CSB final report on Chevron Richmond refinery fire

A safety dashboard can only track the performance indicators that are input to the system. Chevron’s operational excellence and reliability intelligence dashboard missed one crucial KPI.

The Chemical Safety Board has produced another no punches pulled report on an industrial accident, the August 2012 Chevron Richmond Refinery pipe rupture and fire. An 8” line flowing 10,800 bbls/day of light gasoil ruptured releasing a vapor cloud that subsequently ignited.

While there were no serious injuries or fatalities, 15,000 people from the surrounding communities sought treatment at nearby medical facilities for breathing and other problems, ten of whom were admitted. Root cause of the rupture was found to be sulfidation corrosion, a damage mechanism that causes steel to thin over time when exposed to sulfur compounds at high temperature.

The CSB found that in the 10 years prior to the incident, Chevron’s own energy technology company’s (ETC) personnel with understanding of sulfidation corrosion recommended inspection and/or upgrade of the unit, in a ‘sulfidation failure prevention initiative’ SFPI, but this was not implemented effectively. Along with such chain-of-command shortcomings, the CSB found that Chevron’s ‘operational excellence and reliability intelligence’ (Oeri) online dashboard failed to catch the issue.

Oeri uses 26 different process safety indicators, to track the implementation status of ETC recommendations and new industry guidance. Oeri visually displays the status of many different process safety indicators. However, Oeri did not track progress of implementing the recommendations of its own in-house specialists. The CSB believes that by monitoring a KPI of the status of the SFPI the accident could have been avoided. Read the final CSB report.

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