Board of Inquiry Tosco Avon Refinery Incident

1. Board of Inquiry Tosco Avon Refinery Incident February 23, 1999 Is Paul presenting these CSB mission points? CSB Investigation Team Purpose: CSB was created to investigate catastrophic accidents and provide recommendations for prevention of recurrence of such. The investigation team mission is to identify the root causes and contributing factors that propitiated the accident. The decision to investigate this accident was based on the severity and the potential for lessons learned that can benefic the refining industry. The CSB will publish accident reports to disseminate lessons learned to the particular industry and other industries that use the same technologies or analogous procedures in the conduct of their daily operations. Why investigate this incident? The Severity of the accident and generic lessons learned Our purpose is to learn from this accident in the hopes that others can be prevented) Is Paul presenting these CSB mission points? CSB Investigation Team Purpose: CSB was created to investigate catastrophic accidents and provide recommendations for prevention of recurrence of such. The investigation team mission is to identify the root causes and contributing factors that propitiated the accident. The decision to investigate this accident was based on the severity and the potential for lessons learned that can benefic the refining industry. The CSB will publish accident reports to disseminate lessons learned to the particular industry and other industries that use the same technologies or analogous procedures in the conduct of their daily operations. Why investigate this incident? The Severity of the accident and generic lessons learned Our purpose is to learn from this accident in the hopes that others can be prevented)

2. CSB Investigation Team Lead Investigator Armando Santiago Field Investigators Gary Swearingen Dennis Walters Oil Refinery Safety Analysis Don Holmstrom Bill Hoyle Jim Wescoat Presenter: Armando After Chairman�s intro: Thank you, Mr. Chairman. I'd like to first give a brief introduction of the investigation team at the table. My name is Armando Santiago and after a brief career summary, I will let other investigators introduce themselves. They will provide some background of their experience and how it relates to our investigation. I am a chemical engineer and have worked for 21 years in research, development, testing and evaluation of industrial and military chemical processes. I have conducted failure analyses studies and accident investigations for federal agencies including the Department of Defense, the Environmental Protection Agency and now the Chemical Safety Board. Most of my investigations were performed in cooperation with a variety of national and local government agencies responsible for the implementation of OSHA Process Safety Management (PSM) and EPA Risk Management Program regulations. At this point I'd like to introduce the rest of the field investigation team, Mr. Dennis Walters (an electrical engineer) Mr. Gary Swearingen (a mechanical engineer). Include reference to safety professionals with refinery experience On February 23rd a fire at Tosco Avon facility 50 Crude Unit killed 4 workers and severely injured another. Workers were attempting to replace a 6 inch diameter piping attached to the crude fractionator tower while the process unit was in operation. The piping contained flammable naphtha liquid and was not isolated, nor drained. The piping runs from the tower at a height of 112 feet to another vessel at a height of 38 feet. During the removal of the piping, naphtha was released onto the hot fractionator tower. The naphtha ignited and the flames engulfed workers four of whom were unable to escape from their elevated positions. One worker jumped from the tower sustaining serious injuries. Presenter: Armando After Chairman�s intro: Thank you, Mr. Chairman. I'd like to first give a brief introduction of the investigation team at the table. My name is Armando Santiago and after a brief career summary, I will let other investigators introduce themselves. They will provide some background of their experience and how it relates to our investigation. I am a chemical engineer and have worked for 21 years in research, development, testing and evaluation of industrial and military chemical processes. I have conducted failure analyses studies and accident investigations for federal agencies including the Department of Defense, the Environmental Protection Agency and now the Chemical Safety Board. Most of my investigations were performed in cooperation with a variety of national and local government agencies responsible for the implementation of OSHA Process Safety Management (PSM) and EPA Risk Management Program regulations. At this point I'd like to introduce the rest of the field investigation team, Mr. Dennis Walters (an electrical engineer) Mr. Gary Swearingen (a mechanical engineer). Include reference to safety professionals with refinery experience On February 23rd a fire at Tosco Avon facility 50 Crude Unit killed 4 workers and severely injured another. Workers were attempting to replace a 6 inch diameter piping attached to the crude fractionator tower while the process unit was in operation. The piping contained flammable naphtha liquid and was not isolated, nor drained. The piping runs from the tower at a height of 112 feet to another vessel at a height of 38 feet. During the removal of the piping, naphtha was released onto the hot fractionator tower. The naphtha ignited and the flames engulfed workers four of whom were unable to escape from their elevated positions. One worker jumped from the tower sustaining serious injuries.

