November, 2016

This is a repeating event

201622NovAll DayExxonmobil (Baton Rouge) Fire 2016ExxonMobil Baton Rouge (US-LA) Origin: CSB Lessons:Asset integrity,Competency,Operating ProceduresIndustry:RefiningCountry:United StatesLanguage:ENLoC:Maintenance error

Summary

On November 22, 2016, an isobutane release and fire seriously injured four workers in the sulfuric acid alkylation unit at the ExxonMobil Refinery in Baton Rouge, Louisiana (‘Baton Rouge refinery’). During removal of an inoperable gearbox on a plug valve, the operator performing this activity removed critical bolts securing the pressure-retaining component of the valve known as the top-cap. When the operator then attempted to open the plug valve with a pipe wrench, the valve came apart and released isobutane into the unit, forming a flammable vapor cloud. The isobutane reached an ignition source within 30 seconds of the release, causing a fire and severely burning four workers who were unable to exit the vapor cloud before it ignited.

KEY ISSUES:
• HUMAN FACTORS
• EQUIPMENT DESIGN
• HIERARCHY OF CONTROLS
• OPERATING PROCEDURES & TRAINING

ROOT CAUSES:
1. Human factors associated with operational difficulties that exist in machinery and other equipment.
2. Deficient procedures for workers performing potentially hazardous work.
3. Inadequate training to ensure workers can perform all anticipated job tasks safely.


Image credit: CSB

Origin

CSBUS Chemical Safety Board

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