coordinate all planned RMP audits with ECEJ; 

• any serious compliance and enforcement-related matters encountered during an RMP 

audit will be discussed as soon as practicable and referred to ECEJ for investigation and 

possible enforcement action; 

• ECEJ will conduct all RMP Section 112(r) inspections; and 

• the Region will develop a protocol for interactions between EPR and ECEJ regarding 

RMP audits and investigations. 

In 2004, Region 8 issued an Implementation Protocol (Interim Final) describing coordination 

activities between the two offices. The Protocol states that: 

• inspections conducted by EPR must always be coordinated with ECEJ; 

• RMP audits conducted by EPR can result in a Preliminary Determination Letter, which 

establishes deadlines for audited facilities to correct deficiencies; 

• facilities missing one or more established deadlines documented in a Preliminary 

Determination Letter should always be referred to ECEJ for enforcement action, and 

when a referral is made, ECEJ and EPR will meet to discuss the best approach for 

addressing the noncompliance; 

 

2

 Section 114 of the CAA provides EPA with the broad authority to inspect facilities for compliance with CAA 

requirements. 
 09-P-0130 

3 

• EPR should coordinate requests and referrals to ECEJ via e-mail or an internal 

memorandum that includes a brief summary of the situation and audit results; and 

• when ECEJ receives a referral from EPR, ECEJ will evaluate the referral and input the 

results of this evaluation into a Coordination Table located on the shared drive. 

Allocation of Risk Management Program Resources in Region 8 

EPR and ECEJ share the Risk Management Program resources provided to the Region from 

Headquarters. OEM provides the Region with funds to implement both the Risk Management 

Program and the Emergency Planning and Community Right-to-Know Act through the same 

account. The Region receives about $150,000 annually in extramural funds to implement both 

programs. These funds are shared by EPR and ECEJ. The amount of funds received by ECEJ 

has increased from $9,000 in FY 2005 to $50,000 in FY 2008. In FY 2007 and FY 2008, EPR 

received an average of slightly more than two-thirds ($104,500/year) and ECEJ received an 

average of almost one-third ($45,500/year) of the extramural funds. 

The Region also receives funding for 2.5 full-time equivalents (FTEs) from OEM for both the 

Risk Management Program and the Emergency Planning and Community Right-to-Know Act. 

According to EPR managers, 2.0 FTEs were assigned to EPR.3

 OEM also funds five Senior 

Environmental Employment (SEE) Program employees in Region 8 to perform activities 

supporting several different programs, including the Risk Management Program. Four of the 

SEE employees are allocated to EPR and one is used by ECEJ to conduct inspections at RMP 

facilities. According to the former RMP Team Lead in EPR, the cumulative amount of time that 

the four SEE employees in EPR spend on Risk Management Program activities during a year is 

approximately equal to one full-time person. The SEE employees’ remaining time is spent on 

other programs. 

Noteworthy Achievements 

Region 8 has partnered with North Dakota to conduct RMP audits of agricultural ammonia 

facilities. In 2004, EPR entered into an MOU with North Dakota’s Departments of Agriculture 

and Insurance, under which the State conducts RMP audits at anhydrous ammonia storage 

facilities. Following the implementation of the MOU, EPR managers and staff told us that the 

State inspectors in North Dakota were trained to conduct audits at agricultural ammonia 

facilities. Although the MOU was not a delegation of authority under the Risk Management 

Program, EPR staff told us that the State has expressed interest in proceeding with delegation of 

the Program for agricultural ammonia facilities. Since 2004, North Dakota has assisted 

Region 8 by conducting 40 audits at RMP facilities. 

Scope and Methodology

For our nationwide evaluation of EPA’s implementation of the Risk Management Program, we 

interviewed staff and managers from EPA’s OEM, OECA, Office of Air and Radiation, 10 EPA 

 

3

 EPR could not account for the remaining 0.5 FTE funded by OEM. ECEJ managers said they did not receive the 

0.5 FTE. The Region had not resolved the allocation and usage of the 0.5 FTE as of November 2008. 
 09-P-0130 

4 

regions, and 4 States with delegation of the Risk Management Program. We issued this report on 

February 10, 2009. As part of the nationwide evaluation, we conducted work in Region 8, where 

we identified several concerns with the Region’s management of the Program. During our review 

of the Program in Region 8, we interviewed EPR and ECEJ staff and managers and reviewed 

guidance, procedures, budget reports, and other materials regarding the implementation of the 

Program by these offices. We obtained lists of audits and inspections completed since the 

inception of the Program from both EPR and ECEJ. We compared the lists of audits and 

inspections completed in Region 8 to the RMP National Database and the lists of high-risk 

facilities to identify facilities that have never been audited or inspected in Region 8. We also used 

the lists provided by EPR and ECEJ to track the referral process and coordination efforts between 

the two offices. We conducted our work from January 2008 to February 2009. Additional 

information on our scope and methodology is in Appendix A. 

