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S.

No Incident Occurred On Location


ExxonMobil 11/22/2016 Baton Rouge,
Refinery LA
Chemical Release
and Fire

Delaware City 11/29/2015 Delaware City,


Refining DE
Company

ExxonMobil 2/18/2015 Torrance, CA


Refinery
Explosion
3

Macondo 4/20/2010 GoM


Blowout and
Explosion
4

Chevron Refinery 1/28/2015 Richmond, CA


Fire
5

Tesoro Refinery 4/2/2010 Anacortes, WA


Fatal Explosion
6 and Fire
Silver Eagle 1/12/2009 Woods Cross,
Refinery Flash UT
Fire and
Explosion and
Catastrophic Pipe
Explosion
7

Valero Refinery 2/16/2007 Sunray, TX


Propane Fire

BP America 3/23/2005 Texas City, TX


Refinery
Explosion

Tosco Avon 2/23/1999 Martinez, CA


Refinery
Petroleum
Naphtha Fire
10

BP Amoco 3/13/2001 Augusta, GA


Thermal
Decomposition
Incident
11
Consequence
On November 22, 2016, an isobutane release occurred in the sulfuric acid
alkylation unit at the ExxonMobil Refinery in Baton Rouge, Louisiana which resulted
in four serious injuries to workers and injured two others. The incident occurred
during minor maintenance on a flammable isobutane line which failed, releasing
isobutane into the unit which ignited.

On Sunday, November 29, 2015, an operator at the Delaware City Refining


Companys (DCRC) Kellogg Alkylation Unit suffered second degree burns to his face
and neck areas while performing de-inventorying activities on a vessel in
preparation for the removal of a pipe spool from a connected process. This incident
follows two other incidents at the same facility which occurred on August 21, and
August 28, 2015.

A February 18, 2015, explosion in a gasoline processing unit at the ExxonMobil


Refinery in Torrance, CA, led to two workers suffering minor injuries and debris
being dispersed into the surrounding community.

On April 20, 2010, a sudden explosion and fire occurred on the oil rig. The accident
resulted in the deaths of 11 workers and caused a massive, ongoing oil spill into the
Gulf of Mexico. The rig was located approximately 50 miles southeast of Venice,
Louisiana, and had a 126-member crew onboard.

An August 6, 2012, release of flammable vapor led to a fire at the Chevron Refinery
in Richmond, California. The CSB released three investigation reports into this
incident - an Interim Report, a Regulatory Report and a Final Report.

An explosion and fire led to the fatal injury of seven employees when a nearly
forty-year-old heat exchanger catastrophically failed during a maintenance
operation to switch a process stream between two parallel banks of exchangers at
the Tesoro refinery in Anacortes, Washington
On the evening of January 12, 2009, 2 refinery operators and 2 contractors suffered
serious burns resulting from a flash fire at the Silver Eagle Refinery in Woods Cross,
Utah. The accident occurred when a large flammable vapor cloud was released
from an atmospheric storage tank, known as tank 105, which contained an
estimated 440,000 gallons of light naphtha. The vapor cloud found an ignition
source and the ensuing flash fire spread up to 230 feet west of the tank farm. On
November 4, 2009, a second accident occurred at the Silver Eagle Refinery in
Woods Cross, Utah, when a powerful blast wave - - caused by the failure of a 10
inch pipe - damaged nearby homes.

On February 16, 2007, a propane fire erupted at the Valero McKee Refinery in
Sunray, Texas, north of Amarillo. Three workers suffered serious burns, and the
refinery was forced to shut down. The fire began following a leak in the propane
deasphalting unit and spread quickly, in part because of the rapid collapse of a
major pipe rack carrying flammable hydrocarbons. Some of the rack's support
columns had not been fireproofed.

At approximately 1:20 p.m. on March 23, 2005, a series of explosions occurred at


the BP Texas City refinery during the restarting of a hydrocarbon isomerization unit.
Fifteen workers were killed and 180 others were injured. Many of the victims were
in or around work trailers located near an atmospheric vent stack. The explosions
occurred when a distillation tower flooded with hydrocarbons and was
overpressurized, causing a geyser-like release from the vent stack.

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.

On March 13, 2001, three people were killed as they opened a process vessel
containing hot plastic at the BP Amoco Polymers plant in Augusta, Georgia. They
were unaware that the vessel was pressurized. The workers were killed when the
partially unbolted cover blew off the vessel, expelling hot plastic. The force of the
release caused some nearby tubing to break. Hot fluid from the tubing ignited,
resulting in a fire.
Cause
Human factors;
Poor valve design; and
No detailed and accurate procedure on maintenance of gear box of isolation valves

Isolation valve passing


Confusing maintenance procedures on deinventorying of process equipment

Operations integrity management system


PHA
Mechanical Integrity;
Worker participation;
SCE management; and
Non routine operations

Cement barrier failure and subsequent BOP closure failure

Ineffective PSM program;


Deficient mechanical integrity programs;
Poor ERP

Inherently safer design issue;


Tesoro Process safety Culture;
Control of Non routine work;
Mechanical integrity
Aged equipment;
Mechanical integrity

Freeze protection of dead legs;


Isolation failure;
Fire proofing of supporting steel;
Fire protection for High pressure LPG service;
Chlorine release

Overfilling Raffinate splitter column;


Column level indicator malfunction;
Redundant High level alarm failure;
No automatic safety devices;
No proper superviosion durring startup;
Fatigue on operators working for 12 hours a day for past 29 consecutive days.
No appropriate OTS training (simulators unavailable)

Control of Non routine maintenance hazards;


Management of Change;
Corrosion control (Mechanical Integrity)

Thermal decomposition of hot plastic in isolated equipment under maintenance.

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