Mar 28, 2001
Federal Investigation of Tosco Refinery Fire Finds Flawed Management Supervision
(Washington, DC - March 28, 2001) A fire at Tosco's Avon refinery in Martinez, California, could have been prevented by better management supervision of safety, according to the final report of the U.S. Chemical Safety & Hazard Investigation Board (CSB). The report culminates an exhaustive two-year investigation of the 1999 petroleum fire that claimed the lives of four workers. The Avon refinery was acquired by UDS Corporation last year.
According to Board Member Irv Rosenthal, "Better management of job planning and execution could have prevented this tragedy. Our investigation uncovered two root causes of the accident. First, Avon refinery management did not have an effective process for assessing the dangers of maintenance operations and implementing needed safeguards. Second, neither the parent Tosco Corporation nor the facility management had investigated or corrected a pattern of serious unsafe practices at the Avon refinery."
The incident occurred on February 23, 1999, two years after an explosion at the refinery killed one and injured 46 others. Management deficiencies were also a significant factor in that incident, according to a federal report.
The 1999 incident occurred as workers attempted to remove and replace a leaky petroleum pipe which was attached to an operating oil distillation tower, known as a fractionator. Over a 13-day period prior to the accident, workers had repeatedly tried to isolate and drain the pipe, but leaking and corroded shut-off valves hampered their efforts. At the time of the incident, the pipe still contained a significant volume of pressurized naphtha, a highly flammable petroleum mixture similar to gasoline. While workers were in the process of replacing the pipe, the naphtha was released and burst into flame, killing the four workers. At the time of the fire, workers were positioned on scaffolding up to a hundred feet off the ground and had limited means of escape.
According to the Board's Rosenthal: "The refinery's own procedures directed that the piping should be isolated and drained prior to attempting this kind of repair. This procedure was not followed. Opening a pipe containing naphtha in the presence of multiple ignition sources was a formula for disaster. The entire process unit should have been shut down, which would have eliminated ignition sources and allowed the naphtha to be fully and safely drained."
Rosenthal continued: "Management had a responsibility to see that work was halted, and should not, as has been suggested, have relied solely upon individual workers to stop an unsafe activity. Worker error was not a root cause of this accident. A satisfactory management system is one that, anticipating that humans will inevitably make mistakes, still ensures the safe conduct of work. Effective job planning, hazard review, and management oversight could have prevented the Avon tragedy."
The Board recommended that the refinery implement a comprehensive system for safely managing hazardous maintenance work. Key provisions include a process for evaluating hazards before work is started and increased management oversight of ongoing work. The Board also recommended that Tosco Corporation improve its safety auditing procedures and ensure that its seven other refineries do not have the safety deficiencies that were found at Avon.
The CSB is an independent federal agency whose mission is to ensure the safety of workers and the public by preventing chemical incidents. The CSB is a scientific investigatory organization, not an enforcement or regulatory body. The Board determines the root causes of accidents, issues safety recommendations, and performs special studies on chemical safety issues.