INSTRUCTOR GUIDE: USING

CHEMICAL SAFETY BOARD

REPORTS AND VIDEOS
A RESOURCE FOR DEVELOPING CASE STUDIES TO
USE IN HEALTH AND SAFETY TRAINING
Prepared By: Gail Bateson and Rocelyn de Leon-Minch with Linda Delp
www.losh.ucla.edu
Table of Contents Introduction to the Guide
This Instructor Guide is an annotated tool for facilitators that includes a
Introduction to this Guide 2 wealth of resources available from the U.S. Chemical Safety and
Hazard Investigation Board (CSB). This Guide and other resources can
About the CSB and its materials 3
be used in worker training programs to encourage discussion about
ways to prevent the fatalities, injuries, illness, or hazardous situations
Suggestions for Using CSB Videos & Materials to train and 4 investigated by the CSB.
inform workers
The Guide is organized into two sections. Section one is organized
around special topics that are a part of process safety management,
Tips When Developing and Using CSB Materials in Training 5
drawing common themes from multiple investigations. Section two is
organized by location; it summarizes key information from incident
Guide to CSB Videos and Materials: investigations at one chemical plant and eight refineries located
throughout the U.S. Each major incident investigation typically covers
I. CSB Sources Categorized by Special Topic 7 multiple issues.
• Inherently Safety Design & Hierarchy of Hazard Under the guidance of an instructor, workers in a class can use
Control Analysis (ISD & HCA) materials in this guide to discuss underlying causes of chemical and
• Safety Culture refinery incidents as well as recommendations from CSB
• Hot Work investigations. Possible discussion questions for workers are provided.
• Management of Change (MOC)
• Emergency Response & Stop Work Authority
Additional Resources
II. CSB Sources Categorized by Geographic Location 15 In addition to this Guide, UCLA LOSH collaborated with the USW to
1. ExxonMobil Refinery, Baton Rouge, LA (2016) develop a series of videos highlighting California’s Process Safety
2. ExxonMobil Refinery, Torrance, CA (2015) Management Standard for refineries:
3. Delaware City Refining Company, Delaware City, DE
(2015) • “Process Safety Management: The Fight for Workers’ Lives” is a
4. Tesoro Avon Refinery, Martinez, CA (2014) compelling 12 minute video that illustrates refinery explosions and
5. Chevron Refinery, Richmond, CA (2012) the coalition that came together to protect workers and
6. Tesoro Refinery, Anacortes, WA (2010) surrounding communities.
7. BP America Refinery, Texas City, TX (2005) • Three 6 min videos highlight key aspects of the Cal/OSHA PSM
8. Tosco Avon Refinery, Martinez, CA (1999) standard:
9. Phillips 66 Houston Chemical Plant Complex, 1) What is PSM?
Pasadena, TX (1989) 2) Employee Participation
3) Management of Change/Management of Organizational Change.
• The United Steelworkers also has materials available at:
www.usw.org/
 Instructor Guide for Use of Chemical Safety Board (CSB) Reports and Videos

About the Chemical Safety What types of CSB materials are available?

Board • CSB Investigation Reports – include specific safety

recommendations from major incidents. The reports from the Chevron 2012
fire are a good example of this.
The Chemical Safety and Hazard Investigation Board (CSB) conducts
investigations following major industrial chemical incidents and posts • CSB Case Studies – discuss themes that emerge from multiple
detailed information on their website, www.csb.gov. investigations.

CSB investigations look for the underlying causes of major incidents • CSB Safety Bulletins – combine information from incidents with
and recommend changes in management safety systems to prevent similar themes or root causes into an accessible bulletin.
future incidents. While CSB primarily focuses on improving the work • Safety Videos – most use animation to help visualize what happened
environment and organization, it may also recommend changes to in major incidents. Viewing the video before reading the longer reports can
regulatory agencies and industrial trade associations. This approach help determine if a report can be adapted into a useful case study.
is much broader than traditional safety programs that narrowly focus
on tracking and reducing individual worker injury rates. CSB now posts • Press Releases – summarize the key findings and recommendations
from investigations.
its videos at www.youtube.com/user/USCSB.
Documents describing completed and ongoing CSB investigations can Do not overlook potentially useful charts and summary documents
be found at www.csb.gov/investigations. Links to some videos may found in the appendices of individual investigations as these often
also be found on the CSB website. cover a common theme from multiple incidents.

