The U.S. Chemical Safety Board (CSB) released its final report Monday on a 2012 Chevron refinery fire and blasted Chevron management, EPA, OSHA, and California regulators for not doing enough to have prevented it in the first place.The CSB will be accepting public comments on the report until January 3, 2014.
The fire occurred at Chevron's refinery in Richmond, California on August 6, 2012. A catastrophic pipe failure in the #4 Crude Unit resulted in a vapor cloud that engulfed 19 employees and ignited. Although no lives were lost, about 15,000 residents from nearby communities fled to emergency rooms with numerous ill effects resulting from smoke from the fire, which could be seen for miles and miles (see related video at left).
An animation of the events leading up to and including the fire is available here: Chevron Richmond Refinery Fire Animation
Chevron has a large oil & gas production presence in Bakersfield, Kern County, and the San Joaquin Valley. Produced crude is sent to refineries in Richmond and the Los Angeles area for processing into gasoline, diesel, and other products.
The CSB criticized Chevron management for failing to heed the recommendations of its own staff and engineers who had proposed changes years earlier that would have prevented the incident. The CSB did not spare CAL/OSHA or EPA either, saying that regulators responsible for ensuring the safety of refinery operations were inadequately trained and that the regulations in place needed to be strengthened to minimize the risk of incidents like this from happening again. Indeed, the CSB stated that after investigating similar incidents, it had made numerous safety recommendations to EPA and OSHA over the last 10 years, none of which has been implemented by either agency.
Don Holmstrom, director of the CSB’s Western Regional Office, which is conducting the Chevron investigation, said, “OSHA’s Process Safety Management [PSM] standard, the EPA’s Risk Management Program, and California’s system do not work consistently to prevent industrial process accidents. What is lacking, and what the safety case regime requires, is an adaptable, rigorously inspected, goal-setting approach, aimed at continuously reducing risks to ‘as low as reasonably practicable’ – known in the industry as ALARP.”
The CSB recommended the following actions:
- California State Legislature and Governor of California - Develop and implement a step-by-step plan to establish a more rigorous safety management regulatory framework for petroleum refineries in the state of California based on the principles of the “safety case” framework.
- Occupational Safety and Health Administration - Develop questions and evaluate issues raised from the findings and conclusions in this report concerning the safety case regime.
More detailed findings from the draft report include the following:
1. For the prior ten years, highly knowledgeable and experienced Chevron technical staff repeatedly recommended that inspectors perform 100 percent component inspections on high temperature carbon steel piping susceptible to sulfidation corrosion. These recommendations were not implemented by Chevron management.
2. Chevron technical staff recommended implementing inherently safer designs through the Management of Change (MOC) process, incident investigations, technical reports, and past recommendations from employees, including changes to the pipe that failed. However, Chevron management failed to do so.
3. A similar fire in January 2007, due to a failure due to sulfidation corrosion, caused a shelter-in-place for the surrounding community. A carbon steel piping spool failed catastrophically during operation. Chevron informed Contra Costa Health Services’ Hazardous Materials Program in a letter that the crude unit piping metallurgy had been upgraded following this incident as an inherently safer solution, but, only applied the upgrade to the section that failed and not the entire crude unit.
4. Chevron metallurgists, materials engineers, and piping inspectors had expertise regarding sulfidation corrosion, but, little practical influence to implement their recommendations. They did not participate in the most recent crude unit (Process Hazard Analysis) PHA, and they did not affect decisions concerning control of sulfidation corrosion during the crude unit turnaround process.
5. A 2009 crude unit PHA did not identify corrosion as a potential cause of a leak or rupture in piping and relied on non-specific, judgment-based qualitative safeguards whose effectiveness were not evaluated. Had it done so, the possibility of failure due to corrosion would have been addressed.
6. Cal/OSHA's PSM standards do not require documentation of the effectiveness of safeguards. If they did, Chevron would have been obligated to do so.
7. California regulators lack the technical skills , knowledge, and experience to provide sufficient direct oversight of petroleum refineries in California. In addition, there is significant difference in compensation between the regulators and the refinery employees with whom they interact.
8. The CSB noted a considerable problem with significant and deadly incidents at petroleum
refineries over the last decade. In 2012 alone, 125 significant process safety incidents at US petroleum refineries, including 17 in California occurred.
9. Current regulations do not require risks be reduced to As Low As Reasonably Practicable (ALARP). As a result, a process hazard analysis (PHA) may meet regulatory requirements but inadequately identify or mitigate major hazard risk. Additionally, PHAs are not required to be submitted for regulatory review and the regulator is not responsible for assessing its quality nor its proposed safeguards.
10. Despite making numerous regulatory recommendation to OSHA and EPA over the last 10 years after reviewing several incidents, none of the recommendations has been implemented. Furthermore, no substantive changes have been made to the PSM and RMP regulations to improve the prevention of major accidents.
11. Available data from Norway and the United Kingdom (UK) shows a reduction in hydrocarbon
releases offshore under the safety case regulatory regime.
12. Other agencies, such as the Nuclear Regulatory Commission (NRC) and the National Aeronautics and Space Administration (NASA), require risk reduction to ALARP or equivalent.
13. Support for such a regulatory regime in the United Kingdom has come from a variety of stakeholders, including major oil companies.
In addition to the findings above, the CSB detailed other concerns with the regulatory framework for onshore refineries in California and the rest of the country and found that they:
1. Are primarily activity-based rather than goal-based risk reduction to as low as reasonably practicable (ALARP) or equivalent.
2. Are static and unable to adapt to innovation and advances in the management of major hazard risks.
3. Place the burden on the regulator to verify compliance with the regulations instead of on the industries to effectively manage the risks they create and ensure regulator acceptance of their plans for controlling those risks.
4. Do not effectively incorporate lessons learned from major accidents; nor do they have the authority to require industry to address newly-identified safety issues as a result of such incidents.
5. Do not effectively collect or promote industry use of major accident performance indicators to drive
industry to reduce risks to ALARP.
6. Do not require the use or implementation of inherently safer systems analysis or hierarchy of controls.
7. Do not effectively involve the workforce in hazard analysis and prevention of major accidents.
8. Do not provide the regulator with the authority to accept or reject a company’s hazard analysis, risk
assessment, or proposed safeguards; and
9. Do not employ the requisite number of staff with the technical skills, knowledge, and experience to
provide sufficient direct safety oversight of petroleum refineries.