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Caribbean Petroleum Refining Tank Explosion and Fire
FINAL REPORT: Final Investigation Report - Caribbean Petroleum
Location: Bayamón, PR
Accident Occurred On: 10/23/2009
Final Report Released On: 10/21/2015
Accident Type: Chemical Distribution - Fire and Explosion
Company Name: Caribbean Petroleum Refining

statistics

Total # of Recommendations
9
Total # of Open Recommendations
9
Total # of Closed Recommendations
0
Total % of Open 100 vs. Closed 0

investigation information

Image
Accident Description
A massive fire and explosion sent huge flames and smoke plumes into the air at the Carribean Petroleum Corporation near San Juan, Puerto Rico. The resulting pressure wave damaged surrounding buildings and impacted moving vehicles.
Investigation Status
The CSB investigation is final.


 

Recommendations

American Petroleum Institute (API)
2010-02-I-PR-7
Revise ANSI/API 2350, Overfill Protection for Storage Tanks in Petroleum Facilities (2015), to require the installation of an automatic overfill prevention systems for existing and new facilities at bulk aboveground storage tanks storing gasoline, jet fuel, other fuel mixtures or blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher. At a minimum, this system shall meet the following requirements:
a. Separated physically and independent from the level control and monitoring system.
b. Engineered, operated, and maintained to achieve an appropriate safety integrity level in accordance with the requirements of Part 1 of International Electrotechnical Commission (IEC) 61511-SER ed1-2004, Functional Safety – Safety Instrumented Systems for the Process Industry Sector.
c. Specified to achieve the necessary risk reduction as determined by a documented risk assessment methodology set in accordance with Center for Chemical Process Safety Guidelines for Hazard Evaluation Procedures, 3rd Edition, accounting for the following factors:
1. The existence of nearby populations and contamination of nearby environmental resources;
2. The nature and intensity of facility operations;
3. Realistic reliability for the tank gauging system; and
4. The extent/rigor of operator monitoring.
d. Proof tested with sufficient frequency in accordance with the validated arrangements and procedures to maintain the required safety integrity level.
e. Ensure that the above changes are not subject to grandfathering provisions in the standard.
Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2010-02-I-PR-8
Develop detailed guidance on conducting a risk assessment for onsite and offsite impacts of a potential tank overfill during transfer operations involving one and multiple tanks and for determining the Safety Integrity Level of the required overfill prevention safeguard to replace Annex E of ANSI/API 2350, Overfill Protection for Storage Tanks in Petroleum Facilities (2015).
Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2010-02-I-PR-9
Develop a single publication or resource describing all API standards and other relevant codes, standards, guidance, and information for filling operations of aboveground storage tanks in petroleum facilities that describes:
a. The required design and management practices for control of filling operations;
b. The minimum set of independent overfill prevention safeguards if the control fails; and
c. Operational challenges (e.g., monitoring/calculating flow rates, ability to maintain constant line pressures, and influences of valve cracking) related to loading multiple tanks concurrently from a single product source.
Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Environmental Protection Agency (EPA)
2010-02-I-PR-1
Revise where necessary the Spill Prevention, Control and Countermeasure (SPCC); Facility Response Plan (FRP); and/or Accidental Release Prevention Program (40 CFR Part 68) rules to prevent impacts to the environment and/or public from spills, releases, fires, and explosions that can occur at bulk aboveground storage facilities storing gasoline, jet fuels, blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher.
 
At a minimum, these revisions shall incorporate the following provisions:
 
a) Ensure bulk above ground storage facilities conduct and document a risk assessment that takes into account the following factors:
1. The existence of nearby populations and sensitive environmenls;
2. The nature and intensity of facility operations;
3. Realistic reliability of the tank gauging system; and
4. The extent/rigor of operator monitoring
b) Equip bulk aboveground storage containers/tanks with automatic overfill prevention systems that are physically separate and independent from the lank level control systems.
c) Ensure these automatic overfill prevention systems follow good engineering practices.
d) Engineer, operate, and maintain automatic overfill prevention systems to achieve appropriate safety integrity levels in accordance with good engineering practices, such as Part 1 of lnternational Electro-technical Commission (IEC) 61511-SER ed1.0B-2004, Functional Safety - Safety Instrumented Systems for the Process Industry Sector.
e) Regularly inspect and test automatic overfill prevention systems to ensure their proper operation in accordance with good engineering practice.
Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2010-02-I-PR-2
Conduct a survey of randomly selected bulk aboveground storage containers storing gasoline or other flammable liquids with a NFPA 704 flammability rating of 3 or higher, at terminals in high risk locations (such as near population centers or sensitive environments) that are already subject to the Spill Prevention, Control and Countermeasure (SPCC) and/or Facility Response Plan (FRP) rules to determine:
a) The nature of the safety management systems in place to prevent overfilling a storage tank during loading operations. Analysis of the safety management systems should include equipment, training, staffing, operating procedures and preventative maintenance programs.
b) The extent to which terminals use independent high level alarms, automated shutoff/diversion systems, redundant level alarms or other technical means to prevent overfilling a tank
c) The history of overfilling incidents at the facilities, with or without consequence
d) Whether additional reporting requirements are needed to understand the types of incidents leading to overfilling spills that breach secondary containment and have the potential to impact the environment and/or the public, as well as the number of safeguards needed to prevent them.
Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2010-02-I-PR-3
As an interim measure, until the rule changes in CSB Recommendation No. 2009-02-I-PR-R1 are adopted and go into effect: issue appropriate guidance or an alert, similar to EPA’s previously issued Chemical Safety Alert addressing Rupture Hazard from Liquid Storage Tanks, to illustrate the hazards posed by spills, releases, fires and explosions due to overfilling bulk aboveground storage containers storing gasoline, jet fuel, blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher.
Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

