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PA EPA RELEASES ACCIDENT INVESTIGATION REPORT ON TOSCO AVON REFINERY

Release Date: 11/20/98
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EPA released a Chemical Accident Investigation Report on the Task Avon Refinery in Martinez, Calif. An explosion and fire occurred in the hydrocracker unit at the facility on Jan. 21, 1997, killing one person and injuring 46. The accident resulted when a flammable mixture of hydrocarbons and hydrogen was released from a ruptured pipeline causing the explosion and fire. Operators did not follow required emergency procedures to depressure and shutdown the reactor. Investigators identified some causes of the accident as:

•Lack of management and supervisory oversight to ensure that emergency procedures were followed;
•Management unawareness and tolerance of other safety hazards and risky operator practices;
•Poor consideration of human factors in the design and operation of the temperature monitoring and control system which did not allow operators to make critical decisions quickly;
•Operating with unreliable or malfunctioning equipment which created operating hazards and increased risk;
•Outdated and incomplete procedures, training materials and a process hazard analysis that did not reflect actual process and operating conditions.

The report makes several recommendations to prevent future incidents at this and other facilities. Although EPA will continue to have a role in accident investigation and prevention of chemical accidents, the recently funded Chemical Safety and Hazard Investigation Board has responsibilities for chemical accident investigations. EPA, however will complete investigations initiated prior to the funding of the Board. The report can be accessed on the Internet at: https://www.epa.gov/ceppo/acc-his.html. Copies of the report also can be obtained by calling 1-800-490-9198.


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