3. Investigation Process Conduct of the Field Investigation Sharing of Factual Information Evidence Reviewed Methodology Independent Analysis of Facts Presenter: Armando On February 26 a team of investigators from the Chemical Safety Board Arrived on site, Cal OSHA site security and evidence Met with interested parties, including� Union officials, Company, CCC, Cal OSHA, and other state and federal agencies. Some will present here today. To minimize the impact of duplicate requests by CSB and other investigating agencies, we cooperate during the fact finding phase of the investigation. We shared factual information with Cal/OSHA and the CCC Hazmat investigators. Barrier analysis, Events and causal factor analysis, Change Analysis The analysis, findings and recommendations were independently derived from such facts and were used by the CSB accident investigation team. There were no external influences by other agencies, trade organizations or the company during this analysis. Presenter: Armando On February 26 a team of investigators from the Chemical Safety Board Arrived on site, Cal OSHA site security and evidence Met with interested parties, including� Union officials, Company, CCC, Cal OSHA, and other state and federal agencies. Some will present here today. To minimize the impact of duplicate requests by CSB and other investigating agencies, we cooperate during the fact finding phase of the investigation. We shared factual information with Cal/OSHA and the CCC Hazmat investigators. Barrier analysis, Events and causal factor analysis, Change Analysis The analysis, findings and recommendations were independently derived from such facts and were used by the CSB accident investigation team. There were no external influences by other agencies, trade organizations or the company during this analysis.

4. Investigation Process Evidence Testing Performed Test plan developed and witnessed by all interested parties Cal OSHA FTI Anamet Metallurgical Evaluation Report TOSCO Valve Leak Test Presenter: Armando -Cal-OSHA lab testing FTI-Anamet Metallurgical analysis of samples Identify corrosions products and Identify chemical composition of sludge Determine failure mechanism of piping and bypass globe valve -TOSCO T&E valves labs Bypass valve Leak Testing in Tosco Maintenance Shop Determine isolation capability of valve Determine leak rates Presenter: Armando -Cal-OSHA lab testing FTI-Anamet Metallurgical analysis of samples Identify corrosions products and Identify chemical composition of sludge Determine failure mechanism of piping and bypass globe valve -TOSCO T&E valves labs Bypass valve Leak Testing in Tosco Maintenance Shop Determine isolation capability of valve Determine leak rates

5. Cooperation Contra Costa County Cal OSHA Federal OSHA Federal EPA PACE Union American Petroleum Institute Presenter: Armando CCC - Logistics of Presentation, Technical Resources Cal OSHA - Evidence gathering, preserving the scene, Technical Resources Federal OSHA - assistance during the initial deployment Federal EPA - technical support PACE - Assistance during interviews and cooperation API - Technical references, and support Presenter: Armando CCC - Logistics of Presentation, Technical Resources Cal OSHA - Evidence gathering, preserving the scene, Technical Resources Federal OSHA - assistance during the initial deployment Federal EPA - technical support PACE - Assistance during interviews and cooperation API - Technical references, and support

6. Major Investigation Issues Shut down of process unit to safely conduct repairs Management oversight of process operations and maintenance activities Maintenance and operating procedures, including process equipment isolation, drainage and opening Management of Change Safety personnel mission and deployment The investigation team will present facts and findings relevant to the five major safety issues on this vu-graph. We continue to probe into these and other safety issues for potential lessons learned. Final results will be determined Some of those issues are: (1) the relevance and timelines of the decision making to shut down the unit (2)Tosco�s approach to mgmt�. (3) ...specifically process equipment isolation, drainage and opening (4) Tosco�s Mechanical Integrity program in place at Unit 50 (5) Tosco,s history and deployment of safety personnel Later in our presentation we will examine each of these issues in detail, providing evidence uncovered during our investigation.The investigation team will present facts and findings relevant to the five major safety issues on this vu-graph. We continue to probe into these and other safety issues for potential lessons learned. Final results will be determined Some of those issues are: (1) the relevance and timelines of the decision making to shut down the unit (2)Tosco�s approach to mgmt�. (3) ...specifically process equipment isolation, drainage and opening (4) Tosco�s Mechanical Integrity program in place at Unit 50 (5) Tosco,s history and deployment of safety personnel Later in our presentation we will examine each of these issues in detail, providing evidence uncovered during our investigation.

