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– Outdated and incomplete procedures, training materials and a process hazard analysis that did not reflect actual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