Results of Review 

Region 8 has not managed the Risk Management Program efficiently or effectively. Two offices 

in Region 8 – EPR and ECEJ – are tasked with implementing the Program. However, these 

offices have not effectively coordinated their planning and compliance assurance activities. As a 

result, over half of the Region’s 61 high-risk facilities have never been audited or inspected by 

the Region, while 59 lower-risk facilities were both audited and inspected. Further, seven cases 

of noncompliance identified through audits remained unresolved for more than 2 years, and the 

Region has taken a lower number of CAA 112(r)-related enforcement actions than other EPA 

regions. 

EPR and ECEJ Have Not Effectively Coordinated Program Efforts 

EPR and ECEJ have not coordinated activities and planning to best utilize resources and provide 

compliance assurance at RMP facilities. Although the Region has an MOU and an 

Implementation Protocol that outline the two offices’ responsibilities and coordination 

procedures, neither office was consistently following the MOU or Implementation Protocol, and 

the two documents provided inconsistent guidance regarding each office’s roles and 

responsibilities. 

The 2004 Implementation Protocol states that “normal coordination” should occur between EPR 

and ECEJ, and that the two offices will have coordination meetings on an “as needed” basis to 

discuss issues of importance to either or both groups. However, coordination between the two 

offices was not sufficient to effectively manage the Program. EPR and ECEJ did not coordinate 

their compliance assurance activities to ensure that high-risk facilities are inspected or audited. 

Rather, each office planned its activities independent of the other and maintained separate lists 

outlining the facilities they planned to visit. The list of RMP facilities each office planned to 

audit or inspect was posted on the Region’s shared drive so both offices could view the lists. 

However, this was the extent of planning coordination between the two offices. 

The lack of coordination between the two offices continued during our field work. For example, 

in May 2008, EPR began conducting inspections under CAA Section 114 authority without 
 09-P-0130 

5 

informing or coordinating with ECEJ.4 Coordination is particularly necessary when EPR 

conducts inspections because ECEJ may have to take enforcement actions on the deficiencies 

identified during those inspections. However, EPR and ECEJ disagreed on whether EPR staff 

should be conducting RMP inspections, and the MOU and Implementation Protocol contain 

conflicting information regarding responsibility for inspections. Specifically, the MOU states 

that “all Section 112(r) inspections will be conducted by 8ENF-T [ECEJ].” In contrast, the 

Implementation Protocol allows for inspections by EPR, but states that inspections conducted by 

EPR “must always be coordinated” with ECEJ. 

Further, EPR and ECEJ were not coordinating cases referred from EPR to ECEJ for possible 

enforcement action as outlined in the Implementation Protocol. According to the Protocol, EPR 

and ECEJ have shared responsibility to maintain a Coordination Table on the Region’s shared 

drive that tracks the progress and outcome of enforcement referrals. However, this was not 

occurring at the time of our evaluation. 

Majority of Region 8 High-Risk Facilities Not Audited or Inspected 

Program guidance from OECA encourages regions to address public safety concerns by targeting 

RMP inspections based on several risk-related factors. However, Region 8 has duplicated its 

oversight efforts by conducting both audits and inspections at mostly lower-risk facilities, while 

the majority of the high-risk RMP facilities have never been audited or inspected since the 

Program’s inception in 1999. 

Using three separate criteria, we identified 61 high-risk RMP facilities in Region 8.5

 Between 

January 2000 and January 2008, Region 8 conducted audits at 519 facilities, but only 21 of those 

were high-risk facilities. Additionally, Region 8 conducted inspections at 86 RMP facilities, but 

only 9 of those were high-risk facilities. However, 7 of the 9 high-risk facilities inspected by 

ECEJ had previously been audited by EPR. Thus, 23 of the 61 high-risk facilities have been 

audited and/or inspected, while 38 (or 62 percent) have never been audited or inspected (see 

Table 1). Cumulatively, the 38 high-risk facilities that have not been audited or inspected could 

potentially impact over one million people during a worst-case chemical release. 

Table 1: Audits and Inspections at the 61 High-Risk Facilities in Region 8, through January 2008

No. of 

High-Risk 

Facilities 

No. of 

 High-Risk 

Facilities 

Audited 

No. of 

 High-Risk 

Facilities 

Inspected 

After an Audit 

No. of 

 High-Risk 

Facilities 

Inspected 

Only 

No. of 

 High-Risk 

Facilities 

Audited and/or 

Inspected 

No. of 

 High-Risk 

Facilities 

Never Audited 

or Inspected 

61 21 7 2 23 38 

Source: OIG list of high-priority facilities in Region 8 and audit and inspection data provided by Region 8 

 

 

4

 An EPR manager told us in November 2008 that EPR was no longer conducting RMP inspections and would wait 

until EPR and ECEJ jointly developed a strategy for the Program before conducting RMP inspections in the future. 

