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Refinery chemical incident probe highlights safety culture gaps


A U.S. Chemical Safety and Hazard Investigation Board report about two sulfuric acid releases at a California refinery owned by Tesoro Corp. highlighted multiple concerns about the refinery’s safety culture.

In February 2014, an incident occurred at the Tesoro Refinery in Martinez, California, which burned two workers and released an estimated 84,000 pounds of sulfuric acid, according to a report issued by the board on Tuesday. In March 2014, sulfuric acid sprayed and burned two contract workers during the removal of piping. Both incidents occurred in the refinery’s alkylation unit where high-octane blending components are produced for gasoline.

The process safety culture case study conducted by the board found a number of safety culture concerns at the refinery, such as minimization of the February 2014 incident as a minor injury instead of being classified as the most serious type of process safety incident under industry guidelines. In addition, there was a failure to develop an action plan to address concerns identified in a 2007 safety culture survey, withdrawal from key national safety programs that workers believed were effective and perceived pressure on alkylation unit workers to expedite training and reduce cost, according to the report.

“The safety culture at the Tesoro Martinez refinery created conditions conducive to the occurrence and recurrence of process safety incidents that caused worker injuries at the refinery over several years,” the board said in its report.

Since 2014, San Antonio-based Tesoro has worked closely with multiple agencies on their investigations and conducted an extensive review of procedures, controls and training, and has identified several areas it is working to improve, including modifying procedures, practices and equipment specifications, as a result of this effort, the company said in an emailed statement.

“We agree on the critical importance of continually learning from incidents and improving the safety of our operations, and inaccuracies in the case study do not detract from our resolve to learn from these incidents,” the company said in the statement. “We have shared and continue to share information with industry groups to ensure that others in our industry can also learn from these events. We are committed to continuing our journey toward an injury-free work place by nurturing a positive process safety culture and employing the right tools and processes.”

Following board investigations into other accidents at petroleum refineries, the agency has recommended changes to strengthen regulations in California and Washington state. California has issued a draft refinery process safety management standard containing more rigorous safety regulations for oversight of petroleum refineries.

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, according to the case study.

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