The CSB report’s executive summary, key findings and

recommendations, and timelines of incidents provide useful Who are potential audiences of CSB videos &
information for case studies to be used in training programs. materials?
Additional technical information can be useful for PSM
representatives and others who want to apply lessons learned to their These materials are a rich resource for developing case studies to use
workplace. in training workers, particularly those employed in industries with the
potential for catastrophic fires, explosions, and chemical releases.
What types of facilities does the CSB investigate? Given the offsite consequences of many incidents, CSB case
materials can be adapted to train potentially affected community
In addition to oil refinery and chemical plant toxic releases, fires, and
members or local emergency response personnel.
explosions, the CSB investigates other facilities including:
PSM representatives can also use the information from CSB reports
• Pharmaceutical plants
to improve conditions at their refineries.
• Paper and pulp mills
• Food processing plants
• Metal processing plants
• Gas wells and gas plants
• Chlorine repackaging facilities
• Fertilizer distribution and storage facilities
 Instructor Guide for Use of Chemical Safety Board (CSB) Reports and Videos

Suggestions for Using CSB WHAT IS THE U.S.

Videos and Materials to CHEMICAL SAFETY BOARD?
Train and Inform Workers The CSB is an independent federal agency charged with
investigating industrial chemical accidents.
CSB videos and associated materials can be used in a variety of ways, Headquartered in Washington, DC, the CSB’s mission is
depending on the amount of time available for teaching. to “drive chemical safety change through independent
investigation to protect people and the environment.” Its
These include:
mission is similar to other federal agencies that
• As ice breakers: Begin a safety class or meeting with a short investigate transportation incidents.
video clip to get the attention of participants and introduce
specific topics. The CSB conducts root cause investigations of chemical
• As part of “on the job” training: A case study built around a short accidents at fixed industrial facilities. Root causes are
video clip of an actual incident can make short, targeted, on-the-job usually deficiencies in safety management systems, but
training more focused and interesting by showing what has can be any factor that would have prevented the accident
happened to workers facing similar hazards. It could be used at if that factor had not occurred. Other accident causes
short “tail-gate” meetings, at Joint Health and Safety Committee often involve equipment failures, human errors,
meetings, or union meetings. Discussions might focus on the unforeseen chemical reactions or other hazards.
need to reflect and apply lessons from similar facilities, to
improve hazard abatement, strengthen incident investigation
procedures, and other elements of safety programs at your The agency does not issue fines or citations, but does
workplace. make recommendations to plants, regulatory agencies
such as the Occupational Safety and Health
• As part of efforts to educate other stakeholders about potential Administration (OSHA) and the Environmental Protection
hazards: Use case studies built around videos at meetings or
Agency (EPA), industry organizations, and labor groups.
conferences to inform community members, offsite emergency
responders, and relevant government agencies about the need for
continual improvement in facility safety programs.
Congress designed the CSB to be non-regulatory and
independent of other agencies so that its investigations
• As part of comprehensive training programs: Formal training might, where appropriate, review the effectiveness of
classes can be enhanced by inserting actual incidents that rein- regulations and regulatory enforcement.
force the message and create interactive discussion among
participants. In a classroom setting where resources (such as Source: www.csb.gov/about-the-csb/mission/
audio/visual equipment, props, safety equipment, display boards,
flip charts) are available, case studies can be analyzed in detail
to reinforce key points. Fact sheets summarizing the key points
may be helpful.
Tips When Developing and Using Case Studies in Training

Keep it Relevant Know Your Audience

Most CSB investigations cover multiple Evaluate the needs of your target audience and choose
issues, usually organized around the major a case study that best fits the group. People with
elements of the OSHA Process Safety different job titles and years of experience will have
Management (PSM) Standard and industry different perspectives and responsibilities. Are you
guidance documents. Choose video clips addressing new or experienced workers? What level of
that complement the specific topic that is decision-making power do participants have? What
relevant to the targeted group of workers, level of safety training have they already received?
but make it clear to the audience that Understand each scenario well enough to use relevant
typically there are multiple underlying questions for operations, maintenance, or contract
factors that together result in a major workers.
incident. For example, if you choose to use a
video clip to focus the discussion on Plan Ahead
operating procedures, be sure to also refer Choose cases in advance and prepare to lead a
to the summary section of your training to discussion about the cases. Identify the key points in the
emphasize that it is just one particular case that relate to the topic you want this training session
element within a strong comprehensive to cover and then remember to reinforce these points in
management safety systems program at the your summary. Before training, anticipate possible
facility. responses the class may generate and be ready to
address them. Then take notes during discussions and
You as instructor, or participant, can use use them in future trainings to refine your list of key
themes raised in the case study to share summary points. As appropriate, gather fact sheets and
personal experiences and apply your other materials, photos, flip charts or A/V equipment to
collective knowledge about hazard show videos or PowerPoint slides.
recognition, prevention, and control.
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Tips When Developing and Using Case Studies in Training

