A federal investigation into two workers’ fatal burns at an Oregon, Ohio, refinery’s crude unit found its operator violated OSHA’s process safety procedures for highly hazardous materials and failed to train the workers adequately. As the workers attempted to correct rising liquid levels in the fuel gas mix drum, a flammable vapor cloud formed, ignited, and then triggered an explosion in September 2022, causing the deadly burns. They also determined naphtha – a flammable liquid hydrocarbon mixture – was released when flow control valves were opened in an attempt to regulate an overfill occurring in upstream process equipment. The opened valve allowed the flammable liquid to enter the refinery’s fuel gas system.
OSHA cited the facility for failing to implement shutdown procedures for the equipment when requested by the operators responding to the naphtha release and for not clearly defining conditions for emergency shutdown of the crude tower.
OSHA proposed $156,250 in penalties, an amount set by federal statutes, and cited the company for 10 serious violations and one other-than-serious violation of process safety management procedures. Specifically, the agency found the facility failed to:
- Train operators to identify the presence of naphtha during an upset condition.
- Develop and implement safe work practices for responding to upset conditions.
- Document design for pressure safety valves, including for an overpressure scenario.
- Address hazards of overfilling process vessels, and safeguards needed to protect against an overfill.
- Evaluate for engineering or administrative controls for draining process equipment during upset conditions.
- Address human factors with the operation of the inside control board screen loading delays.
- Ensure process hazard assessments were accurate with respect to level indicator safeguards.
Citation 1 Item 1
Type of Violation: Serious; $15,625
29 CFR 1910.119(d)(3)(ii): The employer did not document that equipment complies with recognized and generally accepted good engineering practices:
a) On or about September 20, 2022, the employer failed to ensure that it documented that equipment in the process complied with the employer’s chosen recognized and generally accepted good engineering practices such as but not limited to API 520 (2020) Section 5, when the employer did not include an evaluation of excessive built-up backpressure for PSV-1457 located on the tube side of the HVGO/Crude 1 Naphtha Intermediate Reflux Shell & Tube heat exchangers (PR-544011/12). Failure to evaluate excessive built- up back pressure resulted in the exposure of employees to fire and explosion hazards from the release of flammable liquids or gasses.
b) On or about September 20, 2022, the employer failed to ensure that it documented that equipment in the process complied with the employer’s chosen recognized and generally accepted good engineering practices such as but not limited to API 520 (2020) and API 521 (2015), when the employer did not include an evaluation of two-phase flow and all potential relief scenarios for the TIU Fuel Gas Mix Drum (PR-510253) PSV-1464 including but not limited to overfilling of the drum. Failure to evaluate for the potential of two-phase flow and all potential relief scenarios, including but not limited to overfilling of the drum, exposed employees to fire, and explosion hazards from potential releases of flammable liquids or gasses.
c) On or about September 20, 2022, the employer failed to document that the level indicator instrumentation used in conjunction with the TIU Fuel Gas Mix Drum (PR- 510253) complied with recognized and generally accepted good engineering practices in that level instrumentation relied on for controlling liquid level accumulation in the drum was not designed and utilized for determining liquid levels of naphtha.
In accordance with 29 CFR 1903.19(d), abatement certification is required for this violation (using the CERTIFICATION OF CORRECTIVE ACTION WORKSHEET), and in addition, documentation demonstrating that abatement is complete must be included with your certification. This documentation may include but is not limited to, evidence of the purchase or repair of the equipment, photographic or video evidence, or written records.
Citation 1 Item 2
Type of Violation: Serious; $15,625
29 CFR 1910.119(e)(1): The process hazard analysis did not identify, evaluate, and address the control of the hazards involved in the process:
a) On or about September 20, 2022, the employer failed to identify, evaluate, and control the hazard of high liquid levels resulting from all potential flammable liquid overfill scenarios, including but not limited to detecting flammables and stopping the flow of liquid naphtha to the TIU Fuel Gas Mix Drum. The Crude 1 PHA did not include the Coker Gas Plant as a source of liquid naphtha during an overfill scenario involving the Absorber Stripper Tower (PR550025), Sour Gas KO Drum (PR510286), Polishing Amine Contactor (PR550032), Sweet Gas KO Drum (PR510283) to the fuel gas header and the TIU Fuel Gas Mix Drum. Failure to control the high level in the TIU Fuel Gas Mix Drum resulted in a release of liquid naphtha, exposing employees to flammable vapor, fire, hydrogen sulfide, and explosion hazards.
