Refinery accident caused by lack of management, report finds

Lack of management and supervisory oversight was one of the causes of an accident that killed one person and injured 46 at the Task Avon Refinery in Martinez, California in January 1997, a US EPA report has found.


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The US EPA released its a Chemical Accident Investigation Report on the incident on November 20.

The report found that operators did not follow required emergency procedures to depressure and shutdown the reactor after a flammable mixture of hydrocarbons and hydrogen escaped from a ruptured pipeline, leading to an explosion and a fire in the facility’s hydrocracker unit.

EPA 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– Outdated and incomplete procedures, training materials and a process hazard analysis that did not reflect actual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.

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