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Tosco Avon Refinery Petroleum Naphtha Fire
FINAL REPORT: Final Investigation Report
Location: Martinez, CA
Accident Occurred On: 02/23/1999
Final Report Released On: 03/21/2001
Accident Type: Oil and Refining - Fire and Explosion
Company Name: Tosco Corporation

statistics

Total # of Recommendations
7
Total # of Open Recommendations
0
Total # of Closed Recommendations
7
Total % of Open 0 vs. Closed 100

investigation information

Image
Accident Description
On February 23, 1999, a fire occurred in the crude unit at Tosco Corporation. Avon oil refinery in Martinez, California. Workers were attempting to replace piping attached to a 150-foot-tall fractionator tower while the process unit was in operation. During removal of the piping, naphtha was released onto the hot fractionator and ignited. The flames engulfed five workers located at different heights on the tower. Four men were killed, and one sustained serious injuries.
Investigation Status
The final report on this investigation was approved March 21, 2001.


 

Recommendations

American Petroleum Institute (API)
1999-014-I-CA-5

Communicate the findings of this report to your membership.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

National Petrochemical and Refiners Association (NPRA)
1999-014-I-CA-5

Communicate the findings of this report to your membership.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Paper, Allied-Industrial, Chemical and Energy Workers International Union (PACE)
1999-014-I-CA-5

Communicate the findings of this report to your membership.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Tosco Corporation
1999-014-I-CA-1

Conduct periodic safety audits of your oil refinery facilities in light of the findings of this report. At a minimum, ensure that: Audits assess the following: - Safe conduct of hazardous nonroutine maintenance - Management oversight and accountability for safety - Management of change program - Corrosion control program. Audits are documented in a written report that contains findings and recommendations and is shared with the workforce at the facility. Audit recommendations are tracked and implemented.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Ultramar Diamond Shammock Golden Eagle Refinery
1999-014-I-CA-2

Implement a program to ensure the safe conduct of hazardous nonroutine maintenance. At a minimum, require that: A written hazard evaluation is performed by a multidisciplinary team and, where feasible, conducted during the job planning process prior to the day of job execution. Work authorizations for jobs with higher levels of hazards receive higher levels of management review, approval, and oversight. A written decision-making protocol is used to determine when it is necessary to shut down a process unit to safely conduct repairs. Management and safety personnel are present at the job site at a frequency sufficient to ensure the safe conduct of work. Procedures and permits identify the specific hazards present and specify a course of action to be taken if safety requirements such as controlling ignition sources, draining flammables, and verifying isolation are not met. The program is periodically audited, generates written findings and recommendations, and implements corrective actions.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

1999-014-I-CA-3

Ensure that MOC reviews are conducted for changes in operating conditions, such as altering feedstock composition, increasing process unit throughput, or prolonged diversion of process flow through manual bypass valves.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

1999-014-I-CA-4

Ensure that your corrosion management program effectively controls corrosion rates prior to the loss of containment or plugging of process equipment, which may affect safety.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

 
 

Related News

MVC-008S
Federal Investigation of Tosco Refinery Fire Finds Flawed Management Supervision
3/28/2001
(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.
read more
 
 
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