Accident: Tosco Avon Refinery Petroleum Naphtha Fire
Location: Location: Martinez, CA
Accident Occurred On: 02/23/1999 | Final Report Released On: 03/21/2001
Accident Type: Oil and Refining - Fire and Explosion
Investigation Status: The final report on this investigation was approved March 21, 2001.
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.
Communicate the findings of this report to your membership.
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.
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.
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.
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.