AcuSafe -> September 1999 Newsletter
  

 Board of Inquiry Meets in California

 
CSB Chairman and Chief Executive Officer Paul L. Hill, Jr., Ph.D., presided over the inquiry, and was joined by the three other Board members.  They heard from CSB's own investigation team, as well as information on the incident from Contra Costa County, Cal-OSHA, Tosco, and the Paper, Allied Industrial, Chemical and Energy Workers International Union (PACE).

The meeting was attended by about 100 people, five television camera crews, and several print and radio media spokespersons. Dr. Hill stated several times that this hearing was a part of the investigative process.  To that end, the members of the CSB frequently interrupted the presentations with clarifying questions.

Three CSB investigators took most of the morning to present their findings to date.  They told the Board that they are in agreement with the basic factual findings about what happened during the February 23 incident, as reported by the County and Cal-OSHA.  Handouts from the CSB investigators’ presentation are available by clicking here.

Details leading to the fire were presented graphically (see schematic in handouts) to explain the complex physical situation.  The CSB team stated that at the time of the release, a single, closed control valve bypass valve was being depended on to prevent gas and naphtha under 12 psi from entering piping in the work area.  The investigators presented pictures of this control valve undergoing a leak test after the incident and they stated that it showed a high leak rate.  “Bleeder” drain valves at the control valve station were reportedly plugged, preventing normal draining and clearing of the pipeline.  The time-line presented by investigators indicated that just prior to the fire, flanges on the pipe below the work area were separated in order to drain naphtha from a vertical portion of piping that was being dismantled.  This draining removed a “loop seal” in that section of pipe.  When gas entered the work area through the leaking bypass valve, the lighter density of the gas / liquid mixture caused naphtha to spray out from the open top of the dismantled pipe, spraying workers and igniting from the hot surfaces on operating equipment in the area. 

However, the CSB investigators indicated that they are continuing to probe for root causes and they are focusing on five major issues:

1. The shutdown of process equipment to safely conduct repairs

2. Management oversight of process operations and maintenance activities

3. Maintenance and operating procedures, including process equipment isolation, drainage and opening

4. Corrosion control and monitoring program

5. Safety personnel mission and deployment

Larry Ziemba, Tosco's bay area general manager, told the CSB that the company had a different view of some of the facts than those presented by the investigators.  He stated that Tosco would respond to the CSB in writing.  Ziemba said that keeping a refinery unit running during repairs was routine in the industry and California safety regulations take these on-line repair activities into account.  He repeated the company's position that there would not have been an accident if procedures that were in place had been followed.  During his presentation, he also objected to being left off the list of those who cooperated in the investigation.  "Since the accident occurred, we have worked closely with all agencies involved and conducted our own investigation," Ziemba said.

Both Cal-OSHA and Tosco stated that they were limited in what they could present to the Board because of ongoing litigation.

Contra Costa County officials presented a summary of the emergency response activities, the findings from their investigation into the incident, and a summary of the ongoing safety study commissioned by the County Board of Supervisors.

Steve Sullivan, of the national office of PACE, called for the CSB as a part of its final report to recommend more prescriptive “command and control” regulations that would call out when equipment should be shut down and when hot work permits should be used.

Dr. Hill concluded the all day meeting by reiterating that the investigation is not yet complete.  The final report would be “not just an account of the accident, but include targeted recommendations to prevent a similar accident from ever happening again.”

Written comments from anyone with information will be welcome until October 6th at the Chemical Safety and Hazard Investigation Board, 2175 K St. N.W., Suite 400, Washington, D.C., 20037-2809.

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