Citation 1 Item 3
Type of Violation: Serious; $15,625
29 CFR 1910.119(e)(3)(iii): The Process Hazard Analysis did not address engineering and administrative controls applicable to the hazards and their interrelationships, such as appropriate application of detection methodologies to provide early warning of releases:
a) On or about September 20, 2022, the employer failed to evaluate the TIU Fuel Gas Mix Drum in the Crude 1 Unit for engineering or administrative controls needed to maintain drainage to a closed system and prevent the manual draining of liquid in the drum to the sewer. Open draining of liquid from the mix drum can expose employees to hydrogen sulfide, explosion and fire hazards.
Citation 1 Item 4
Type of Violation: Serious; $15,625
29 CFR 1910.119(e)(3)(iv):The process hazard analysis did not address the consequences of the failure of engineering and administrative controls:
a) On or about September 20, 2022, the employer failed to ensure that the PHA addressed the consequences of failure of administrative controls by not following the South/Coker Gas Plant: Bypassing and Returning to Service Coker Gas Plant Procedure (CGP 02.004). The procedure required closing FV-3816 while the Coker Gas Plant was in bypass mode. During the incident, FV-3816 was opened causing the Absorber Stripper Tower (PR-550025) and the downstream equipment including the TIU Fuel Gas Mix Drum (PR-510253) to overfill with liquid naphtha. This led to a direct path of liquid naphtha, causing an uncontrollable high level in the TIU Fuel Gas Mix Drum, exposing employees to fire, explosion hazards, and toxic gases from potential releases of fuel gas, flammable liquids, and hydrogen sulfide.
b) On or about September 20, 2022, the employer failed to ensure that the PHA addressed the consequences of failure of administrative controls by not following Coker Gas Plant and NHT Feed Surge Drum Safe Operating and Design Limits which required steps to avoid an overfill scenario of the Absorber Stripper Tower (PR-550025) to include verifying that the Absorber Stripper Tower bottom valve (XV- 3821) was open. Keeping this valve closed led to overfilling of the Absorber Stripper Tower (PR-550025) and the downstream equipment including the TIU Fuel Gas Mix Drum (PR-510253). This led to a direct path of liquid naphtha, causing an uncontrollable high level in the TIU Fuel Gas Mix Drum, exposing employees to fire, explosion hazards, and toxic gases from potential releases of fuel gas, flammable liquids, and hydrogen sulfide.
c) On or about September 20, 2022, the employer failed to ensure that the PHA addressed the consequences of failure of engineering controls when the high-level switch (LSH-805) was not available to detect high level of flammables in the TIU Fuel Gas Mix Drum during an overfill scenario of the Absorber Stripper Tower (PR-550025) and downstream vessels. Failure to evaluate loss of engineering controls resulted in an uncontrollable high level in the TIU Fuel Gas Mix Drum, exposing employees to fire, explosion hazards, and toxic gases from potential releases of fuel gas, flammable liquids, and hydrogen sulfide.
Citation 1 Item 5
Type of Violation: Serious; $15,625
29 CFR 1910.119(e)(6):The employer did not update and revalidate by a team meeting the requirements in paragraph (e)(4) of this section, to assure that the process hazard analysis is consistent with the current process, at least every five (5) years after the completion of the initial process hazard analysis:
a) On or about September 20, 2022, the employer failed to ensure that the most recent PHA revalidation reflected current process equipment and conditions, in that the high-level switch (LSH-805) was not available to detect high level of flammables in the TIU Fuel Gas Mix Drum during a high liquid level event. Failure to ensure that engineering control safeguard taken credit for in PHA revalidations are in place and operational, can contribute to an uncontrollable high level in the TIU Fuel Gas Mix Drum, exposing employees to fire, explosion hazards, and toxic gases from potential releases of fuel gas, flammable liquids, and hydrogen sulfide.
Citation 1 Item 6
Type of Violation: Serious; $15,625
29 CFR 1910.119(f)(1)(i)(C): The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting temporary operations:
a) On or about September 20, 2022, the employer failed to ensure that temporary operating procedures were developed and implemented for operation of the Crude 1 Unit while the Coker Gas Plant and SatGas/NHT Units were intended to be in a by-pass condition. The lack of operating procedures for this transient operating condition contributed to carry-over of naphtha to the TIU Fuel Gas Mix Drum and led to liquid in the fuel gas system, exposing employees to fire and explosion hazards.
b) On or about September 20, 2022, the employer failed to ensure that operating procedures developed for bypassing the Coker Gas Plant were implemented. Failure to implement this established procedure (CGP 02.004 – Bypassing and Returning to Service Coker Gas Plant) contributed to FCV- 3816 being opened, allowing naphtha to overfill downstream process vessels and flow into the refinery’s fuel gas system, exposing employees to fire and explosion hazards.