7. Event Summary What Happened? Event Time Line February 10-22, 1999 February 23, 1999 Armando Full size picture of 50 Unit Armando Full size picture of 50 Unit

8. Armando Full size picture of 50 Unit On February 23rd a fire at Tosco Avon facility 50 Crude Unit killed 4 workers and severely injured another. Workers were attempting to replace a 6 inch diameter piping attached to the crude fractionator tower while the process unit was in operation. The piping contained flammable naphtha liquid and was not isolated, nor drained. The piping runs from the tower at a height of 112 feet to another vessel at a height of 38 feet. During the removal of the piping, naphtha was released onto the hot fractionator tower. The naphtha ignited and the flames engulfed workers four of whom were unable to escape from their elevated positions. One worker jumped from the tower sustaining serious injuries.Armando Full size picture of 50 Unit On February 23rd a fire at Tosco Avon facility 50 Crude Unit killed 4 workers and severely injured another. Workers were attempting to replace a 6 inch diameter piping attached to the crude fractionator tower while the process unit was in operation. The piping contained flammable naphtha liquid and was not isolated, nor drained. The piping runs from the tower at a height of 112 feet to another vessel at a height of 38 feet. During the removal of the piping, naphtha was released onto the hot fractionator tower. The naphtha ignited and the flames engulfed workers four of whom were unable to escape from their elevated positions. One worker jumped from the tower sustaining serious injuries.

10. Presenter: Armando CCC - Logistics of Presentation, Technical Resources Cal OSHA - Evidence gathering, preserving the scene, Technical Resources Federal OSHA - assistance during the initial deployment Federal EPA - technical support PACE - Assistance during interviews and cooperation API - Technical references, and support Presenter: Armando CCC - Logistics of Presentation, Technical Resources Cal OSHA - Evidence gathering, preserving the scene, Technical Resources Federal OSHA - assistance during the initial deployment Federal EPA - technical support PACE - Assistance during interviews and cooperation API - Technical references, and support


12. Event Time Line Gary Graphic: ? 2/10 1st leak response was an emergency response with team in turnout gear. 2/11 Initial decision made included all piping from V-1 to stripper. 2/12 Priority system is more for timeliness that risk based. 2/13 Operator log entry �full�. 2/14 After pumping down several times stripper drain valve is left open. Include Sizemore request for drainageGary Graphic: ? 2/10 1st leak response was an emergency response with team in turnout gear. 2/11 Initial decision made included all piping from V-1 to stripper. 2/12 Priority system is more for timeliness that risk based. 2/13 Operator log entry �full�. 2/14 After pumping down several times stripper drain valve is left open. Include Sizemore request for drainage



18. Event Time Line Gary Graphic: ? 2/18 cable breaks 2/19 Install blind flange with drain valve. Not successful. 2/22 Skinner plug put in and taken out, platform cut, equipment staged, vacuum truck ordered, permit readiness sheet requested/scheduled. Gary Graphic: ? 2/18 cable breaks 2/19 Install blind flange with drain valve. Not successful. 2/22 Skinner plug put in and taken out, platform cut, equipment staged, vacuum truck ordered, permit readiness sheet requested/scheduled.


20. Event Time Line Gary Graphic: ? 0600 - No preps done on backshift. 0700 - vacuum truck dispatched, maintenance lead mechanic at 50 unit, crane arrived and sets up, walkdown completed, maintenance supervisor at 50 unit. 0930 - After break, got indeterminate amount of naphtha but piping is NOT drained. 1010 - 1st cut about 15 feet below fractionator block valve. Section of piping lowered to ground, no visible naphtha.Gary Graphic: ? 0600 - No preps done on backshift. 0700 - vacuum truck dispatched, maintenance lead mechanic at 50 unit, crane arrived and sets up, walkdown completed, maintenance supervisor at 50 unit. 0930 - After break, got indeterminate amount of naphtha but piping is NOT drained. 1010 - 1st cut about 15 feet below fractionator block valve. Section of piping lowered to ground, no visible naphtha.


23. Event Time Line Gary Graphic: ? 0600 - No preps done on backshift. 0700 - vacuum truck dispatched, maintenance lead mechanic at 50 unit, crane arrived and sets up, walkdown completed, maintenance supervisor at 50 unit. 0930 - After break, got indeterminate amount of naphtha but piping is NOT drained. 1010 - 1st cut about 15 feet below fractionator block valve. Section of piping lowered to ground, no visible naphtha.Gary Graphic: ? 0600 - No preps done on backshift. 0700 - vacuum truck dispatched, maintenance lead mechanic at 50 unit, crane arrived and sets up, walkdown completed, maintenance supervisor at 50 unit. 0930 - After break, got indeterminate amount of naphtha but piping is NOT drained. 1010 - 1st cut about 15 feet below fractionator block valve. Section of piping lowered to ground, no visible naphtha.


