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AVON INVESTIGATION REPORT RELEASED ON TOSCO AVON REFINERY

Release Date: 11/19/1998
Contact Information: Randy Wittorp, U.S. EPA, (415) 744-1589

       (SAN FRANCISCO) -- The U.S. Environmental Protection Agency today released the Chemical Accident Investigation Report on a January 21, 1997 explosion and fire at the Tosco Avon Refinery in Martinez, California.  The accident killed one person and injured 46.

        The fire occurred in the hydrocracker unit when a pipeline ruptured under excessively high operating temperatures, releasing a flammable mixture of hydrocarbons and hydrogen.  Operators did not follow required emergency procedures to shut down the unit prior to the accident.
 
     The report identifies the following problems that contributed to operator error: Management did not ensure that emergency procedures were followed;

     Management tolerance of safety hazards and risky operator practices;
 
     Operating with unreliable or malfunctioning equipment;

     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 reliably and quickly;

     Outdated and incomplete procedures including a hazard analysis that did not reflect actual operating conditions.

     The report makes several recommendations to prevent future incidents at Tosco and other facilities.  The recommendations cover good process safety management which reduces the potential for a catastrophe.

     The report will now undergo technical review by a panel of experts.   Investigating agencies will also meet to review the report and determine the next steps.

     Two enforcement actions have already been taken against the refinery resulting in penalties of nearly $600,000.

     The report is available on the Internet at: www.epa.gov/ceppo/acc-his.html .  Copies of the report also can be obtained by calling National Center for Environmental Publications and Information at 1-800-490-9198.