The CSB issues safety recommendations to prevent the recurrence or reduce the likelihood or consequences of similar incidents or hazards in the future. Recommendations are issued to a variety of parties, including government entities, safety organizations, trade unions, trade associations, corporations, emergency response organizations, educational institutions, and public interest groups. Recommendations are published in CSB reports and are closed only by vote of the Board. The CSB tracks all recommendations and communicates regularly with recommendations recipients to ensure that the recommended corrective actions are implemented. For more information, see Frequently Asked Questions about CSB recommendations.
2024-01-I-CA-8
Revise API RP 556 Instrumentation, Control, and Protective Systems for Gas Fired Heaters, or successor API products, with the following: Requirements for proper response to high tube metal temperatures, including guidance to alert operators when safe operating limits are exceeded and to specify predetermined response actions, such as shutting down the fired heater remotely. The predetermined response actions must include actions that specify when to stop troubleshooting and remove personnel from the vicinity of the fired heater; Design requirements (“shall” rather than “should” language) for protecting fired heaters from low process flow where process piping diverges downstream of a flow meter. Requirements may include achieving proof of flow to the heater through valve position indicators and interlocks on branch Engineering safeguard requirements (“shall” rather than “should” language) to detect and prevent afterburning in fired heaters. These requirements may include the use of instrumentation such as combustibles measurements, flame detectors, and/or thermocouples that measure tube metal, flue gas, and process fluid temperatures. The requirements shall address monitoring capability from the control room. Status: Open - Awaiting Response or Evaluation/Approval of Response
Revise API RP 556 Instrumentation, Control, and Protective Systems for Gas Fired Heaters, or successor API products, with the following:
2024-01-I-CA-1
Implement engineering safeguards to detect and prevent afterburning in the fired heater involved in the November 19, 2023, incident. The safeguards may include the use of instrumentation such as combustibles measurements, flame detectors, and/or thermocouples that measure tube metal, flue gas, and process fluid temperatures. The safeguards shall be capable of being monitored from the control room. Status: Open - Awaiting Response or Evaluation/Approval of Response
Implement engineering safeguards to detect and prevent afterburning in the fired heater involved in the November 19, 2023, incident. The safeguards may include the use of instrumentation such as combustibles measurements, flame detectors, and/or thermocouples that measure tube metal, flue gas, and process fluid temperatures. The safeguards shall be capable of being monitored from the control room.
2024-01-I-CA-2
For the fired heater involved in the incident, after Marathon Petroleum Corporation’s “Process Heater Not-to-Exceed (NTE) Limits and Alarms” standard is updated according to 2024-01-I-CA-R5, implement tube metal temperature alarming consistent with corporate guidance to alert operators when safe operating limits are exceeded and to specify predetermined response actions, such as shutting down the fired heater remotely. The predetermined response actions must include actions that specify when to stop troubleshooting and remove personnel from the vicinity of the fired heater. Status: Open - Awaiting Response or Evaluation/Approval of Response
For the fired heater involved in the incident, after Marathon Petroleum Corporation’s “Process Heater Not-to-Exceed (NTE) Limits and Alarms” standard is updated according to 2024-01-I-CA-R5, implement tube metal temperature alarming consistent with corporate guidance to alert operators when safe operating limits are exceeded and to specify predetermined response actions, such as shutting down the fired heater remotely. The predetermined response actions must include actions that specify when to stop troubleshooting and remove personnel from the vicinity of the fired heater.
2024-01-I-CA-3
Implement changes to improve Walk the Line performance at the Martinez facility by ensuring that the facility’s practices are consistent with tools in the AFPM Safety Portal and guidance in Marathon Petroleum Corporation’s refining reference document titled Operations Excellence. At a minimum: Require that operator field walkdowns ensure that valves are correctly aligned before all unit startup activities from planned or unplanned shutdowns, such as those due to non-normal operations, emergencies, turnarounds, and major maintenance; Improve policies and practices for communications among and between shifts to ensure that operators understand abnormal line-ups in their units; and Reinforce Walk the Line concepts, including the expectation for only trained operators to control valve line-ups at their units, through training for all levels of management in the Operations department. Status: Open - Awaiting Response or Evaluation/Approval of Response
Implement changes to improve Walk the Line performance at the Martinez facility by ensuring that the facility’s practices are consistent with tools in the AFPM Safety Portal and guidance in Marathon Petroleum Corporation’s refining reference document titled Operations Excellence. At a minimum:
2024-01-I-CA-4
Complete a comprehensive gap assessment of the Martinez facility against Marathon Petroleum Corporation policies. At a minimum, address the following policies: a. Operating Limits; b. Process Hazard Analysis; and c. PSM/RMP Refining Operating Procedures. Develop and implement action items to effectively address findings from the assessment. Status: Open - Awaiting Response or Evaluation/Approval of Response
Complete a comprehensive gap assessment of the Martinez facility against Marathon Petroleum Corporation policies. At a minimum, address the following policies:
a. Operating Limits;
b. Process Hazard Analysis; and
c. PSM/RMP Refining Operating Procedures.
Develop and implement action items to effectively address findings from the assessment.
2024-01-I-CA-5
Update the corporate “Process Heater Not-to-Exceed (NTE) Limits and Alarms” standard with tube metal temperature alarming guidance to alert operators when safe operating limits are exceeded and to specify predetermined response actions, such as shutting down the fired heater remotely. The predetermined response actions must include actions that specify when to stop troubleshooting and remove personnel from the vicinity of the fired heater. Status: Open - Awaiting Response or Evaluation/Approval of Response
Update the corporate “Process Heater Not-to-Exceed (NTE) Limits and Alarms” standard with tube metal temperature alarming guidance to alert operators when safe operating limits are exceeded and to specify predetermined response actions, such as shutting down the fired heater remotely. The predetermined response actions must include actions that specify when to stop troubleshooting and remove personnel from the vicinity of the fired heater.
2024-01-I-CA-6
Update the corporate “Heater Application Standard” with the following requirements: Requirements for protecting fired heaters from low process flow where process piping diverges downstream of a flow meter. Requirements may include achieving proof of flow to the heater through valve position indicators and interlocks on branch connections downstream of flow meters to prevent backflow, reverse flow, or other diverted flow scenarios that could defeat the safety instrumented system; and Engineering safeguard requirements to detect and prevent afterburning in fired heaters. The safeguards may include the use of instrumentation such as combustibles measurements, flame detectors, and/or thermocouples that measure tube metal, flue gas, and process fluid temperatures. The safeguards shall be capable of being monitored from the control room. Status: Open - Awaiting Response or Evaluation/Approval of Response
Update the corporate “Heater Application Standard” with the following requirements:
2024-01-I-CA-7
Confirm the results of the Martinez facility’s comprehensive gap assessment required in 2024-01-I-CA-R4. Upon completion, conduct an Operations Excellence full assessment on the Martinez facility. Develop and implement action items to effectively address findings from the assessment. Status: Open - Awaiting Response or Evaluation/Approval of Response
Confirm the results of the Martinez facility’s comprehensive gap assessment required in 2024-01-I-CA-R4. Upon completion, conduct an Operations Excellence full assessment on the Martinez facility. Develop and implement action items to effectively address findings from the assessment.