5

 These 61 facilities appeared on one or more of the following lists: OEM’s list of high-priority facilities; the top 

5 percent of facilities in terms of hazard indices; and facilities that could potentially impact 100,000 people or more 

in a worst-case release scenario. 
 09-P-0130 

6 

Although most high-risk facilities have not been audited or inspected, many lower-risk facilities 

have been both audited and inspected. ECEJ had inspected a total of 86 RMP facilities since the 

inception of the Program, and 65 (or 76 percent) of these were facilities that had previously been 

audited by EPR. In addition, one of the facilities that EPR audited was previously inspected by 

ECEJ. Thus a total of 66 facilities have been both audited and inspected. The majority of these 

66 facilities (59 out of 66, or 89 percent) were lower-risk facilities; i.e., facilities that did not 

appear on any of the three high-risk facility lists discussed earlier. 

In FY 2007, OECA instituted a performance target for each region to inspect 5 percent of its 

RMP facilities per year. This target does not consider whether the facilities are high-risk 

facilities. Although Region 8 was on track to meet this target in FY 2008, 37 of the 39 facilities 

(or 95 percent) that the Region had inspected in FY 2008 were lower-risk facilities.6

 The RMP 

Enforcement Coordinator told us that ECEJ had been focusing inspections on smaller, less 

complex facilities because of the relative inexperience of the inspectors. She also expressed 

concerns that ECEJ may not have sufficient resources to start conducting inspections and taking 

enforcement actions at larger, more complex facilities. 

Accident data suggest that never-inspected high-risk facilities are more than 5 times as likely to 

have an accident as never-inspected lower-risk facilities. The higher accident rate for neverinspected high-risk facilities suggests the need to prioritize inspections based on risk. Without 

procedures in place to prioritize the inspections at these high-risk facilities, Region 8 may not be 

using its resources efficiently to ensure that high-risk facilities are complying with the Risk 

Management Program requirements. As a result, these facilities may not be taking measures to 

operate safely, thus putting the public, employees, and first responders at a higher risk in the case 

of an accident. 

Compliance Status of Some Referred Facilities Remains Unresolved 

The compliance status of seven RMP facilities audited by EPR and then referred to ECEJ 

remained unresolved after more than 2 years. In addition, the case files for some of the referred 

cases we reviewed were incomplete because the files did not include documentation that the 

cases were referred to and/or reviewed by ECEJ or that the compliance status of the facility had 

been resolved. Failure to resolve noncompliance at facilities could increase the risk of an 

accident and public exposure to airborne chemical releases. 

At the beginning of our evaluation, EPR provided us a list of 20 facilities it said it referred to 

ECEJ for enforcement action. However, after discussing these cases with EPR and ECEJ, both 

offices agreed that only 9 of these 20 cases were actually referred to ECEJ. We reviewed files 

for these nine cases to determine what actions ECEJ and EPR took to resolve the noncompliance 

that was the basis for the referral. These nine cases do not necessarily represent the entire 

universe of referred cases. We did not attempt to identify and review the entire universe of 

referred cases from EPR to ECEJ. 

 

6

 The FY 2008 inspection data we obtained from Region 8 only covered the period October 1, 2007, through January 

2008; thus, we did not have inspection data for the full fiscal year. By the end of January 2008, the Region had 

already inspected 4.4 percent of the Region’s RMP universe that year. 
 09-P-0130 

7 

These nine facilities were audited by EPR in August and September 2006 and referred to ECEJ 

in March 2007 for failing to submit a Certificate of Completion after the audit. The Certificate 

of Completion is a document that EPR developed and requires facilities to complete in order to 

certify that they have resolved the deficiencies identified during an audit and subsequently 

described in a Preliminary Determination Letter. The RMP Enforcement Coordinator told us 

that ECEJ was unable to take enforcement actions against facilities that failed to submit a 

Certificate of Completion because it is not a requirement of 40 CFR Part 68. 

In reviewing the RMP case files for these nine facilities, we found that two of the facilities 

submitted their Certificates of Completion late, 3 to 4 months past the due date, while the 

remaining files did not contain a Certificate. Thus, the compliance status at seven of these nine 

facilities remained unresolved. Additionally, the files for these facilities did not contain 

documentation of the facilities’ referral to ECEJ, or correspondence from ECEJ stating that 

ECEJ could not take an enforcement action.7 The RMP Enforcement Coordinator told us that 

she returned the files for these facilities to EPR and told EPR staff she was unable to take 

enforcement action at the facilities. However, there was no documentation of this decision in 

EPR’s case files. The compliance status of these seven facilities has been unresolved for over 2 

years. These facilities have not been inspected or re-audited by ECEJ or EPR, and have not 

received any enforcement action. Cumulatively, these seven unresolved facilities could impact 

over 10,000 people in a worst-case release scenario. 

