The long-anticipated 70-page report from the U.S. Chemical Safety Board released Monday offered a range of critiques and prescriptions for the Chevron refinery, the refining industry nationwide, and regulators at the local, county and state level.

Some of the reports highlights:

  • The report said Richmond and Contra Costa should revise their industrial safety ordinances to require more rigorous safety audits. The goal should be to make the risk of major accidents as low as "reasonably practicable."

  • Regulators need more resources to compel companies to act responsibly, and Cal/OSHA lacks enough technically competent staff to properly monitor oil refineries.

  • At the state level, the safety board put special emphasis on recommending that regulators have the tools to ensure "mechanical integrity" in oil refineries.

  • State regulatory codes should be revised to "require improvements to mechanical integrity and process hazard analysis programs for all California oil refineries. These improvements shall include engaging a diverse team of qualified personnel to perform a documented damage mechanism hazard review."

  • The new comprehensive domain of state regulators would be to work with the refineries to monitor all potential areas where mechanisms could fail, make sure the hazards are minimized and have a firm understanding and plan to deal with the "consequences of failure."


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  • The safety board determined that 19 Chevron employees were engulfed in a vapor cloud formed by the hydrocarbon release from a ruptured pipe, which carried high-temperature gas-oil. Eighteen employees escaped before the fire started and one employee escaped from a fire truck after the fire began, according to the report.

    Officials also disclosed Monday that a firefighter was trapped in a fire engine 65 feet from the leak.

  • Metallurgical analysis found that the 52-inch-long, 8-inch diameter carbon steel pipe where the rupture occurred had undergone extreme thinning since its installation in 1976.

    "The average wall thickness near the rupture location was approximately 40 percent thinner than a dime (the thinnest American coin)," yet continued to be overlooked during inspections.

  • The CSB notes that on Aug. 6, 2012, following discovery of the leak on the 4-sidecut piping, Chevron hoped to forestall a shutdown by installing a leak-repair clamp. "Chevron's mechanical integrity

    management system has not been fully successful in detecting and replacing deteriorated piping components before failure, resulting in the company's frequent use of leak repair clamps to externally stop process fluid leaks ... reliance on such clamps to mitigate process piping component leaks identifies serious questions about its mechanical integrity program. The CSB determined that Chevron has more than 100 clamps on hydrocarbon and other process piping components at the Richmond refinery. The leak repair clamp is typically relied upon to prevent further leaking until the next unit turnaround, when the deteriorated piping component can be repaired."

  • Between 2006 and Aug. 6, 2012, Cal/OSHA conducted three planned inspections of the Chevron Richmond facility, totaling only 150 inspector hours of effort. None of these inspections resulted in citations or fines.

  • Regular planned inspections appropriately emphasize the prevention of accidents that are potentially catastrophic. Issuing fines and prosecuting companies post-incident are not acceptable substitutes for prevention, according to the report. As a result, CSB recommended in its report that OSHA strengthen the planned enforcement of the OSHA Process Safety Management (PSM) standard by developing more highly trained and experienced inspectors to conduct more comprehensive inspections similar to those under OSHA's PQV program at facilities presenting the greatest risk of a catastrophic accident.

  • Establish a multiagency process safety regulatory program for all California oil refineries to improve the public accountability, transparency and performance of chemical accident prevention and mechanical integrity programs.

  • Establish a multiagency process safety regulatory program for all California oil refineries to improve the public accountability, transparency and performance of chemical accident prevention and mechanical integrity programs.

  • For all California oil refineries, identify and require the reporting of leading and lagging process safety indicators, such as the action item completion status of recommendations from damage mechanism hazard reviews, to state and local regulatory agencies that have chemical release prevention authority.

  • At all Chevron U.S. refineries, engage a diverse team of qualified personnel to perform a documented damage mechanism hazard review. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure safeguards are in place to minimize hazards presented by those damage mechanisms. Analyze and incorporate into this review applicable industry best practices, Chevron Energy Technology Company findings and recommendations, and inherently safer systems to the greatest extent feasible.