International Code Council (ICC)
2010-02-I-PR-5
Revise the Section 5704.2.7.5.8 (2015), Overfill Prevention of the International Fire Code (IFC) to require an automatic overfill prevention system (AOPS) for bulk aboveground storage tank terminals storing gasoline, jet fuel, other fuel mixtures or blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher, or equivalent designation. These safeguards shall meet the following requirements:
a) Engineered, operated, and maintained to achieve an appropriate safety integrity level in accordance with the requirements of Part 1 of International Electrotechnical Commission (IEC) 61511-SER ed1-2004, Functional Safety – Safety Instrumented Systems for the Process Industry Sector.
b) Specified to achieve the necessary risk reduction as determined by a documented risk assessment methodology in accordance with Center for Chemical Process Safety Guidelines for Hazard Evaluation Procedures, 3rd Edition, accounting for the following factors:
i. The existence of nearby populations and sensitive environments;
ii. The nature and intensity of facility operations;
iii. Realistic reliability for the tank gauging system; and
iv. The extent/rigor of operator monitoring.
c) Proof tested in accordance with the validated arrangements and procedures with sufficient frequency to maintain the specified safety integrity level.
d) Ensure that the above changes are not subject to grandfathering provisions in the codes.
Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

National Fire Protection Association (NFPA)
2010-02-I-PR-6
Revise NFPA 30, Storage of Flammable and Combustible Liquids, Section 21.7.1.1 (2015) for bulk aboveground storage tank terminals storing gasoline, jet fuel, other fuel mixtures or blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or greater. This modification shall meet the following requirements:
a. More than one safeguard to prevent a tank overfill, all within an automatic overfill prevention system as described in ANSI/API Standard 2350 (2015) Overfill Protection for Storage Tanks in Petroleum Facilities with an independent level alarm as one of the safeguards. The safeguards should meet the following standards:
1. Separated physically and electronically and independent from the tank gauging system;
2. Engineered, operated, and maintained for an appropriate level of safety based on the predetermined risk level after considering part b of this recommendation; and
3. Proof tested with sufficient frequency in accordance with the validated arrangements and procedures.
b. Specified to achieve the necessary risk reduction as determined by a documented risk assessment methodology conducted in accordance with Center for Chemical Process Safety Guidelines for Hazard Evaluation Procedures, 3rd Edition, accounting for the following factors:
1. The existence of nearby populations and contamination of nearby environmental resources;
2. The nature and intensity of facility operations;
3. Realistic reliability for the tank gauging system; and
4. The extent/rigor of operator monitoring.
c. Ensure that the above changes not subject to grandfathering provisions in the code.
Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Occupational Safety and Health Administration (OSHA)
2010-02-I-PR-4
a) Revise the Flammable and Combustible Liquids standard (29 CFR§ 1910.106) to require installing, using, and maintaining a high-integrity automatic overfill prevention system with a means of level detection, logic/control equipment, and independent means of flow control for bulk aboveground storage tanks containing gasoline, jet fuel, other fuel mixtures or blends tocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher, to protect against loss of containment. At a minimum, this system
shall meet the following requirements:
1. Separated physically and electronically and independent from the tank gauging system.
2. Engineered, operated, and maintained to achieve an appropriate level of safety integrity in accordance with the rrequirements of Part 1 of International Electro-technical Commission (IEC) 61511-SER ed1.0B-2004, Functional Safety - Safety Instrumented Systems for the Process Industry Sector. Such a system would employ a safety integrity level (SIL) documented in accordance with the principles in Part 3 of IEC 61511-SER ed1.0B-2004, accounting for the following factors:
i. The existence of nearby populations and sensitive environments;
ii. The nature and intensity of facility operations;
iv. The extent/ rigor of operator monitoring.
3. Proof tested in accordance with the validated arrangements and procedures with sufficient frequency to ensure the specified safety integrity level is maintained.
b) Establish hazard analysis, management of change and mechanical integrity management system elements for bulk above ground storage tanks in the revised 1910.106 standard that are similar to those in the Process Safety Management of Highly Hazardous Chemicals standard (29 CFR § 1910.119) and ensure these facilities are subject to Recognized and Generally Accepted Good Engineering Practices (RAGAGEP).
Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

 
 

Related Video

Filling Blind
10/21/2015 7:19:00 PM
CSB Safety Video on the 2009 massive explosion at the Caribbean Petroleum, or CAPECO, terminal facility near San Juan, Puerto Rico. The incident occurred when gasoline overflowed and sprayed out from a large aboveground storage tank, forming a 107-acre vapor cloud that ignited. read more

Download QuickTime Video

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