Although ECEJ determined that they could not take enforcement action against facilities for 

failure to submit Certificates of Completion, the Risk Management Program regulations provide 

a mechanism for enforcing noncompliance identified during an audit. The regulations state that 

after providing the owner of a facility with the opportunity to respond to a Preliminary 

Determination Letter, the implementing agency (Region 8) may prepare a final determination 

letter specifying necessary revisions to a facility’s RMP. Failure to comply with a final 

determination letter is a violation of the Risk Management Program regulations. However, as of 

January 2009, EPR had not used the final determination letter mechanism 

Region 8 Has Lowest Enforcement Rate of All Regions 

A comparison of Region 8’s CAA Section 112(r) enforcement actions with other EPA regions 

suggests a concern with regional enforcement of the Program. Region 8 has taken fewer CAA 

112(r)-related enforcement actions than other regions.8

 As of January 2008, Region 8 had taken 

only 12 such enforcement actions since FY 2001, which is 2.3 to 44 times fewer enforcement 

actions than other regions. The number of actions taken by other EPA regions ranged from 28 to 

532. Further, none of the 12 enforcement actions in Region 8 were at high-risk facilities. Region 

8 also had the lowest number of enforcement actions in comparison to number of RMP facilities. 

 

7

 EPR provided us with an e-mail documenting the referral of these nine facilities to ECEJ in March 2007. 

However, neither this e-mail nor other documentation of the referral to ECEJ were included in the case files for 

these facilities. 

8

 Our analysis of enforcement actions includes all CAA Section 112(r)-related enforcement actions, as identified in 

the Integrated Compliance Information System database. Section 112(r) includes both the General Duty Clause and 

the Risk Management Program. Thus, some of the enforcement actions included in our analysis may be actions 

taken for violation of the General Duty Clause. 
 09-P-0130 

8 

Based on the RMP universe as of November 29, 2007, the ratio of enforcement actions per RMP 

facility was 0.01 (12 actions/890 facilities) in Region 8. This is less than the ratio for the other 

regions, which ranged from 0.02 to 0.23. In our view, the issues described in this report 

negatively impacted the Region’s enforcement of the Program. 

Conclusions 

Region 8 has not established effective processes and controls to provide reasonable assurance 

that resources are used effectively to accomplish the Risk Management Program’s goals. The 

two offices tasked with implementing the Risk Management Program have not consistently 

followed operating guidance, which has resulted in an inefficient use of resources and 

insufficient coverage of RMP facilities. In addition, the Region’s two existing guidance 

documents for the Program contain contradictory language on which offices should be 

conducting RMP inspections. Consequently, most of the Region’s high-risk facilities have not 

been audited or inspected, while duplicative oversight activities have been performed at many 

lower-risk facilities. Further, the compliance status of seven facilities identified as noncompliant 

has remained unresolved for over 2 years. Some case files were incomplete and lacked 

documentation regarding their referral for enforcement and their compliance status. Region 8 

has not clarified its guidance regarding how the two offices will coordinate inspection and 

enforcement activities, nor assigned responsibility and accountability for the Program. 

Recommendations

We recommend that the Regional Administrator, EPA Region 8: 

1. Develop a strategy for administering the Risk Management Program that defines 

program goals, performance measures, organizational responsibilities, documentation 

requirements, and required coordination between offices. 

2. Develop an oversight process to evaluate the Region’s success in implementing the 

Program strategy. 

Region 8 Comments and OIG Evaluation 

Region 8 agreed with our findings and recommendations. Additionally, in response to our draft 

report, Region 8 has already completed the recommended actions. The Region developed an 

Implementation Strategy that addressed Program goals, performance measures, organizational 

responsibilities, coordination, and Program resources. In addition, it includes an oversight 

process to evaluate EPR’s and ECEJ’s success in implementing the Strategy. Thus, both 

recommendations are being “closed” in our tracking system upon issuance of this final report. 

In accordance with EPA Manual 2750, the Region is responsible for recording completion of this 

corrective action in the Management Audit Tracking System. 

Appendix B contains the full text of Region 8’s response to the draft report, including its Risk 

Management Program Implementation Strategy.
 09-P-0130 

9

Status of Recommendations and 

Potential Monetary Benefits 

RECOMMENDATIONS 

POTENTIAL MONETARY 

BENEFITS (in $000s) 

Rec. 

No. 

Page 

No. Subject Status1 Action Official 

Completion 

Date 

Claimed 

Amount 

Agreed To 

Amount 

1 8 Develop a strategy for administering the Risk 

Management Program that defines program goals, 

performance measures, organizational 

responsibilities, documentation requirements, and 

required coordination between offices. 

 

C Regional Administrator, 

Region 8 

3/18/2009 

2 8 Develop an oversight process to evaluate the 

Region’s success in implementing the Program 

strategy. 