Consider Literacy, Language, Encourage Participation

and Education Levels Case studies are a great way for people to interact with
Literacy is a critical factor in delivering one another and generate energy and interest. There are
effective training and goes hand-in-hand two approaches:
with knowing and respecting your audience. (1) As a class, facilitate a question/response dialogue in
Choose a case study appropriate to your which you view the video and discuss the case as a
participants – neither above nor below their group, or
level of experience – and lead discussions (2) If time allows, break into small groups after viewing
to facilitate understanding and participation the video as a whole class, and have each small group
by everyone. Ask for volunteers to read the review relevant written materials that provide additional
story aloud to ensure that everyone can information, such as a written summary of the major
fully participate in the discussion. Plan findings and recommendations and other materials that
ahead for non-English-speaking audiences reinforce the major themes of the case study. Then
by having a facilitator who knows the reconvene to share ideas among the whole class.
language or arrange for translation.
Remember that some terms in process Both methods elicit interaction, camaraderie, and
safety industries do not translate directly to problem-solving skills.
other languages; identify those terms and Share Stories
how to convey the key concepts before
training. Encourage participants to contribute their own work
stories relevant to the topic. This can promote new
ideas for working together and supporting each other on
the job.
 Instructor Guide for Use of Chemical Safety Board (CSB) Reports and Videos

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Guide to CSB Videos and Materials:

I. CSB SOURCES CATEGORIZED

BY SPECIAL TOPICS
• Inherently Safety Design & Hierarchy of Hazard Control Analysis
(ISD & HCA)
• Safety Culture
• Hot Work
• Management of Change (MOC)
• Emergency Response & Stop Work Authority
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INHERENTLY SAFER DESIGN (ISD) &

HIERARCHY OF HAZARD CONTROL
ANALYSIS (HCA)
CSB Source Description, Application and Discussion Questions

Safety Video: Description:

“Inherently Safer: The Future of Risk This safety video examines the concept of Inherently Safer Design (ISD) and its application
Reduction” (2012) (11 minutes) across industry. California’s revised PSM standard for refineries requires Hierarchy of
Hazard Controls Analysis (HCA) using ISD principles. This video focuses on two incidents: a
runaway chemical reaction at Bayer Crop Science in a pesticide plant in West Virginia and
(Note sometimes the term IST is used: the Kleen Energy explosion in Connecticut. It provides recommendations for inherently safer
Inherently Safer Technologies) ways to clean piping.
Experts give a basic overview of the four approaches to ISD. The Amyotte et al. article
identified over 90 ISD recommendations pulled from CSB reports (through 2012), including
those at the Valero and BP refineries, DuPont, and ConAgra Foods.
Article:
Application:
Amyotte, P. R., MacDonald, D. K. and Khan, F.
I. (2011), An Analysis of CSB Investigation • Skip video section (4:47 – 7:17) which details the Bayer Crop Science West Virginia plant
that closed down due to a settlement with EPA related to phasing out production of the final
Reports Concerning the Hierarchy of product
Controls. Process Safety Progress, 30: 261- The Kleen Energy explosion in Connecticut provides a positive example of using ISD to
265. change standard industry practices at other locations
Possible Discussion Questions for Workers:
1. How would you explain to a co-worker the basic concept of inherently safer design?
How is it different from “add-on” protections?
2. The four inherently safer design strategies discussed in the video are: minimize,
substitute, modify, and simplify. Can you give an example of these strategies, based on
this video or hazard control methods used in your plant?
3. The California revised PSM standard requires applying ISD strategies from the most
effective to the least effective. The required sequence is: “first order” strategies are
 Instructor Guide for Use of Chemical Safety Board (CSB) Reports and Videos

_________ measures that eliminate a hazard, such as chemical substitution; “second order”
measures reduce risks without use of add-on devices, such as reducing operating
temperature or pressure. Next are passive safeguards (dike), active safeguards
(alarms, auto shutoffs), and procedural safeguards. Why do you think operating
procedures are considered the least effective method of controlling hazards? How
does this sequence of hazard control strategies compare with the management safety
culture in your plant?

Safety Video: Description:

“Chevron Richmond Refinery Fire Animation” This safety video shows the sequence of events that led to the August 2012 fire at Chevron’s
(2013) (selected segments - total 3:07 Richmond, California refinery. It also highlights the history of safety system deficiencies that
minutes) were ignored by Chevron and their repeated failure to implement internal engineering
recommendations. Note that California’s PSM standard for refineries now requires Hierarchy of
Hazard Controls Analysis (HCA) using ISD principles.

