Preventive Maintenance Recommendations

Investigation

Recipient

Record Number

Recommendation Text

Chevron Refinery Fire

American Petroleum Institute

2012-3-I-CA-R26

Revise API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries to establish minimum requirements for preventing catastrophic rupture of low-silicon carbon steel piping.  At a minimum:   a. Require users to identify carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components.  These circuits have the potential to contain carbon steel components that were not manufactured to the American Society for Testing and Materials (ASTM) A106 specification and may contain less than 0.10 weight percent silicon content.   b. For piping circuits identified to meet the specifications detailed in 2012-03-I-CA-R26(a), require users to either (1) enact a program to inspect every component within the piping circuit once, known as 100 percent component inspection (per the requirements established pursuant to recommendation 2012-03-I-CA-28(c)), or (2) replace the identified at-risk carbon steel piping with a steel alloy that is more resistant to sulfidation corrosion.   c. If low-silicon components or components with accelerated corrosion are identified in a carbon steel piping circuit meeting the specifications detailed in 2012-03-I-CA-R26(a), require designation of these components as permanent Condition Monitoring Locations (CMLs) until the piping components are replaced. 

2012-3-I-CA-R27

Revise API RP 571: Damage Mechanisms Affecting Fixed Equipment in the Refining Industry to:  a. Describe the potential for increased rates of sulfidation corrosion occurring in low-silicon carbon steel in Section 4.4.2.3 Critical Factors;   b. Specify that sulfidation corrosion rates in carbon steel piping can be significantly faster in a few, individual piping components in section 4.4.2.5 Appearance or Morphology of Damage; and c. Refer the reader to the 100 percent component inspection or pipe replacement requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to recommendation 2012-03-I-CA-26)  and API 570: Piping Inspection Code:  In-service Inspection, Rating, Repair, and Alteration of Piping Systems (pursuant to 2012-03-I-CA-28(c)) for carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components.    

2012-3-I-CA-R29

Revise API RP 578: Material Verification Program for New and Existing Alloy Piping Systems, to require users to establish and implement a program to identify carbon steel piping circuits that are susceptible to sulfidation corrosion and may contain low-silicon components.  These circuits have the potential to contain carbon steel components that were not manufactured to the American Society for Testing and Materials (ASTM) A106 specification and may contain less than 0.10 weight percent silicon content.  Refer the reader to the 100 percent component inspection or pipe replacement requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to recommendation 2012-03-I-CA-26(b))  and API 570: Piping Inspection Code:  In-service Inspection, Rating, Repair, and Alteration of Piping Systems (pursuant to 2012-03-I-CA-28(c)) for carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components.

2012-3-I-CA-R30

Revise API RP 574: Inspection Practices for Piping System Components (3rd edition) to:   a. Incorporate as a normative reference API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries;   b. Reference API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries when discussing that non-silicon-killed carbon steel is susceptible to sulfidation corrosion; and c. In Section 9.3 Investigation of Leaks, require users to follow the leak response protocol requirements established in API RP 2001: Fire Protection in Refineries (pursuant to 2012-03-I-CA-R31). 

2012-3-I-CA-R31

Revise API RP 2001: Fire Protection in Refineries to require users to develop a process fluid leak response protocol specific to their own facility that must be followed when a process fluid leak is discovered.  Recommend users to incorporate the following actions into their leak response protocol:   a. Establish an Incident Command structure upon identification of a process fluid leak; b. Conduct a pre-response meeting with personnel with specific technical expertise (e.g., inspectors, operators, metallurgists, engineers, and management) and the Incident Commander to determine pressure, temperature, remaining inventory of process fluids, potential damage mechanisms that caused the leak, and worst-case leak scenario; c. Establish a hot zone that identifies the area of risk of exposure or injuries due to flame contact, radiant heat, or contact to hazardous materials, taking into consideration the worst-case leak scenario; d. Limit site access around leak location to essential personnel only; e. Isolate the leaking piping or vessel, or if isolation is not possible, shutdown of the unit when the leaking process fluid poses immediate danger to safety, health, or the environment—such as piping fluid that is toxic or near the auto-ignition temperature. 

2012-3-I-CA-R32

Revise ASME PCC-2-2011: Repair of Pressure Equipment and Piping to require users to follow the minimum process fluid leak response requirements established in API RP 2001: Fire Protection in Refineries, developed in response to recommendation 2012-03-I-CA-R31, before conducting process fluid leak repair.

