REFINERY FIRE INCIDENT: A CASE STUDY OF A MULTIPLE FATALITY INCIDENT AT THE TOSCO AVON REFINERY, MARTINEZ, CALIFORNIA

摘要

On February 23, 1999, a fire occurred at the Tosco Avon Refinery in Martinez, California. Workers were attempting to replace piping attached to a 150-foot-tall crude fractionator while the process unit was in operation. The piping, which had developed a pinhole leak, contained flammable naphtha liquid that was not successfully drained or isolated during the thirteen-day period before the removal work began. During the removal of the piping, naphtha was released onto the hot fractionator tower where it ignited. Four workers were killed and one sustained serious injuries. The U.S. Chemical Safety and Hazard Investigation Board (CSB) initiated an incident investigation. The CSB examined the following safety issues in the Tosco case: 1. Control of hazardous nonroutine maintenance 2. Management oversight and accountability 3. Management of change 4. Corrosion control program This paper summarizes the results of the investigation, including a review of the incident, causes identified by CSB, and recommendations to prevent future similar incidents.