Application:
• Use video from 1:00 – 2:00 (discovery of leak, lack of shut-off valve or way to isolate leak)
and 5:43 – 7:50 (investigation, Chevron history of failing to replace corroded pipe, CSB
recommendations)

Possible Discussion Questions:

• How could employee involvement in process safety decision-making (e.g. pipe
corrosion assessments) have prevented the fire from occurring?
• How can implementation of inherently safer design prevent major chemical incidents or
other failures in refineries?
• The 2017 California PSM revised standard now requires a Damage Mechanism Review
(DRM) to identify material degradation of equipment. How could a DMR report after an
incident help inform better use of ISD methods?
• (See also discussion questions from previous page)
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SAFETY CULTURE
CSB Source Description, Application and Discussion Questions

CSB Case Study: Description:

Tesoro Martinez Refinery: Process Safety This case study examines the February and March 2014 sulfuric acid incidents that occurred
Culture Case Study (2014, Report No. 2014- at the Tesoro Martinez refinery in Martinez, California during maintenance activities. CSB
found that the recurrence of these incidents was a result of process safety culture
02-I-CA) (60 pages) deficiencies, which routinely exposed workers to avoidable risks by minimizing the
seriousness of process safety incidents and failing to take corrective actions.

Application:
• Discusses the importance of a strong process safety culture led by management to
prevent incidents
• Findings related to a poor safety culture include the failure to implement lessons from past
incidents, conduct preventive inspections, and use process safety indicators to measure
performance

Possible Discussion Questions:

1. How would you explain to a new hire some of the ways you can measure the process
safety culture in your plant? What were some of the findings that supported CSB’s
conclusion that there was a weak process safety culture?
2. Process Safety Indicators are now required in the California PSM standard. They include
two types: looking back at past events (lagging indicators – such as frequent leaks) and
programs in place to detect new hazards (leading indicators – frequency of pipe
inspections). Make a short list of some of the lagging and leading indicators that you think
would be most useful to identify and eliminate potential hazards in your unit or refinery.
3. Has your refinery conducted a Process Safety Culture Assessment (PSCA)? How were
employees involved in developing and participating in this assessment? What changes
were made after the PSCA to improve the safety culture?
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CSB Investigation Report: Description:

Catastrophic Rupture of Heat Exchanger This report illustrates the catastrophic rupture of a heat exchanger in the naphtha
(Seven Fatalities) (2010, Report No. 2010-08-I- hydrotreater unit due to a High Temperature Hydrogen Attack (HTHA) at the Tesoro
Anacortes refinery in 2010. Highly flammable hydrogen and naphtha were released, causing
WA) (148 pages) (Pages 4-13 are key; pages
a massive explosion and fire, killing seven workers who were working in the vicinity. They
51-73 provide additional background) were in the final stage of a start-up activity following the cleaning of heat exchangers.
Although the refinery had a history of frequent leaks and some fires during this activity,
“management repeatedly failed to ensure that these hazards were controlled and that the
number of workers exposed to these hazards was minimized.”

Application:
• Use the Table of Contents of this comprehensive investigation to find sections discussing
the “organizational deficiencies” identified by CSB
• Note that the report also covers Inherent Safety Technologies (IST) and Mechanical
Integrity issues
• Use in conjunction with CSB Investigation Reports and/or videos of the 2012 Chevron
Richmond refinery fire to compare the similarities between the two incidents and the
Tesoro Martinez special report above

Possible Discussion Questions:

1. CSB found that management ignored frequent leaks and often failed to investigate the
causes and fix them. They also made decisions based on design parameters rather than
data from actual process operating conditions. And the Process Hazard Analysis (PHA)
failed to identify some key hazards that needed to be controlled. Pick one of these
examples and discuss how it is handled in the plant where you work. What protections are
in place? What more could be done?
2. What precautions should be taken to eliminate unnecessary personnel in an area when a
process starts up?
3. See discussion questions above from the Tesoro Martinez case study.
 Instructor Guide for Use of Chemical Safety Board (CSB) Reports and Videos

HOT WORK
_________

CSB Source Description, Application and Discussion Questions

CSB Safety Bulletin: Description:

