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Chairperson Vanessa Allen Sutherland said, “The CSB urges all refineries to review the key findings and conclusions of the board’s case study and to apply those learnings to their own facilities. It is imperative that companies continually work towards improving their operations in an effort to prevent future incidents and ensure the safety of their workforce.”

The CSB’s case study examines the Tesoro Martinez Refinery through the evaluation of previous incidents, worker statements, gaps in safety standards, deviations from established procedures and practices, and past efforts to assess and strengthen site safety culture.

The investigation found a number of safety culture concerns at the refinery, such as:

o Characterization of the February 2014 incident as a minor injury while the incident should have been classified as the most serious type of process safety incident under industry guidelines;

o Exposure of alkylation unit workers to hazardous materials including vapors, acids, and corrosives;

o Removal of safer sulfuric acid sampling systems from service and reliance on inadequate temporary alkylation unit equipment;

o Failure to provide alkylation unit workers with necessary protective equipment;

o Existence of site-specific safety policies that were less protective than corporate policies and established industry good practice;

o Failure to develop an action plan to address concerns identified in a 2007 safety culture survey;

o Withdrawal from key national safety programs that workers believed were effective; and

o Perceived pressure on alkylation unit workers to expedite training and reduce cost.

The state of California has issued a draft refinery process safety management standard containing more rigorous safety regulations for the oversight of petroleum refineries, and the CSB is encouraged by these proactive changes to improve safety for workers and communities. The CSB’s case study underscores the need for the proposed refinery safety reforms as well as individual refineries to continually assess and improve their process safety programs.  The CSB’s case study emphasizes that regulators can use what are known as lagging process safety indicators, such as spills, fires, or gas releases, as well as leading indicators such as timely maintenance on safety critical equipment to focus inspections, audits, and timely closure of action items resulting from incident investigations to help drive process safety improvement.  “The continued recurrence of sulfuric acid incidents demonstrates the need for improvements at the Tesoro refinery. We recommend that the refinery report process safety indicators to the regulator, said Lead Investigator Dan Tillema. “Regulators should monitor these indicators and conduct preventive inspections that lead to corrective actions –this is a critical component of an effective safety program – the ultimate goal is to ensure that risk is continually reduced.”  www.satprnews.com

August 19, 2014 - In a report published last Friday, the US Chemical Safety Board (CSB) said that loose pipe fittings caused the 84,000 pound sulfuric acid spill that seriously injured two workers at Tesoro’s Golden Eagle refinery on February 12.  Golden Eagle is located in Martinez, California, about 35 mile northwest of San Francisco.  The report was prepared by California engineering and laboratory testing firm Anamet Inc.  The report details findings from an examination of a stainless-steel tube assembly recovered from the accident site by the California Division of Occupational Safety and Health (Cal/OSHA).  The report said that the tubes and a compression joint at the sulfuric acid sampling station were not sufficiently tightened during installation.  The tubes were shaken loose from the compression joint when they were pressurized.  Cal/OSHA closed down the Golden Eagle alkylation unit from February 18 to 28.  Employees told Cal/OSHA that they had been afraid to work in the unit before the accident because of safety concerns.  “This incident highlights the need for strong process safety management at facilities that ensures mechanical integrity is verified prior to the introduction of hazardous chemicals into equipment,” CSB Chairperson Rafael Moure-Eraso said.  Moure-Eraso said the need for safety management is pressing because of another sulfuric acid spill at the same refinery on March 10.  Two contract workers were sprayed with sulfuric acid while conducting planned maintenance during that incident.  “Four workers burned by sulfuric acid in less than a month clearly demonstrates there are significant opportunities within the refinery for improvement in safety performance,” Moure-Eraso said.  Cal/OSHA is continuing a separate investigation at the refinery, focusing on the refinery’s mechanical integrity and operating procedures.  The Golden Eagle refinery has a crude oil capacity of 166,000 barrels per day and employees 650 people.  San-Antonio based Tesoro is an independent downstream company.  Tesero has not commented on the report. (Petro Global News)