Chevron USA

2012-3-I-CA-R34

Develop an auditable process to be available for all recommended turnaround work items necessary to address mechanical integrity deficiencies or inspection recommendations that are denied or deferred.  This process shall provide the submitter of the denied or deferred recommendation with the option to seek further review by his or her manager, who can further elevate and discuss the recommendation with higher level management, such as the Area Business Unit Manager.  Maintain an auditable log of each of these potential turnaround work items, including the ultimate determination of approval, deferral, or rejection, justification determination, and the person or team responsible for that decision.

Governor and Legislature of the State of California

2012-3-I-CA-R14

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R9 and 2012-03-I-CA-R10), so that all necessary mechanical integrity work at all California Chevron Refineries is identified and recommendations are completed in a timely way.

ExxonMobil Refinery Explosion (Torrance)

ExxonMobil Corporation

2015-02-I-CA-R4

ExxonMobil extended the maintenance interval of the spent catalyst slide valve and the inspection interval of the pumparound heat exchanger without analyzing whether the extended operation lowered their availability (by operating them beyond their predicted safe operating life) and could result in negative safety consequences. In the event safety-critical equipment is operated beyond its inspection and/or maintenance interval (e.g. extended turnaround interval), require all ExxonMobil U.S. refineries to perform a risk evaluation (e.g. MOC or risk assessment) to identify the safety consequences of the extended operation. Require that each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation is evaluated during the risk evaluation.

Hoeganaes Corporation Fatal Flash Fires

Hoeganaes Corporation

2011-4-I-TN-R8

Implement a preventive maintenance program and leak detection and leak mitigation procedures for all flammable gas piping and gas processing equipment.

Tesoro Refinery Fatal Explosion and Fire

Tesoro Refining & Marketing Company LLC

2010-8-I-WA-R14

Revise and improve the Process Hazard Analysis (PHA), the Integrity Operating Window (IOW), and the damage mechanism hazard review (DMHR) programs and cross-linking among these three programs such that all identified hazards are effectively managed in each program. For all Tesoro refineries require: a. the IOW to review damage mechanism hazards from the most recent PHA and safeguards identified to control these hazards; b. the IOW review or revalidation to be conducted at least every five years; c. the IOW to analyze and incorporate applicable industry best practice, the hierarchy of controls, and inherently safer design to the greatest extent reasonably practicable; d. the DMHR report to be developed by the DMHR team and not just the “corrosion expert;” e. the DMHR team to review the operating data to verify an accurate understanding of how the data was obtained, what it represents, and that it appropriately addresses both routine and non-routine operations; f. the DMHR and/or IOW review to identify and review gaps between current industry best practices and existing Tesoro practices with regard to material selection and process controls and make recommendations that reduce risks from damage mechanism hazards; g. the DMHR and IOW review to review applicable Tesoro and industry-wide damage mechanism incidents as part of the respective DMHR or IOW review; h. the DMHR to review relevant MOCs to fully evaluate the impact of the MOC on damage mechanism hazards; i. the identification of minimum qualifications for the “corrosion expert” and ensure that the DMHR team has the necessary skills to meet these requirements; j. for sites that have a corrosion/materials engineer, the corrosion/materials engineer shall be a required participant in the DMHR;  k. the PHA to review the most recent DMHR and IOW reviews in order to contain a complete record of all identified damage mechanism hazards, evaluate existing safeguards, and propose new safeguards to control the identified hazards; l. the PHA to review the consequence of damage mechanism hazards identified in the risk-based inspection (RBI) program and IOW reviews to ensure effective safeguards are present to control the damage mechanism hazard; and m. the PHA to use the hierarchy of controls and implement opportunities for inherently safer design to the greatest extent reasonably practicable.

Investigation

Recipient

Record Number

Recommendation Text

Allied Terminals Fertilizer Tank Collapse

Allied Terminals Inc.

2009-3-I-VA-R6

Hire a qualified independent reviewer to verify that maximum liquid levels for all tanks at Allied’s Norfolk and Chesapeake terminals meet the requirements of American Petroleum Institute Standard 653, Tank Inspection, Repair, Alteration, and Reconstruction. At a minimum, the review should verify that all requirements for welding, inspection of welds, and In-Service and Out-of-Service tank inspections are met. Make the complete review report for both terminals available to the Cities of Norfolk, Chesapeake, and Portsmouth, Virginia, as well as the Virginia Department of Environmental Quality.