Seven Key Lessons to Prevent Worker Deaths This safety bulletin provides summaries and findings from eleven CSB investigations
During Hot Work In and Around Tanks (2010, including Motiva Enterprises refinery in Delaware (2001) and Pennzoil Product Company
refinery in Pennsylvania (1995), in which hot work on storage tanks or containers ignited
Report No. 2009-01-SB) (13 pages)
flammable gas inside. In some cases, workers had no knowledge that a flammable
material was present; in all cases, workers had no knowledge that an explosive amount
of flammable vapor had accumulated.
Seven key lessons drawn from these incidents highlight recurring safety issues, aimed at
preventing worker deaths during hot work (or spark-producing) operations.
Application:
• Relevant to refinery maintenance and contract workers
• Use with the OSHA or Cal/OSHA standard for hot work, which addresses welding,
cutting, and brazing as well as guidance documents from NFPA and the PSM
Possible Discussion Questions:
1. Before reading the report, make a list of steps that should be taken before starting
hot work to avoid these types of accidents.
2. Compare your list above with the list of seven action items in the report.
3. Pick a couple of the key action items and discuss how well you think they are being
applied in your unit or department. Is there any gap between the written hot work
procedures and testing protocol and how these steps are actually done? Identify
any areas for improvement by making a list of items to raise with your PSM Rep or
H&S committee.
4. (California refineries): Review the latest HCA (Hierarchy of Hazards Control
Analysis) or PHA (Process Hazard Analysis) for a process covered by where you
work. Did it identify areas where hot work could be avoided or explore the use of
alternatives? Where any of these recommendations implemented?
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MANAGEMENT OF CHANGE (MOC)

CSB Source Description, Application and Discussion Questions

CSB Safety Bulletin: Description:

Management of Change (2001, Report No. This bulletin profiles the following two incidents that occurred in 1998 to highlight the
need for a systematic approach to management of change to effectively evaluate
2001-04-SB) (8 pages)
the safety effects of process changes in the chemical industry.
1. Equilon Enterprises Refinery, Anacortes, WA – A fire in the coker unit following
a severe storm and power outage; six workers were killed following attempts to deal
with a partially filled drum. Lessons learned: need for MOC policies that include
abnormal situations, changes to procedures, and deviations from standard operation
conditions (variance procedures).
2. CONDEA Vista Chemical Plant, Baltimore, MD – A reaction vessel explosion and fire;
4 workers injured. The absence of written instructions and miscommunication
between shift supervisors contributed to the incident; the incident illustrates the
importance of having an authorization or approval step for an MOC covering
abnormal situations.
Application:
• MOC is relevant not only for preplanned changes when new processes are
added, but also to manage deviations from normal operations and for variance
procedures
• Changing a chemical or catalyst can trigger an MOC
Possible Discussion questions:
1. CSB notes that all workers should be trained on their facility’s MOC policy and be
made knowledgeable about normal limits for process variance so they can make
informed judgments about when to apply the MOC system. How well do you think
you and the other employees and contractors who work on your unit have been
trained to manage non-routine or upset conditions?
2. CSB encourages management to “gather the right people and resources to review the
situation” to ensure that the change is managed by a multidisciplinary team that
includes those with hands-on operations as well as engineers and technical experts.
Do the MOC teams at your facility meet this criteria?
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EMERGENCY RESPONSE AND STOP WORK

AUTHORITY
CSB Source Description, Application and Discussion Questions

Safety Video: Description:

“Chevron Richmond Refinery Fire Chevron Richmond 2012 fire and explosion: while the big picture from this incident is
Animation” (2013) (selected segments) understanding management decisions that caused the leak and taking steps to prevent it
(see ISD section above), the video also covers lessons related to emergency response,
such as the authority to stop a process unit and limit the number of people in the leak
zone.

Application:
• Use video from 1:00 – 2:00 (describes the leak); 2:00 – 5:43 (describes the emergency
response and resulting fire and explosion); 5:43 – 7:50 (covers the CSB investigation
and its recommendations)

Possible Discussion Questions for Workers:

1. Were hot zone and safe distance areas appropriately identified to consider the
possibility of a pipe rupture?
2. Were fire department personnel sufficiently informed of the hazards and process
conditions?
3. At what point should the Stop Work Authority have been implemented?
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Guide to CSB Videos and Materials:

II. CSB SOURCES CATEGORIZED

BY GEOGRAPHIC INCIDENTS
(STARTING WITH MOST RECENT):
1. ExxonMobil Refinery: Baton Rouge, LA, (2016)
2. ExxonMobil Refinery, Torrance, CA: 2015
3. Delaware City Refining Company, Delaware City, DE (2015)
4. Tesoro Avon Refinery, Martinez, CA (2014)
5. Chevron Refinery, Richmond, CA (2012)
6. Tesoro Refinery, Anacortes, WA (2010)
7. BP America Refinery, Texas City, TX (2005)
8. Tosco Avon Refinery, Martinez, CA (1999
9. Phillips 66 Houston Chemical Plant Complex, Pasadena, TX (1989)
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1. EXXONMOBIL REFINERY, BATON ROUGE,