26. Event Time Line Graphic: ? 11:30 One Scaffold worker is reassigned and does not return 11:40 Drain efforts shifted from control valve area to lower flange. 12:18 Tosco lead mechanic is working at draining at lower flange Tosco pipefitter at saw. Crane supervisor at saw platform. 2 Scaffolding personnel above the second cut platform. 12:18 All personnel appeared to be soaked with naphtha and attempted to evacuate before the fire ball 12:18 Fireball initiated above the Tosco lead mechanic at the lower flange and below the second cut platform. Vacuum truck operator reports fire to nearby 50 Unit control room and alarm is initiated.Graphic: ? 11:30 One Scaffold worker is reassigned and does not return 11:40 Drain efforts shifted from control valve area to lower flange. 12:18 Tosco lead mechanic is working at draining at lower flange Tosco pipefitter at saw. Crane supervisor at saw platform. 2 Scaffolding personnel above the second cut platform. 12:18 All personnel appeared to be soaked with naphtha and attempted to evacuate before the fire ball 12:18 Fireball initiated above the Tosco lead mechanic at the lower flange and below the second cut platform. Vacuum truck operator reports fire to nearby 50 Unit control room and alarm is initiated.









35. Major Investigation Issues Shut down of process unit to safely conduct repairs Management oversight of process operations and maintenance activities Maintenance and operating procedures, including process equipment isolation, drainage and opening Management of Change Safety personnel mission and deployment In this section the presentation will review and analyze the conditions present at the 50 Unit to determine if the Naphtha Draw Line Piping Removal could be conducted safely with the unit on-line or if it required the unit to be shutdown. Examine the conditions to determine if the work was high hazard and non-routine Examine operations and maintenance activities between Feb 10- Feb23 In this section the presentation will review and analyze the conditions present at the 50 Unit to determine if the Naphtha Draw Line Piping Removal could be conducted safely with the unit on-line or if it required the unit to be shutdown. Examine the conditions to determine if the work was high hazard and non-routine Examine operations and maintenance activities between Feb 10- Feb23

36. Unit Shutdown Issues Piping replacement issues that made this a non-routine, high-hazard job: Multiple sources of ignition, some as close as three feet from naphtha draw line piping Inability to steam and wash piping Crane lift over live process equipment Vacuum truck used to drain naphtha Vacuum Truck potential source of ignition use of plastic bucket Vacuum Truck potential source of ignition use of plastic bucket

37. Unit Shutdown Issues Piping replacement issues that made this a non-routine, high-hazard job: Large amount of naphtha in piping Replacement of 80 feet of 6 inch piping Complex workgroup interface High work Limited means of egress

39. Unit Shutdown Issues Inability to isolate the piping was demonstrated by: Recurrence of leak Repeated need to pump out stripper level

40. Unit Shutdown Issues Inability to drain piping was demonstrated by: Work order to unplug drain valves could not be completed successfully on February 18th Mechanics removed piping downstream of the control valve and could not drain on February 19th Drain valves were plugged at the low point in the piping Broke tool trying to unplug piping drainage- horizontal run, could not steam no bleeder valves at high pointBroke tool trying to unplug piping drainage- horizontal run, could not steam no bleeder valves at high point

41. Unit Shutdown Issues Unsafe activities that should have triggered shutdown on February 23rd: Cutting of piping that was not drained and isolated from energy sources system pressure ignition Opening flanges to attempt draining while piping full of naphtha

42. Unit Shutdown Issues Although multiple hazards were present, the unit was not shut down to ensure worker safety high-hazard non-routine Despite multiple opportunities during the preceding 13 days of preparation for this work, it was not recognized that this pipe replacement was a high hazard maintenance job.Despite multiple opportunities during the preceding 13 days of preparation for this work, it was not recognized that this pipe replacement was a high hazard maintenance job.