C Regional Administrator, 

Region 8 

3/18/2009 

 

 

 

 

 

1 O = recommendation is open with agreed-to corrective actions pending 

C = recommendation is closed with all agreed-to actions completed 

U = recommendation is undecided with resolution efforts in progress 
 09-P-0130 

10

Appendix A 

Details on Scope and Methodology 

For our nationwide evaluation of EPA’s implementation of the Risk Management 

Program, we interviewed staff and managers from EPA’s OEM, OECA, Office of Air 

and Radiation, 10 EPA regions, and 4 States with delegation of the Risk Management 

Program. We also obtained data from all EPA regions and the 9 States and 5 local 

agencies with delegation of the Risk Management Program. The EPA OIG had not 

conducted any prior audits or evaluations of the CAA 112(r) Risk Management Program 

in Region 8 before the nationwide evaluation. The results of our nationwide evaluation 

are included in the report, EPA Can Improve Implementation of the Risk Management 

Program for Airborne Chemical Releases (Report No. 09-P-0092, February 10, 2009). 

In order to determine whether procedures were in place in Region 8 to provide reasonable 

assurance that all facilities subject to the Program regulations had submitted RMPs 

(Objective 1), we reviewed the 2006 Toxics Release Inventory to identify facilities in 

Colorado that reported having on-site quantities of ammonia, chlorine, or hydrogen 

fluoride at levels well above the Risk Management Program thresholds. We then 

reviewed the RMP National Database (current as of November 29, 2007) to identify 

facilities that had not submitted RMPs or had not re-filed an RMP within its 5-year 

anniversary date. We met with Region 8 staff to discuss whether these facilities may be 

subject to Program requirements. 

To determine whether the inspection process provided reasonable assurance that covered 

facilities in Region 8 comply with Risk Management Program requirements (Objective 

2), we obtained lists of audits and inspections completed since the inception of the 

Program in 1999 from both EPR and ECEJ.9

 We used these lists to identify facilities that 

had never been audited/inspected. We also compared the lists of audited/inspected 

facilities to three lists of high-risk facilities. The three lists we used included: 

• OEM’s lists of high-risk facilities (Tier 1 and Tier 2 facilities),10 

• facilities that could impact 100,000 people or more in a worst-case release 

scenario, and 

• facilities with the highest 5 percent of hazard indices in their respective 

implementing agency. 

 

9

 The inspection and audit data we obtained from EPR and ECEJ went through January 2008. However, in 

our nationwide evaluation of the Risk Management Program, we used a cut-off date of December 31, 2007, 

for all audit and inspection analyses. Thus, the inspection and audit figures for Region 8 in this evaluation 

report may differ slightly from those in our nationwide Risk Management Program report. 

10 OEM’s criteria for identifying high-risk facilities included the population impacted in a worst-case 

release scenario, the amount of chemical held in a process above the regulatory threshold quantity, and the 

worst-case release scenario endpoint distance. OEM divided its list into two tiers, with Tier 1 facilities 

representing a higher inspection priority than the Tier 2 facilities. 
 09-P-0130 

11

The hazard index of each facility was calculated using a formula11 developed by the 

Wharton School of the University of Pennsylvania. We used these three lists as OIG’s 

criteria for identifying RMP facilities that are high-risk facilities. We interviewed EPR 

and ECEJ staff and managers and reviewed guidance, procedures, budget reports, and 

other materials regarding the implementation of the Program by these offices. In order to 

determine the number of 112(r)-related enforcement actions for Region 8 and the other 

regions, we searched the Integrated Compliance Information System database for all 

enforcement actions from FY 2001 to January 2008 that listed CAA 112(r) as the primary 

law and section. 

We conducted our evaluation of EPA’s implementation of the Risk Management Program 

in accordance with generally accepted government auditing standards. Those standards 

require that we obtain sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions. During our evaluation we identified concerns with Region 8’s 

management of the Risk Management Program. We believe the evidence obtained 

provides a reasonable basis for our findings and conclusions based on our objectives. 

 

 

11 The Wharton School’s hazard index is defined as “the sum over all chemicals of log2 (maximum quantity 

of inventory on-site/threshold), or, alternatively, as the number of chemicals times log2 of the geometric 

mean of the maximum-to-threshold quantity ratio.” 
 09-P-0130 

12

Appendix B 

Region 8 Response to Draft Report 

March 19, 2009 

MEMORANDUM

SUBJECT: EPA Region 8 Response to OIG Draft Evaluation Report, “EPA Region 8 

Needs to Better Manage the Risk Management Program for Airborne 

Chemical Releases” 

FROM: Carol Rushin 

Acting Regional Administrator 

TO: Wade T. Najjum 

Assistant Inspector General 

 Office of Program Evaluation 

Office of Inspector General 

 Thank you for the opportunity to review and comment on the draft evaluation report 

titled, “EPA Region 8 Needs to Better Manage the Risk Management Program for Airborne 

Chemical Releases,” Project Number OPE-FY08-0001. The report focuses on improving 

the implementation of the Clean Air Act Risk Management Program in Region 8, and 

includes recommendations. 