2009-3-I-VA-R1

Take immediate action to reduce the risk of a catastrophic failure of Tanks 202, 205, and 209 at the Allied Terminals Hill Street facility including but not limited to significantly reducing the maximum liquid levels (“safe fill height”) based on sound engineering principles.  Report the actions taken to the City of Chesapeake.

2009-3-I-VA-R2

Select and retain a qualified, independent tank engineering firm to evaluate Tanks 202, 205, and 209 and determine their fitness for continued service.  The evaluation should be based on recognized and generally accepted good engineering practices, such as API 653 - Tank Inspection, Repair Alteration, and Reconstruction and API 579 - Fitness for Service.

Fertilizer Institute, The

2009-3-I-VA-R10

Formally recommend to all member companies the incorporation of The Fertilizer Institute tank inspection guidelines into contracts for the storage of liquid fertilizer at terminals.

BP Texas City

BP Texas City, TX

2005-4-B-TX-R1

Revise the maintenance quality control program to require positive material identification testing or another suitable material verification process for all critical service alloy steel piping components removed and reinstalled during maintenance and inform work crews of special material handling precautions.

JV Industrial Companies

2005-4-B-TX-R2

Develop / update the written piping component installation quality control procedure to require positive material identification testing or other suitable verification or tracking process for all alloy steel piping components removed during maintenance.

BP Texas City, TX

2005-4-I-TX-R15

2. Ensure that instrumentation and process equipment necessary for safe operation is properly maintained and tested. At a minimum, a. Establish an equipment database that captures the history of testing, inspections, repair, and successful work order completion. b. Analyze repair trends and adjust maintenance and testing intervals to prevent breakdowns. c. Require repair of malfunctioning process equipment prior to unit startups.

Carbide Industries Fire and Explosion

Carbide Industries

2011-5-I-KY-R03

Implement a mechanical integrity program for the electric arc furnace and cover, including preventive maintenance based on periodic inspections, and timely replacement of the furnace cover. At a minimum, the program should include factors such as leak detection and repair and refractory lining wear.

Chevron Refinery Fire

American Petroleum Institute

2012-3-I-CA-R28

Revise API 570: Piping Inspection Code:  In-service Inspection, Rating, Repair, and Alteration of Piping Systems to:  a. Use terminology consistent with API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries and other API standards and recommended practices discussed in this report.  Replace the terminology “high-temperature sulfur corrosion” with “sulfidation corrosion”; b. Specify that sulfidation corrosion rates in carbon steel piping can be significantly faster in some individual piping components than in others; c. Establish a new section that details inspection requirements to identify low-silicon piping components in carbon steel circuits susceptible to sulfidation corrosion.  This section shall require users to identify carbon steel piping circuits at risk to contain low-silicon components by following the requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to 2012-03-I-CA-26(a)) and API RP 578: Material Verification Program for New and Existing Alloy Piping Systems (pursuant to 2012-03-I-CA-29).  At a minimum, require users to either: i. Inspect every component within all carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components once.  The purpose of this practice is to identify any low-silicon components that are corroding at accelerated rates.  Inspection may be performed through ultrasonic thickness measurements to establish corrosion rates for each component, destructive laboratory analysis, or other methods.  Following the inspection, require users to follow the low-silicon corrosion rate monitoring requirements established in 2012-03-I-CA-R26(c); or     ii. Replace the identified at-risk carbon steel piping with a steel alloy that is more resistant to sulfidation corrosion.  d. Incorporate as a “normative reference” API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries; and e. Require users to follow the minimum leak response guidance established in API RP 2001: Fire Protection in Refineries, developed in response to recommendation 2012-03-I-CA-R31.

City of Richmond, CA; Mayor and City Council

2012-3-I-CA-R05

Ensure the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R1 and 2012-03-I-CA-R2), so that all necessary mechanical integrity work at the Chevron Richmond Refinery is identified and recommendations are completed in a timely way.

Contra Costa County, CA; Board of Supervisors

2012-3-I-CA-R08

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R1 and 2012-03-I-CA-R2), so that all necessary mechanical integrity work at the Chevron Richmond Refinery is identified and recommendations are completed in a timely way.

DPC Enterprises Festus Chlorine Release

Branham Corporation

2002-4-I-MO-R11

Implement a materials verification procedure to improve quality assurance during chlorine transfer hose fabrication and shipment, such that hoses shipped to customers are readily identifiable and meet required specifications. (2002-04-I-MO-R11)

Chlorine Institute, Inc.