LA (2016)
CSB Source(s) Description, Key Issues or Recommendations

CSB Safety Bulletin: Description:

Key Lessons from the ExxonMobil Baton An isobutane release and fire occurred in the sulfuric acid alkylation unit, resulting in
Rouge Refinery Isobutane Release and Fire four serious burn injuries to workers. The incident occurred during minor maintenance
(2016, Report No. 2016-02-I-LA) (32 pages) on a flammable isobutane line: while removing a gearbox of older design on a plug valve,
critical bolts were also removed; the valve came apart, releasing isobutane which then
ignited. Workers were following accepted plant practice applicable to 97% of valves.
This valve was different; there were no written procedures or training provided.
Safety Videos:
“Animation of Fire at ExxonMobil’s Baton Key Issues or Recommendations:
Rouge Refinery” (2016) (3 minutes) • Apply the Hierarchy of Hazard Controls (HCA) to mitigate identified hazards (upgrade
the old valves per accepted guidelines)
“Fire in Baton Rouge” (2017) (8.27 minutes, • Procedures and Training: Establish detailed and accurate procedures and provide
includes findings and recommendations) training to ensure workers can perform all anticipated jobs safely (i.e., all models and
designs of equipment)

• Recent PHA lacked a Human Factors evaluation of operator interaction with valves
to identify older plug valve design and reliability issues

• Management Safety Culture – Allowed accepted practice versus using hierarchy of

controls to address the problem
 Instructor Guide for Use of Chemical Safety Board (CSB) Reports and Videos

2. EXXONMOBIL REFINERY, TORRANCE, CA

_________

(2015)
CSB Source(s) Description, Key Issues or Recommendations

CSB Investigation Report: Description:

ExxonMobil Torrance Refinery Electrostatic Explosion on the refinery’s Electrostatic Precipitator (ESP) during normal operation as
facility was attempting to isolate equipment for maintenance while in an idled mode of
Precipitator Explosion (2017, Report No. operation. Preparation activities for maintenance caused a pressure deviation that
2015-02-I-CA) (73 pages) allowed hydrocarbons to back-flow through the process and ignite in the ESP.

A near miss event occurred in the modified hydrofluoric acid (MHF) alkylation unit when
explosion debris nearly hit tanks in close proximity to the ESP, each containing
Safety Video: hydrofluoric acid (HF) and other substances.
“Animation of 2015 Explosion at ExxonMobil The refinery was shut down over a year, causing a rise on gasoline prices; at least $2.4
Refinery in Torrance, CA” (2017) (7.12 billion cost to California motorists.
minutes) Key Issues or Recommendations:

• Overall gaps in management’s PSM program

RAND Report: • Lack of safe operating limits and operating procedures for all modes of operation
Gonzales, D., Gulden, T.R., Strong, A. and • Lack of instrumentation to detect hydrocarbons flowing to the ESP (appears to be an
Hoyle, W. (2016), Cost–Benefit Analysis of industry-wide problem)
Proposed California Oil and Gas Refinery
• Mechanical Integrity: Operating safety-critical equipment beyond predicted safe
Regulations. RAND Corporation, RR-1421- operating life; erosion damage to critical valve
DIR.
• Re-use of previous procedure variance without sufficient MOC or hazard analysis to
verify if its application was still valid

• The RAND report was unique in its analysis of costs of incidents external to those
borne by the company
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3. DELAWARE CITY REFINING COMPANY,

DELAWARE CITY, DE (2015)
CSB Source(s) Description, Key Issues or Recommendations

CSB Safety Bulletin: Description:

Key Lessons for Preventing Incidents When Operators were draining and isolating a section of piping to be replaced; problems
Preparing Process Equipment for encountered led to expanding the isolation scope, making it non-routine work. This is not
Maintenance, Flash Fire at the Delaware City unexpected given the complexity of refineries. However, this did not trigger additional
Refinery (2015, Report No. 2015-01-I-DE) (23 hazard review.
pages)
Key Issues or Recommendations:
• See Appendix A: CSB Incident • Preparation for maintenance activities requires pre-planning and hazard
Investigations Involving Maintenance identification before starting work (MOC)
and Non-Routine Operations that cites
• Procedures are needed to cover steps for all types of equipment and tasks
39 examples
• Avoid reliance on single block valves and use closed systems to control potential
releases – ISD, HCA
News Clip from former CSB Chairperson:
“CSB Offer Releases Findings of Fire
Investigation at Delaware City Refinery”
(2017) (1.22 minutes)
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4. TESORO AVON REFINERY, MARTINEZ,