43. Major Investigation Issues Shut down of process unit to safely conduct repairs Management oversight of process operations and maintenance activities Maintenance and operating procedures, including process equipment isolation, drainage and opening Management of Change Safety personnel mission and deployment Management processes, did not assure positive control and effective monitoring of operations and maintenance actionsManagement processes, did not assure positive control and effective monitoring of operations and maintenance actions

44. Management processes, did not assure positive control and effective monitoring of operations and maintenance actionsManagement processes, did not assure positive control and effective monitoring of operations and maintenance actions

45. Management Oversight Functions Routine management review and approval of maintenance work orders and permits Management systems to monitor and audit work activity on the process unit Assurance that permit procedures are followed Work orders are brought to closure Direction from managers and safety personnel Documented program Deficiency in three phases of safety permit process (Safety Orders) Authorization/Approval - Requiring appropriate levels of approval commensurate with risk Execution - conforming with requirements, insufficient direction Closure -closing out the work orders Conflicting communication Shut down if you can show it isn�t safe... Else... keep it on line Ineffectiveness of stop work procedure Managers did not often visit the 50 Unit - relied on email and telephones Operating logs not reviewed Found no documentation of findings or corrective actions from due to self-assessment or oversight by refinery management Layered safety Survey program had managers walking the spaces to identify physical hazards and safety conditions but it did not document, track or trend what was found, nor did the program include verification of overall safety program performance Deficiency in three phases of safety permit process (Safety Orders) Authorization/Approval - Requiring appropriate levels of approval commensurate with risk Execution - conforming with requirements, insufficient direction Closure -closing out the work orders Conflicting communication Shut down if you can show it isn�t safe... Else... keep it on line Ineffectiveness of stop work procedure Managers did not often visit the 50 Unit - relied on email and telephones Operating logs not reviewed Found no documentation of findings or corrective actions from due to self-assessment or oversight by refinery management Layered safety Survey program had managers walking the spaces to identify physical hazards and safety conditions but it did not document, track or trend what was found, nor did the program include verification of overall safety program performance

46. Major Investigation Issues Shut down of process unit to safely conduct repairs Management oversight of process operations and maintenance activities Maintenance and operating procedures, including process equipment isolation, drainage and opening Management of Change Safety personnel mission and deployment Procedures needed to safely operate the 50 Unit and administratively control the replacement of the Naphtha Draw Line were not effectively implemented Procedure not existing Procedure not clear Procedure not followed Procedures needed to safely operate the 50 Unit and administratively control the replacement of the Naphtha Draw Line were not effectively implemented Procedure not existing Procedure not clear Procedure not followed

47. Work Protocol and Procedure Issues Formal decision making protocol to determine the need to shut down the process for repairs Written procedure for non-routine, high-hazard maintenance Unacceptable hazards identification criteria Non-conformance in procedure execution Written procedures completeness and clarity There is no written guidance or criteria for determining special hazard controls needed to work safely No specific guidance determining when to shutdown the unit No specific guidance for identifying high hazard, non-routine work Refer to previous information about not shutting down the unit Had guidance and criteria existed it could have provide additional barriers that would likely have resulted in doing the work with the unit off line, and with significant management involvement. The procedural barriers that did exist did not provide adequate worker protections because they were either unclear or not being followed. Lockout tagout procedure �Operations will block and bleed line pressure to zero psig where practical before blinding� There is no written guidance or criteria for determining special hazard controls needed to work safely No specific guidance determining when to shutdown the unit No specific guidance for identifying high hazard, non-routine work Refer to previous information about not shutting down the unit Had guidance and criteria existed it could have provide additional barriers that would likely have resulted in doing the work with the unit off line, and with significant management involvement. The procedural barriers that did exist did not provide adequate worker protections because they were either unclear or not being followed. Lockout tagout procedure �Operations will block and bleed line pressure to zero psig where practical before blinding�

48. Major Investigation Issues Shut down of process unit to safely conduct repairs Management oversight of process operations and maintenance activities Maintenance and operating procedures, including process equipment isolation, drainage and opening Management of Change Safety personnel mission and deployment Safe operations of oil refinery crude units require effective monitoring and close control of corrosion to maintain process integrity. Safe operations of oil refinery crude units require effective monitoring and close control of corrosion to maintain process integrity.

