CSB Report: Workers Needlessly Injured in Refinery Fire

A report by the U.S. Chemical Safety Board (CSB) concluded that a November 2016 fire that severely burned four workers at the ExxonMobil refinery in Baton Rouge, Louisiana, resulted from a failure to use good safety practices.

The fire occurred during maintenance activities when operators inadvertently removed bolts securing a piece of pressure-containing equipment to a plug valve. When the operators attempted to open the plug valve, it came apart, releasing flammable hydrocarbons that formed a vapor cloud that quickly ignited.

CSB chair Vanessa Allen Sutherland commented, “Our investigation found that these accepted practices were conducted without appropriate safety hazard analysis, needlessly injuring these workers. It is important to remember that good safety practices are good maintenance practices and good business practices.”

A key safety lesson addressed in the CSB findings is the hierarchy of controls, a method of implementing safeguards in a designated priority order to provide effective risk reduction. Within the hierarchy of controls, an engineering control, such as improved valve design, is more effective than a lower-level administrative control, such as a warning sign. The CSB says that updating all of the older valves to the safer design, (most, but not all had been updated) would have prevented the incident.

The CSB investigation revealed a culture that was accepting of operators performing maintenance without written procedures or adequate training. Among other lessons learned:

1. Evaluate human factors associated with operational difficulties, especially when the equipment is part of a process covered by OSHA’s process safety management (PSM) standard. Apply the hierarchy of controls to mitigate identified hazards.
2. Establish detailed and accurate procedures for workers performing potentially hazardous tasks, such as removing an inoperable gearbox.
3. Provide training to ensure workers can perform all anticipated job tasks safely. The training should include a focus on processes and equipment to improve hazard awareness and help prevent chemical accidents.

The full CSB report is available at http://www.csb.gov/assets/1/19/ExxonMobil_Baton_Rouge_Safety_Bulletin_-_Final_-_2017-09-01.pdf