 As a whole, Region 8 agrees with the findings and recommendations as outlined in 

the report. Since October 2008, both offices responsible for implementing the Risk 

Management Program have worked closely towards resolution of issues outlined in the draft 

report. We are committed to effectively managing our resources, planning and coordinating 

compliance activities and clarifying the roles and responsibilities of both offices. We will 

follow-up with the appropriate action at the seven facilities identified in the draft report as 

being unresolved. In addition, we will increase inspection and enforcement activities at 

high-risk facilities as defined by OECA and OEM. Below is our specific response to each of 

the recommendations. 

Recommendation number 1: Develop a strategy for implementing the Risk Management 

Program in Region 8 that defines program goals, performance measures, and organizational 

responsibilities. 

 

- Region 8 concurs with this recommendation. As mentioned above, the two offices 

within Region 8 have worked closely the past several months to clarify the 

organizational responsibilities and to properly align resources that will increase 

inspection and enforcement activities at high-risk facilities. As a result of this 

effort, we have finalized a strategy (Attachment) that defines program goals, 
 09-P-0130 

13

performance measures, and organizational responsibilities. In addition, the 

strategy includes outreach and inspection strategies and standard operating 

procedures for sharing information between offices and associated recordkeeping. 

The inspection strategy is based on the specific risk-related factors encompassed in 

OSWER and OECA’s jointly revised National Program Manager’s guidance. 

These factors will be considered in deciding which facilities will be included in the 

annual inspection strategy. 

Recommendation number 2: Develop an oversight process to evaluate the Region’s success 

in implementing the Program strategy. 

- The strategy also includes an oversight process to ensure successful 

implementation of the program strategy. End-of-year reviews will be conducted 

by management in the individual offices to assess progress over the past year and 

modify approaches for program implementation as needed. EPR will prepare an 

end-of-year report on all outreach and training activities for the CAA 112(r) 

program and report to management on the activities. ECEJ oversight of the 

program will be based on an end-of-year review of all inspection files. The review 

will be conducted by ECEJ management and the inspection team and will include 

an accounting of the high-risk facilities inspected and evaluation of the findings. 

Based on the findings, the enforcement team will formulate an approach for the 

upcoming year to ensure effective inspection targeting. 

- Each office will maintain records for the information forwarded from one office to 

the next. An annual summary of the records will be reviewed between the offices 

and shared with management in both offices. 

 Region 8 feels confident that the above described measures concurrent with the 

realignment of resources and clear delineation of duties across offices will resolve the issues 

identified in the February 20, 2009 Draft OIG Evaluation Report. 

 Again, we appreciate the opportunity to review and comment on this Report. If you 

have any questions or comments, the person most knowledgeable about this report is Cindy 

Reynolds, Director of the Air and Toxics Technical Enforcement Program. She can be 

reached at (303) 312-6206. 

Attachment 
 09-P-0130 

14

EPA REGION 8 

CAA 112(R)/RISK MANAGEMENT PROGRAM 

IMPLEMENTATION STRATEGY

March 18, 2009 

I. INTRODUCTION

In November 2007, the Office of the Inspector General (OIG) began an evaluation of the 

EPA’s national CAA 112(r) program. The objectives of the OIG review were to 

determine whether: 

• Procedures are in place to provide reasonable assurance that all facilities subject 

to the program have submitted risk management plans; and 

• The inspection process provides reasonable assurance that covered facilities 

comply with the risk management program requirements. 

During the evaluation, the OIG identified concerns with Region 8’s program and issued a 

separate report in February 2009 to address these concerns. This report (“EPA Region 8 

Needs to Better Manage the Risk Management Program for Airborne Chemical 

Releases”) identified areas of concern and recommended a strategy be developed to 

address program goals, performance measures, and organizational responsibilities. The 

report also recommended an oversight process be developed to evaluate Region 8’s 

implementation of the strategy. This strategy addresses the OIG recommendations and 

replaces the Implementation Protocol for Coordination of Efforts between the Technical 

Enforcement Program and the Preparedness and Prevention Team for implementation of 

the CAA 112(r) program. 

II. PROGRAM GOALS

EPR and ECEJ have jointly developed the following goals for the CAA 112(r) program: 

• Implement the CAA 112(r) program consistent with national program guidance, 

meet performance measures, and reduce accident risk at chemical facilities in 

Region 8; 

• Provide a framework that delineates responsibilities across EPR and ECEJ for 

jointly implementing the program; 

• Provide a mechanism for forwarding incoming information to the appropriate 

office to ensure seamless implementation; and 

• Provide a mechanism for recordkeeping to allow for individual program oversight 

of the program’s implementation. 
 09-P-0130 

15

III. PERFORMANCE MEASURES

Performance measures for the CAA 112(r) program are defined in EPA’s Annual 

Commit System (ACS). These two measures are: 

• CH2 – Number of risk management plan audits and inspections completed; and 

• CAA11 - Conduct inspections at 5% of the total number of facilities in the region 

required to submit RMPs. Of these inspections, 10% must be conducted at highrisk facilities. These inspections at high-risk facilities must also include an 

evaluation of compliance with applicable EPCRA and CERLA requirements. 