CA (2014)
CSB Source(s) Description, Key Issues or Recommendations

CSB Case Study: Description:

Tesoro Martinez Refinery Process Safety On February 2014, a sulfuric acid spill resulted from insufficient tightening of a joint at a
Culture Case Study (2016, Report No. 2014- sulfuric acid sampling station; two workers were hospitalized for acid burns. Cal/OSHA
02-I-CA) (60 pages) ordered the unit shutdown for several days. A month later, on March 2014, in the same
sulfuric acid alkylation unit, two contract workers were sprayed with acid during planned
maintenance to remove some piping.

News Clip from NBC Bay Area:

Key Issues or Recommendations:
“Federal Investigation Faults Martinez’s CSB issued a special case study on how a weak process safety culture created conditions
Tesoro Refinery for Safety Deficiencies, that were contributing factors to these two similar incidents. Examples to support this
Worker Injuries” (2016) (2.34 minutes) finding:
• Incident investigations: Failure to learn from past incidents

• Removal of a better ISD sample system

• Deficiencies in permits and procedures, less protective than corporate standard

• Staffing resource limitations and pressure on workers to put production and costs
before safety
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5. CHEVRON RICHMOND REFINERY,

RICHMOND, CA (2012)
CSB Source(s) Description, Key Issues or Recommendations

CSB Investigation Reports: Description:

Final Investigation Report: Chevron Richmond The crude unit experienced a catastrophic pipe rupture, releasing flammable, high
Refinery Pipe Rupture and Fire (2015, Report temperature light gas oil which then vaporized into a large vapor cloud that engulfed 19
employees. Two minutes later, the cloud ignited, just after the employees escaped. The
No. 2012-03-I-CA) (122 pages) subsequent burning of the hydrocarbon fluids resulted in a large plume of black smoke,
which traveled into the surrounding community. A shelter-in-place alert was issued for
Interim Investigation Report: Chevron Richmond nearby cities. About 15,000 sought medical care related to smoke inhalation.
Refinery Fire (2013) (70 pages)
Key Issues or Recommendations:
CSB Regulatory Report: Interim CSB report:
Regulatory Report: Chevron Richmond • Failed to apply inherently safer design principles
Refinery Pipe Rupture and Fire (2014, Report
• Failed to identify and evaluate damage mechanism hazards
No. 2012-03-I-CA) (126 pages)
• Need for prescribed methodology to effectively identify and analyze process hazards
Final CSB report:
Safety Video: • Failure to invoke Stop Work Authority
“Chevron Richmond Refinery Fire Animation” • Incident Command structure had insufficient technical expertise to effectively
(2013) (8.14 minutes) respond to hazardous process fluid leaks
• Mechanical integrity industry standard deficiencies
California’s Interagency Refinery Task Force • Leak evaluation and response industry standard deficiencies
Report: • Failure to follow RAGAGEP guidelines, delaying maintenance
Improving Public and Worker Safety at Oil • Need for MOC when crude oil, content, temperature and pressure change
Refineries, Report of the Interagency Working
Group on Refinery Safety (2014)
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6. TESORO REFINERY, ANACORTES, WA

(2010)
CSB Source(s) Description, Key Issues or Recommendations

CSB Investigation Report: Description:

Catastrophic Rupture of Heat Exchanger A catastrophic rupture of a heat exchanger in the naphtha hydrotreater unit occurred due
(Seven Fatalities) (2014, Report No. 2010-08-I- to a High Temperature Hydrogen Attack (HTHA). Highly flammable hydrogen and
WA) (148 pages) naphtha were released, causing a massive explosion and fire, killing one shift supervisor
and six operators who were working in the vicinity. They were in the final stage of a start-
up activity following the cleaning of heat exchangers. Given the history of frequent leaks
and some fires during this activity, CSB considered the work to be hazardous and non-
Safety Video:
routine.
“Behind the Curve” (2014) (14 minutes)
Key Issues or Recommendations:
• Failure to use inherently safer design and the hierarchy of controls to prevent
equipment failure from HTHA

• Implement a process safety culture program to continually assess and improve safety

• Control of non-routine work activities

• Mechanical Integrity industry standard deficiencies

• Regulatory oversight of petroleum refineries

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7. BP AMERICA REFINERY, TEXAS CITY,

TX (2005)
CSB Source(s) Description, Key Issues or Recommendations

CSB Investigation Report: Description:

Following lengthy maintenance with over 1100 contractors onsite, workers began to start
Refinery Explosion and Fire (15 Killed, 180
up the isomerization unit when a raffinate splitter tower was overfilled. Pressure relief
Injured) (2007, Report No. 2005-04-I-TX) (341 devices opened, resulting in a liquid geyser from a blowdown stack that was not
pages) equipped with a flare. The resulting fire and explosion killed 15 in or near office trailers
close to the blowdown drum.