49. Management of Change The purpose of Management of Change is to establish �...a formal mechanism for ensuring that changes do not degrade the safety that was purposefully designed into the original process operation.� -The Chemical Manufacturers� Association Management of change The following actions were taken without Management of Change evaluations: Describe what Management of Change is Crude Mix Changes Frequent changes in crude mixes that result unstable, ineffective desalter operations were not evaluated Type of crudes being processed Processing Crude oils that exceeds the design limits of the 50 Unit were not reviewed Desalter Operations Operating desalter system at 150% of the design capacity for extended periods was not reviewed Heavier crudes have more impurities such as salts, sediments and acids. Higher corrosivity causes increased metal loss and sediment deposits in piping and valves. Flow rates through the desalter affect the efficiency and ability of the desalter to remove corrosive chemicals, solids and water. These conditions make it harder for the desalter to perform its design function. Corrective measures were not implemented to adequately compensate for the degraded condition as a consequence: hole in piping plugging of the piping plugging of the control valve plugging of drain valve damage to the bypass valve (The isolating device) Management of change The following actions were taken without Management of Change evaluations: Describe what Management of Change is Crude Mix Changes Frequent changes in crude mixes that result unstable, ineffective desalter operations were not evaluated Type of crudes being processed Processing Crude oils that exceeds the design limits of the 50 Unit were not reviewed Desalter Operations Operating desalter system at 150% of the design capacity for extended periods was not reviewed Heavier crudes have more impurities such as salts, sediments and acids. Higher corrosivity causes increased metal loss and sediment deposits in piping and valves. Flow rates through the desalter affect the efficiency and ability of the desalter to remove corrosive chemicals, solids and water. These conditions make it harder for the desalter to perform its design function. Corrective measures were not implemented to adequately compensate for the degraded condition as a consequence: hole in piping plugging of the piping plugging of the control valve plugging of drain valve damage to the bypass valve (The isolating device)

50. Management of Change Application of Management of Change procedures to Crude mix Desalter operations Operating using bypass valve Management of change The following actions were taken without Management of Change evaluations: Describe what Management of Change is Crude Mix Changes Frequent changes in crude mixes that result unstable, ineffective desalter operations were not evaluated Type of crudes being processed Processing Crude oils that exceeds the design limits of the 50 Unit were not reviewed Desalter Operations Operating desalter system at 150% of the design capacity for extended periods was not reviewed Heavier crudes have more impurities such as salts, sediments and acids. Higher corrosivity causes increased metal loss and sediment deposits in piping and valves. Flow rates through the desalter affect the efficiency and ability of the desalter to remove corrosive chemicals, solids and water. These conditions make it harder for the desalter to perform its design function. Corrective measures were not implemented to adequately compensate for the degraded condition as a consequence: hole in piping plugging of the piping plugging of the control valve plugging of drain valve damage to the bypass valve (The isolating device) Management of change The following actions were taken without Management of Change evaluations: Describe what Management of Change is Crude Mix Changes Frequent changes in crude mixes that result unstable, ineffective desalter operations were not evaluated Type of crudes being processed Processing Crude oils that exceeds the design limits of the 50 Unit were not reviewed Desalter Operations Operating desalter system at 150% of the design capacity for extended periods was not reviewed Heavier crudes have more impurities such as salts, sediments and acids. Higher corrosivity causes increased metal loss and sediment deposits in piping and valves. Flow rates through the desalter affect the efficiency and ability of the desalter to remove corrosive chemicals, solids and water. These conditions make it harder for the desalter to perform its design function. Corrective measures were not implemented to adequately compensate for the degraded condition as a consequence: hole in piping plugging of the piping plugging of the control valve plugging of drain valve damage to the bypass valve (The isolating device)

51. Major Investigation Issues Shut down of process unit to safely conduct repairs Management oversight of process operations and maintenance activities Maintenance and operating procedures, including process equipment isolation, drainage and opening Management of Change Safety personnel mission and deployment Safety specialists can provide additional assurance of process safety during the conduct of high hazard maintenance activities. They can provide an independent analysis of potential hazards due to their special expertise. Safety specialists can provide additional assurance of process safety during the conduct of high hazard maintenance activities. They can provide an independent analysis of potential hazards due to their special expertise.

52. Safety Personnel Issues Safety personnel review of hazardous maintenance activities Involvement in work permitting system Auditing of safety work practices Safety personnel were not involved in the review or approval of the naphtha draw line replacement. Work permit system did not require their involvement at any stage of this job. Safety personnel involvement in this high-hazard work could have provided a specialized safety focus.Safety personnel were not involved in the review or approval of the naphtha draw line replacement. Work permit system did not require their involvement at any stage of this job. Safety personnel involvement in this high-hazard work could have provided a specialized safety focus.

53. Conclusion Investigation team preliminary findings ongoing investigation Encourage relevant info from all parties Open comment period for three weeks Wednesday, October 6, 1999

Board of Inquiry Tosco Avon Refinery Incident

Board of Inquiry Tosco Avon Refinery Incident

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