February, 1999

This is a repeating event

199923FebAll DayTosco Avon (Crude Unit) Fire 1999Tosco Avon Martinez (US-CA) Origin: CSB Lessons:Asset integrity,Commitment & Culture,Control of Work,Management of ChangeIndustry:RefiningCountry:United StatesLanguage:ENLoC:Maintenance error

Summary

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.

KEY ISSUES:
• CONTROL OF HAZARDOUS NONROUTINE MAINTENANCE
• MANAGEMENT OVERSIGHT & ACCOUNTABILITY
• MANAGEMENT OF CHANGE
• CORROSION CONTROL

ROOT CAUSES:
1. Tosco Avon refinery’s maintenance management system did not recognize or control serious hazards posed by performing nonroutine repair work while the crude processing unit remained in operation.
2. Tosco’s safety management oversight system did not detect or correct serious deficiencies in the execution of maintenance and review of process changes at its Avon refinery.


Image Credit: CSB

Origin

CSBUS Chemical Safety Board

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