BP - Husky Oregon Chemical Release and Fire

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Accident Description

Accident: BP - Husky Oregon Chemical Release and Fire

Location: Location: Oregon, OH

Accident Occurred On: 09/20/2022 | Final Report Released On: 06/24/2024

Accident Type: Oil and Refining - Fire and Explosion

Investigation Status: The CSB's investigation was released on June 24, 2024.

At about 6:46 p.m. on September 20, 2022, an accidental release of flammable chemicals ignited, creating a fire that fatally injured two workers and resulted in substantial property damages at the BP-Husky refinery in Oregon, Ohio

Final Reports

FINAL REPORT: Fatal Naphtha Release and Fire at BP-Husky Toledo Refinery

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Recommendations

American Petroleum Institute (API)

2022-01-I-OH-5

Develop a new publication or revise an existing publication, such as API Recommended Practice 556 Instrumentation, Control, and Protective Systems for Gas Fired Heaters, to incorporate the process hazards associated with Fuel Gas Mix Drum overflow. The publication should include the following at a minimum:

a) Description of the process hazards associated with Fuel Gas Mix Drum overflow and the consequential impacts on equipment using fuel gas,

b) Guidance for Fuel Gas Mix Drum design and sizing criteria which includes consideration of condensation, entrainment, overflow, and draining,

c) Guidance for instrumentation to detect high level to prevent overfilling of Fuel Gas Mix Drums, and

d) Recommended practices for selecting preventive safeguards to prevent overfilling of Fuel Gas Mix Drums.

Status: Open - Awaiting Response or Evaluation/Approval of Response

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Recommendation Status Change Summary

2022-01-I-OH-6

Develop a publication that addresses preventing the overflow of pressure vessels such as towers and drums. The publication should be applicable to both new and existing pressure vessels. Include the following at a minimum:

a) Description of typical overflow events that could result during normal, upset, or transient operations (startup, shutdown, standby) including the formation of a vapor cloud,

b) Recommended practices for instrumentation to monitor and detect a pressure vessel overflow,

c) Process hazard analysis guidance for pressure vessel overflow scenarios,

d) Recommended practices for safeguards to prevent a pressure vessel overflow,

e) Recommended field and board operator process safety training topics and methods to prevent a pressure vessel overflow,

f) Guidelines for process safety assessments to prevent a pressure vessel overflow, and

g) Incorporate lessons learned from this CSB investigation and the CSB’s BP Texas City Refinery investigation throughout the document.

Status: Open - Awaiting Response or Evaluation/Approval of Response

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Recommendation Status Change Summary
International Society of Automation (ISA)

2022-01-I-OH-7

Revise American National Standard ANSI/ISA 18.2-2016, Management of Alarm Systems for the Process Industries, to include performance targets for short-term alarm flood analysis so that users can evaluate alarm flood performance for a single alarm flood event. The performance targets should include:

a) number of alarm floods,
b) duration of each flood,
c) alarm count in each flood, and
d) peak alarm rate for each flood.

At a minimum, a target peak alarm flood rate should be defined, such as in the guidance provided by the ASM Consortium or Engineering Equipment and Materials Users Association (EEMUA), to establish trigger points that require alarm performance improvement actions.

Status: Open - Awaiting Response or Evaluation/Approval of Response

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Recommendation Status Change Summary
Ohio Refining Company

2022-01-I-OH-1

Revise the safeguards used in the refinery’s process hazard analyses high level and overflow scenarios. At a minimum, establish effective preventive safeguards that use engineered controls to prevent liquid overfill and do not rely solely on human intervention.

Status: Open - Awaiting Response or Evaluation/Approval of Response

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Recommendation Status Change Summary

2022-01-I-OH-2

Revise the Abnormal Situation Management policy to incorporate guidance provided by the ASM Consortium and the Center for Chemical Process Safety (CCPS). The revised policy should include, at a minimum:

a) A broader definition of abnormal situations, such as that defined by the CCPS,

b) Additional predictable abnormal situations and their associated corrective procedures. At a minimum include the following abnormal situations:

1) unplanned crude slate changes,
2) continued operation of the Crude 1 unit with the naphtha hydrotreater unit shut down, and
3) an emergency pressure-relief valve opening.

c) Guidance to determine when an abnormal situation is becoming too difficult to manage and the appropriate actions to take, such as shutting down a process, putting it into a circulation mode, or implementing proper procedures for bringing it to a safe state.

Status: Open - Awaiting Response or Evaluation/Approval of Response

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Recommendation Status Change Summary

2022-01-I-OH-3

Develop and implement a policy or revise existing policy that clearly provides employees with the authority to stop work that is perceived to be unsafe until the employer can resolve the matter. This should include detailed procedures and regular training on how employees would exercise their stop work authority. Emphasis should be placed on exercising this authority during abnormal situations, including alarm floods.

Status: Open - Awaiting Response or Evaluation/Approval of Response

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Recommendation Status Change Summary

2022-01-I-OH-4

Revise the ‘Toledo Alarm Philosophy’ by incorporating the Engineering Equipment and Manufacturers Users Association (EEMUA) guidance for alarm rate following an upset and not limiting alarm performance to a single metric averaged over a month. In addition to including analyzing individual alarm flood events, the revised philosophy document should improve refinery alarm performance to reduce alarm flood duration and peak rate for events similar to the September 20, 2022, incident. Consult EEMUA Publication 191, Chapter 6.5.1, for guidance regarding abnormal condition performance levels. Apply the improved performance levels where applicable, but specifically to the Crude 1 control board alarm performance.

Status: Open - Awaiting Response or Evaluation/Approval of Response

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Recommendation Status Change Summary

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Statistics

7 7 0

Total Recommendations # 7

Open Recommendations # 7

Closed Recommendations # 0

100 vs 0 Total % Open Vs. Closed

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