IV. ORGANIZATIONAL RESPONSIBILTIES 

The division of responsibility between ECEJ and EPR ensures that there is not overlap in 

the individual responsibilities of the two offices. EPR will interface with industry while 

delivering outreach in group forums such as workshops and conferences. ECEJ will 

interface directly with regulated industry during inspections and investigations. EPR 

developed a strategy for conducting outreach (Attachment 1) and ECEJ developed a 

strategy for inspection activities (Attachment 2). 

The following provides a summary of the activities for the individual offices: 

EPR

• Provide outreach for States, locals, industry on EPA software programs (e.g., Tier 

II submit, RMP Submit); 

• Provide outreach at SERC, LEPC and TERC meetings; 

• Provide outreach to industry as needed on requirements of EPCRA, CERCLA 103 

and RMP; 

• Conduct cleanup and maintenance of OEM’s RMP database; 

• Work with States to encourage RMP program assumption; 

• Identify industrial sectors for outreach; and 

• Identify potential non-filers through database reviews and local groups (fire 

departments, SERCs and LEPCs) and forward to ECEJ. 
 09-P-0130 

16

EPR will develop an outreach plan that incorporates OEM priorities and guidance and 

meets the Region’s overall implementation of the program as outlined in Attachment 1. 

ECEJ

• Conduct inspections and investigations to evaluate compliance with EPCRA, 

CERCLA 103, RMP and GDC; 

• Develop enforcement actions as appropriate; 

• Respond to State and local requests regarding specific facility compliance; 

• Evaluate the NRC spill log to determine possible noncompliance with CERCLA 

103, EPCRA and RMP; 

• Identify RMP non-reporters during EPCRA inspections and CERCLA 103 

investigations; and 

• Conduct enforcement initiatives in industry sectors when noncompliant trends are 

found. 

OECA and OEM jointly created inspection priorities in the FY2010 NPM guidance. 

ECEJ will create an inspection strategy which encompasses these priorities as outlined in 

Attachment 2. 

V. PROGRAM COORDINATION

A Standard Operating Procedure has been developed (Attachment 3) that addresses how 

information will be forwarded between ECEJ and EPR regarding the CAA 112(r) and 

EPCRA programs. 

POINTS OF CONTACTS: The contact in ECEJ is the Enforcement Coordinator for 

RMP/EPCRA/CERCLA 103 program. The contact in EPR is the RMP Coordinator. 

COORDINATION MEETINGS: On a quarterly basis, EPR and ECEJ will meet to 

discuss any pertinent coordination issues. These meetings will provide the opportunity 

for offices to share information of mutual interest, review any information forwarded 

between the offices, and share outreach and inspection results. 

VI. RESOURCES

Prior to the 1995 reorganization, the emergency preparedness program and related 

enforcement activities fell into the Emergency Response Branch. Funding and resources 

are provided by the OEM in OSWER. When Region 8 reorganized, compliance 

monitoring and enforcement responsibility for these programs was placed in ECEJ. 
 09-P-0130 

17

After detailed review and discussions of the division of responsibilities, Region 8 has realigned resources as follows: 

PROGRAM 

 & FUNDING

EPR ECEJ 

FTE EXTRAMURAL FTE EXTRAMURAL 

EPM

0.5 2.0 $150K 

SUPERFUND 

PREPAREDNESS 2.0 $160K 

SEEs 3.0 2.0 

 (Note: this redistribution does not currently alter the FTE ceiling of either office.) 

VII. OVERSIGHT

EPR will prepare an end-of-year report on all outreach and training activities for the CAA 

112(r) program and report to management on the activities. 

ECEJ oversight of the program will be based on an end-of-year review of all inspection 

files. The review will be conducted by ECEJ management and the inspection team and 

will include an accounting of the high-risk facilities inspected and evaluation of the 

findings. Based on the findings, the team will formulate an approach for the upcoming 

year to ensure effective inspection targeting. 

Each office will maintain records for the information forwarded from one office to the 

next. The mechanism for this recordkeeping is outlined in Attachment 3. An annual 

summary of the records will be reviewed between the offices and shared with 

management in both offices. 

ATTACHMENTS:

1 - OUTREACH STRATEGY 

2 - INSPECTION STRATEGY 

3 - SOP FOR FORWARDING INFORMATION BETWEEN OFFICES AND 

ASSOCIATED RECORDKEEPING 
 09-P-0130 

18

Attachment 1 

OUTREACH STRATEGY 

EPR will perform outreach activities to the regulated community on the requirements of 

the Risk Management Program (RMP) to enhance the overall safety at facilities and the 

general public. 