Citation 1 Item 7
Type of Violation: Serious; $15,625
29 CFR 1910.119(f)(1)(i)(D):The employer did not develop and implement written operating procedures that provide clear instructions for emergency shutdown, including the conditions under which emergency shutdown is required, and the assignment of shutdown responsibility to qualified operators to ensure that emergency shutdown is executed in a safe and timely manner:
a) On or about September 20, 2022, the employer failed to ensure that emergency shutdown of process equipment in the NHT/Sat Gas units occurred when requested by outside operators. Upset conditions involving the lifting and reseating of PSV-1457 and PSV-1462 caused process equipment vibration and instability. A release of naphtha during this upset condition exposed employees to explosion and fire hazards.
b) On or about September 20, 2022, the employer failed to ensure that emergency operating procedures for the Crude 1 Unit Crude Tower (PR556936) included the scenario involving the loss of all three process pump around on the tower simultaneously, which can inhibit process temperature control and stable operation of the tower. Failure to shutdown the Crude Unit during this process upset condition can expose employees to explosion and fire hazards.
The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury or illness.
Citation 1 Item 8a
Type of Violation: Serious; $15,625
29 CFR 1910.119(f)(1)(i)(E):The employer did not develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each covered process consistent with the process safety information and did not address at least emergency operations:
a) On or about September 20, 2022, the employer failed to ensure that procedure PSM 025 was implemented for the closing of PSV-1457 in the SatGas/NHT Unit, for the purpose of reseating the relief valve, exposing employees to explosion and fire hazards.
b) On or about September 20, 2022, the employer failed to ensure that emergency operating procedures were developed and implemented for the safe draining of liquid from the TIU Fuel Gas Mix Drum in the Crude 1 Unit during process upset conditions. The lack of emergency operating procedures for this condition exposed employees to hydrogen sulfide, explosion and fire hazards.
Citation 1 Item 8b
Type of Violation: Serious
29 CFR 1910.119(f)(4): The employer did not develop and implement safe work practices to provide for the control of hazards during operations such as lockout/tagout; confined space entry; opening process equipment or piping; and control over entrance into a facility by maintenance, contractor, laboratory, or other support personnel:
a) On or about September 20, 2022, the employer failed to ensure that safe work practices were developed and implemented for the safe draining of liquid from the TIU Fuel Gas Mix Drum in the Crude 1 Unit during process upset conditions. The lack of safe work practices developed and implemented for this work activity exposed employees to hydrogen sulfide, explosion and fire hazards.
Citation 1 Item 9
Type of Violation: Serious; $15,625
29 CFR 1910.119(f)(1)(ii): The employer did not develop and implement written operating procedures that provided clear instructions for safely conducting activities involved in each covered process consistent with the process safety information that addressed operating limits:
a) On or about September 20, 2022, the employer failed to ensure that the procedure for Normal Operation of Crude 1 (CRD1 02.012) included steps to avoid or correct deviations in process parameters, including for liquid level in the TIU Fuel Gas Mix Drum. The lack of detailing steps to avoid or correct deviations for all process parameters such as liquid level, exposed employees to hydrogen sulfide, explosion and fire hazards.
Citation 1 Item 10
Type of Violation: Serious; $15,625
29 CFR 1910.119(g)(1)(i): Each employee involved in operating a process was not provided training which included emphasis on the specific safety and health hazards, emergency operations including shutdown, and safe work practices applicable to the employee’s job tasks:
a) On or about September 20, 2022, the employer failed to ensure that operators in the Crude Unit were trained to respond to rising liquid levels in the TIU Fuel Gas Mix Drum located in the Crude 1 Unit, in that there was no prohibition against draining the liquid to the oily water sewer. This lack of training resulted in employees being exposed to fire, explosion and hydrogen sulfide hazards.
b) On or about September 20, 2022, the employer failed to ensure that inside and outside operators were trained to evaluate and identify the presence of naphtha in the TIU Fuel Gas Mix Drum located in the Crude 1 Unit, during transient, temporary operating conditions, including the NHT/SatGas and Coker Gas Plants being outside of normal operating conditions. The lack of training resulted in employees being exposed to fire, explosion and hydrogen sulfide hazards.
c) On or about September 20, 2022, the employer failed to ensure that inside and outside operators were trained on operating limits of the TIU Fuel Gas Mix Drum, related to liquid level, including the consequences of deviation and steps to avoid and correct liquid level outside of acceptable limits. The lack of training resulted in employees being exposed to fire, explosion and hydrogen sulfide hazards.
Citation 2 Item 1
Type of Violation: Other-than-Serious; $0.00
29 CFR 1910.119(e)(3)(vi): The process hazard analysis did not address human factors:
a) On or about September 20, 2022, the employer failed to address human factors in the process hazard analysis to ensure that delays in screen loading on the South A Board in the Control Room were corrected to allow for timely operator response in the event of an upset condition. Delays in the inside board operators to access control board screens timely, can inhibit their response in the operating units in the South Area.
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