2002-4-I-MO-R19

Develop recommended practices to address moisture in dry chlorine piping systems. Include information on suggested material specifications, prevention and corrective measures, and adverse consequences (particularly for emergency shutdown [ESD] systems). (2002-04-I-MOR19)

2002-4-I-MO-R20

Develop recommended practices for testing, inspection, and preventative maintenance of ESD systems for bulk transfer of chlorine. (2002-04-I-MO-R20)

DPC Enterprises L.P. Festus Site

2002-4-I-MO-R1

Revise the mechanical integrity program: Develop and implement a quality assurance management system, such as positive materials identification, to confirm that chlorine transfer hoses (CTH) are of the appropriate materials of construction. (2002-04-I-MO-R1)

2002-4-I-MO-R2

Revise the mechanical integrity program: Implement procedures and practices to ensure the emergency shutdown (ESD) system operates properly. Include procedures to verify that the ESD valves will close to shut down the flow of chlorine. (2002-04-I-MO-R2)

2002-4-I-MO-R3

Revise the mechanical integrity program: Revise the preventive maintenance and inspection program for the chlorine transfer system to address moisture-related corrosion. Evaluate and correct any problems associated with corrosion that could potentially lead to chlorine transfer and safety system failure. (2002-04-I-MO-R3)

2002-4-I-MO-R4

Revise the mechanical integrity program: Require periodic inspection of the above critical safety systems by the operations or facility manager. (2002-04-I-MO-R4)

DX Distribution Group

2002-4-I-MO-R8

In light of the findings of this report, conduct periodic audits of the safety management systems involved in this incident, such as mechanical integrity, emergency response, and material quality assurance. Ensure that the audit recommendations are tracked and implemented. Share findings and recommendations with the work force at your repackaging facilities. (2002-04-I-MO-R8)

DuPont Corporation Toxic Chemical Releases (Belle)

American Chemistry Council Phosgene Panel

2010-6-I-WV-R11

Revise the Phosgene Safe Practice Guidelines Manual to • Advise against the use of hoses for phosgene transfer that are constructed of permeable cores and materials subject to chlorides corrosion. • Include guidance for the immediate reporting and prompt investigation of all potential (near-miss) phosgene releases.

DuPont Belle Plant

2010-6-I-WV-R3

Improve the existing maintenance management by • Supplementing the computerized system with sufficient redundancy to ensure tracking and timely scheduling of preventive maintenance for all PSM-critical equipment. • Conducting Management-of-Change (MOC) reviews for all changes to preventive maintenance orders for all PSM-critical equipment in the computerized maintenance management system.

E.I. du Pont de Nemours and Company

2010-6-I-WV-R6

Revise safeguards for phosgene handling at all DuPont facilities by • Requiring that all indoor phosgene production and storage areas, as defined in NFPA 55, have secondary enclosures, mechanical ventilation systems, emergency phosgene scrubbers, and automated audible alarms, which are, at a minimum, consistent with the standards of NFPA 55 for highly toxic gases. • Prohibiting the use of hoses with permeable cores and materials susceptible to chlorides corrosion for phosgene transfer. • Conducting annual phosgene hazard awareness training for all employees who handle phosgene, including the hazards associated with thermal expansion of entrapped liquid phosgene in piping and equipment.

Hoeganaes Corporation Fatal Flash Fires

Gallatin Fire Department

2011-4-I-TN-R12

Ensure that all industrial facilities in the City of Gallatin are inspected periodically against the International Fire Code. All facility inspections shall be documented.

Marcus Oil and Chemical Tank Explosion

Marcus Oil

2005-2-I-TX-R1

Implement the requirements of the National Board Inspection Code (NB-23) to repair all pressure vessels that have been altered at the facility. Require the application of NB-23 to all future pressure vessel repairs and alterations

Motiva Enterprises Sulfuric Acid Tank Explosion

American Petroleum Institute

2001-5-I-DE-R11

Revise API tank inspection standards to emphasize that storage tanks with wall or roof holes or thinning beyond minimum acceptable thickness that may contain a flammable vapor are an imminent hazard and require immediate repair or removal from service. (2001-05-I-DE-R11)

Delaware Department of Natural Resources and Environmental Control

2001-5-I-DE-R2

Ensure that regulations developed for the recently enacted Jeffrey Davis Aboveground Storage Tank Act require that facility management take prompt action in response to evidence of tank corrosion that presents hazards to people or the environment. (2001-05-I-DE-R2)