EPR will use staff, SEE personnel, and contractors to provide general outreach on the 

RMP to emergency planners and responders by attending and providing program 

information at SERC, TERC and LEPC meetings. When specific industry groups are 

identified or request RMP outreach activities, EPR will take appropriate actions to insure 

the needs of these groups are met. 

EPR will develop outreach materials to address specific needs related to the RMP 

program and present these materials to appropriate emergency planning groups or 

industry sectors or facilities. An example of such a need is the current shift from paper or 

floppy disks to electronic submittal using RMP e*Submit software for re-submittal of 

RMP data. As other program changes, court decisions, or regulatory interpretations 

dictate, EPR will develop and present other outreach materials to assist the public in 

understanding the requirements of the program. 

If there is an industry segment or category that is found to present safety elevated risks of 

the release of a covered chemical, outreach activities may be developed and made 

available in an effort to abate the risks and improve public safety. 
 09-P-0130 

19

Attachment 2 

INSPECTION STRATEGY FOR THE RMP PROGRAM 

ECEJ’s annual inspection strategy will based on a table of high risk inspection sites 

considering the following factors identified in OECA’s and OSWER’s FY2010 NPM 

guidance: 

 Facilities whose reported RMP worst-case scenario population exceeds 100,000 

people; 

 Facilities holding any RMP-regulated substance on site in an amount more than 10,000 

times the RMP threshold quantity for the substance; 

 Facilities whose reported RMP worst-case scenario endpoint distance equals or 

exceeds 25 miles; 

 Any RMP facility with a hazard index greater than or equal to 25; 

 Facilities that have had one or more significant accidental releases within the previous 

five years; and 

 Other facilities where information possessed by the Regional office indicates that the 

facility may be high-risk. 

• On an as needed basis, modifications to the strategy will be made if chemical 

events occur at RMP reporting facilities and an immediate investigation/ 

inspection is warranted. 

• ECEJ will conduct a minimum of 10% of the total RMP inspections at high-risk 

facilities consistent with the OEM and OECA’s national program guidance for the 

RMP program. 

• Additional inspections will be based on geographic opportunity while conducting 

RMP inspections throughout the Region’s six states. These inspections will 

include non-reporting facilities that may meet the RMP reporting criteria. 

• ECEJ is also responsible for the NPM measure for TRI non-reporter and data 

quality inspections. Concurrent with these inspections, compliance with both 

CAA 112r’s RMP and GDC will be evaluated. 
 09-P-0130 

20

Attachment 3 

STANDARD OPERATING PROCEDURES FOR 

FORWARDING INFORMATION BETWEEN ECEJ AND EPR 

AND ASSOCIATED RECORDKEEPING 

PURPOSE 

This SOP defines the process by which information will be forwarded to the appropriate 

office. This will ensure that information coming into Region 8 will be promptly 

redirected as necessary. 

PROCESS FOR TRANSMITTING INFORMATION 

There are occasions in which information will come into one office that must be 

redirected based on the delineation of tasks. 

If a call comes into voice mail, the voice mail message will be forwarded to the 

appropriate office. Telephone conversations will be summarized and relayed via email to 

the appropriate office. Hardcopy information will be hand delivered, routed by 

interoffice mail, or scanned and transmitted via email. When hardcopy information is sent 

by interoffice mail, an email will follow to confirm transmittal of the information. 

In response to receipt of information transmitted by EPR, ECEJ will complete a tracking 

form that will describe the nature of the information and the subsequent review by ECEJ. 

The completed tracking form will be attached to the corresponding email with the records 

being maintained in a three ring notebook. 

EPR will keep a log of both incoming and outgoing information. 

During quarterly meetings, the teams can discuss specific topics of interest that arise from 

the exchange of information. 

POINTS OF CONTACTS 

ECEJ, Enforcement Coordinator for RMP/EPCRA/CERCLA 103 program 

EPR, RMP Coordinator 
 09-P-0130 

21

Appendix C 

Distribution

Office of the Administrator 

Acting Regional Administrator, Region 8 

Acting Assistant Administrator for Solid Waste and Emergency Response 

Acting Assistant Administrator for Enforcement and Compliance Assurance 

Acting Assistant Administrator for Air and Radiation 

Assistant Regional Administrator, Office of Ecosystems Protection and Remediation, 

 Region 8 

Assistant Regional Administrator, Office of Enforcement, Compliance and 

 Environmental Justice, Region 8 

Director, Office of Emergency Management, Office of Solid Waste and 

 Emergency Response 

Acting General Counsel 

Acting Associate Administrator for Congressional and Intergovernmental Relations 

Acting Associate Administrator for Public Affairs 

Audit Follow-up Coordinator, Region 8 

Acting Inspector General