Key Issues or Recommendations:

Safety Video:
• Safety Culture: “The Texas City disaster was caused by organization and safety
“Anatomy of a Disaster” (2008) (55.33 minutes) deficiencies at all levels of the BP Corporation. Warning signs of a possible disaster
“BP Texas City 10 Year Anniversary Safety were present for several years, but company officials did not intervene effectively to
Message” (2015) (4.04 minutes) prevent it”

• Corporate and Management Oversight and Mechanical Integrity issues: “cost-cutting,

failure to invest and production pressures from BP Group executive managers
United Steelworkers (USW) Report: impaired process safety performance at Texas City”

McQuiston, Thomas H., et al. (2009), Beyond • Human factors issues such as lack of training, operator fatigue, procedure deviations,
Texas City: The State of Process Safety in the understaffing and lack of supervisory oversight contributed to the accident
Unionized U.S. Oil Refining Industry. New
Solutions: A Journal of Environmental and • Process Safety Metrics (use leading and lagging process indicators versus personal
Occupational Health Policy, 19(3), 271-88. injury statistics)

• Lack of a reporting and learning culture

The Baker Panel Report: • The independent Baker Panel Report found similar problems in other BP-owned U.S.
refineries
Baker, James., et al. (2007), The Report of the
U.S. Refineries Independent Safety Review
Panel
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8. TOSCO AVON REFINERY, MARTINEZ,

CA (1999)
CSB Source(s) Description, Key Issues or Recommendations

CSB Investigation Report: Description:

Refinery Fire Incident (4 Dead, 1 Critically A fire occurred in the crude unit as workers were attempting to replace a pipe in a 15-foot
Injured) (2001, Report No. 99-014-I-CA) (70 tall fractionator tower while the unit was still running. This followed the detection of a
pinhole leak and several days of unsuccessful efforts to drain the pipe. During the removal
pages) of the piping, naphtha was released onto the hot fractionator and ignited engulfing five
workers.
Key Issues or Recommendations:
• Failure to identify or control serious hazards during non-routine maintenance work
activities
• Lack of management oversight and accountability of hazardous work activities
• Failure to conduct a management of change (MOC) analysis
• Corrosion control program was inadequate
• Discussion of stop work authority and supervision during non-routine hazardous
maintenance work
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9. PHILLIPS 66 HOUSTON CHEMICAL

COMPLEX, PASADENA, TX (1989)
CSB Source(s) Description, Key Issues or Recommendations

John Gray / OSHA Report: Description:

Wells, J. C., Kochan, T. A. and Smith, M. (1991),An explosion and ensuing fire occurred on October 23, 1989 at the Phillips Petroleum
Managing Workplace Safety and Health: The Houston Chemical Complex in Pasadena, Texas during regular maintenance operations,
Case of Contract Labor in the U.S. Petrochemical resulting in 23 fatalities and 314 injuries. The accident was caused by a massive release of
process gas, a mixture of four chemicals, through an open valve forming a vapor cloud
Industry. John Gray Institute, Lamar University.
which exploded and led to the fire. This chain reaction also caused the explosion of nearby
chemical storage tanks.
This report was done under contract to OSHA
prior to the passage of the PSM standard and
This incident led to the passage of the 1992 federal OSHA Process Safety Management
creation of the CSB, but its findings are often
cited in subsequent CSB reports and so it is Standard [29 CFR § 1910.119].
included in this guide.
Key Issues or Recommendations:
• Supervision of outside contractors and impact on safety (John Gray Report)

• Lack of effective management systems to prevent release of flammable vapors or

minimize its impact

• Failure to provide adequate fire protection; a dedicated water system

• Failure to follow standard procedure – double blind or flange during online

maintenance

• Design flaw: air hose lacked unique coupling for “open” and “closed” sides

• Design: valve lockout system was inadequate to prevent it from being either
inadvertently or deliberately opened during a maintenance procedure