Motiva Enterprises - Delaware City Refinery

2001-5-I-DE-R3

Implement a system to ensure accountability for mechanical integrity decision making. (2001-05-I-DE-R3)  Include the following specific items - Review of inspection reports by subject area experts, such as metallurgists or equipment design engineers, to ensure adequate analysis of failure trends and suitability for intended service. - Establishment of a planning system to ensure the timely repair of equipment.  The Center for Chemical Process Safety (CCPS) publication, Plant Guidelines for Technical Management of Chemical Process Safety, Chapter 3, “Accountability Objectives and Goals,” presents a model for such a system.

2001-5-I-DE-R5

Ensure that management of change reviews are conducted for changes to tank equipment and operating conditions, such as (2001-05-I-DE-R5): - Tank service and contents - Tank peripherals, such as inerting and venting systems.

2001-5-I-DE-R7

Upgrade the refinery Unsafe Condition Report system to include the following (2001-05-I-DE-R7): - Designation of a specific manager with decision-making authority to resolve issues. - Establishment of a mechanism to elevate attention to higher levels of management if issues are not resolved in a timely manner. - Identification of a means to ensure communication of hazards to all potentially affected personnel.  Work with the Paper, Allied-Industrial, Chemical & Energy Workers International Union (PACE) Local 2-898 to design and implement the improved system.

2001-5-I-DE-R8

In light of the findings of this report, conduct periodic audits of storage tank mechanical integrity and design, Unsafe Condition Reports, hot work, management of change, and accountability systems at Motiva oil refineries. Ensure that the audit recommendations are tracked and implemented. Share the findings with the workforce. (2001-05-I-DE-R8)

NACE International

2001-5-I-DE-R14

Work with the American Petroleum Institute to develop API guidelines to ensure that storage tanks containing fresh or spent H2SO4 are inspected at frequencies at least as often as those recommended in the latest edition of NACE Standard RP 0294- 94, Design, Fabrication, and Inspection of Tanks for the Storage of Concentrated Sulfuric Acid and Oleum at Ambient Temperatures. (2001-05-I-DE-R14)

Paper, Allied-Industrial, Chemical & Energy Workers International Union (PACE) Local 2-898

2001-5-I-DE-R16

Work with Motiva management on the design and implementation of an improved Unsafe Condition Report program. (2001-05-I-DE-R16)

NDK Crystal Inc. Explosion with Offsite Fatality

NDK America, Inc.

2010-4-I-IL-R7

Implement an annual inspection and corrective action program to ensure vessels remain resistant to environmentally induced damage mechanisms based on the inspection guidelines set forth in the American Petroleum Institute (API) Standard 510, Pressure Vessel Inspection Code.

Technic Inc. Ventilation System Explosion

Technic, Inc.

2003-08-I-RI-R3

Implement a preventive maintenance program for the vent collection system that includes regular inspection, training and troubleshooting.

Tesoro Refinery Fatal Explosion and Fire

American Petroleum Institute

2010-8-I-WA-R10

Revise American Petroleum Institute API RP 941: Steels for Hydrogen Service at Elevated Temperatures and Pressures in Petroleum Refineries and Petrochemical Plants to:  a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems; b. Require the use of inherently safer materials to the greatest extent feasible; c. Require verification of actual operating conditions to confirm that material of construction selection prevents HTHA equipment failure; and d. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure.

2010-8-I-WA-R11

Revise American Petroleum Institute API RP 581: Risk-Based Inspection Technology to: a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems; b. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure; and c. Require verification of actual operating conditions to determine potential equipment damage mechanisms.

Tosco Avon Refinery Petroleum Naphtha Fire

Ultramar Diamond Shamrock Golden Eagle Refinery

1999-14-I-CA-R2

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.

1999-14-I-CA-R4

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.

Valero Refinery Propane Fire

American Petroleum Institute

2007-5-I-TX-R1

Issue API-recommended practices for freeze protection in oil refinery process units that include, as a minimum:  -the establishment of a written program;   -periodic inspections to identify freeze hazards in dead-legs or infrequently used piping and equipment where water could collect;   -specific approaches to eliminate or protect against such freeze hazards; and   -identification of infrequently used piping or equipment subject to freezing as a trigger for Management Of Change (MOC) reviews.