CSB Public Meeting

ExxonMobil Refinery Explosion

Torrance, California
J
January 13
13, 2016
Agenda
• Board Opening Remarks
• Statements from Elected Officials
• Investigation
g Team Presentation
• Board Questions to Team
• Torrance Refinery Action Alliance
• Break
• PSM Panel
• Board Questions to Panel
• Public Comment
• Cl i
Closing C
Commentst
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Board Opening Remarks

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Statements
St t t from
f Elected
El t d Officials
Offi i l

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Investigation Team Presentation

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Investigation Presentation
•BBackground
k d and
dPProcess D
Description
i ti
• Incident Description
• Modified Hydrofluoric Acid Near Miss
and Off-site Consequences
q
• Key Issues
• Path Forward
• Obstacles

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Background and Process Design

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Torrance Refinery History and Statistics
Refinery was constructed
i 1928
in 1928-29
29

The Torrance Refineryy

represents about 1/5th of
southern California’s fluid
catalytic cracking
capacity

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Refinery Proximity
to Public Receptors
Within a 3-mile radius
of the refinery, there
are:
• 330,000 residents
• 71 schools
• 8 hospitals

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Fluid Catalytic Cracking (FCC) Unit
The FCC converts low-value, thick oil to higher value
gasoline by
g y “cracking”
g the large
g molecules apart
p into
smaller molecules

Catalytic Cracking

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FCC Layout

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Catalyst
y

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Main Column
Col mn
Operation

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ESP Principle of Operation

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Incident Overview

• February 11 – FCC expander began to

p
experience vibrations
• February 16- Expander vibrations
exceeded limit and unit was
automatically put in “safe park” by logic
controls

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Steam

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Incident Overview
• Incident Response Team formed to deal
with expander issue
• IRT ultimately
lti t l decided
d id d tto use same plan
l
from 2012 to go into expander and clean
it staying
it, t i iin safe
f parkk

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IIncident
id t Timeline
Ti li
• Earlyy on February y 18, maintenance
workers who were to blind the
expander
p outlet became concerned
due to steam coming out of expander
• Steam reduced,, allowing g
hydrocarbons to flow from main
column to flue ggas piping
pp g
• Workers started getting hydrogen
sulfide alarms and exited the unit

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Modified Hydrofluoric Acid
Serious Near Miss

“Dropping loads or other falling objects

within
ithi d
damage range off equipment
i t
containing flammable or toxic material”
-ExxonMobil
ExxonMobil Corporate example of a
near miss incident

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Settler tanks
• Two tank
system
• Approximately
80 feet south
of the ESP
• Still outside of
E
ExxonMobil’s
M bil’
minimum
equipment
spacing
requirement
q

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Original
Location

Settler Tank

Damaged
Scaffold

Intake Intake
Duct Duct

Column

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Potential Health Effects of HF and
MHF
• HF acid is a toxic chemical and poses a
severe hazard to the population and
environment when a release occurs
• Causes severe damage to skin,
respiratory system,
system and bones after
exposure and can lead to death
• Large
L release
l could
ld iimpactt h
hundreds
d d off
thousands of residents

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C
Community
it Exposure
E
• A large quantity of catalyst dust was
released due to the ESP explosion
• Catalyst
C t l t dust
d t fell
f ll in
i the
th nearby
b
communities as far as a mile away
• SCAQMD report can be found on their
website: http://www.aqmd.gov/
p q g

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Key Issues Identified in Investigation
• Implementation of ExxonMobil
Operations Integrity Management System
(OIMS)
• Process Hazard Analysis
• Mechanical
M h i l IIntegrity
t it
• Worker Participation
• Process Safety Regulatory Gaps
• Community Impacts
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Issue: Process Hazard Analysis
• PHA failed to adequately consider
hydrocarbons reaching the ESP
– PHA onlyy considered carbon monoxide
entering the ESP
– As a result, detectors used to shut down the
ESP were only l calibrated
lib d to read
d carbon
b
monoxide
• Investigation team is currently working to
determine rationale behind the ExxonMobil
PHA process
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Issue: Process Hazard Analysis Cont.
• Spent Catalyst Slide Valve not maintaining
catalyst level
yd oca bo s in main
• Hydrocarbons a cocolumn
u
• No analysis of steam flow rate needed into
co u
column

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I
Issue: Mechanical
M h i l Integrity
I t it
• Pressure transmitter in the main column
• Expander
• CO gas detectors
• Heat exchangers leaking naphtha
• Valves attached to these heat
exchangers

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I
Issue: Worker
W k Participation
P ti i ti
• Hourly workers were not included in
Incident Response Team
• Input
I t was nott given
i for
f the
th variance
i
• Workers expressed
p concern for actions
being taken
• Concerns by operators are handled in a
Job Safety and Environmental Analysis
(JSEA) however a JSEA was not done
(JSEA), done.
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Issue: Lack of Hierarchy of
Controls Analysis
• Could have prevented incident through
utilization of passive barriers.
• Shutting all valves leading to the ESP, or
• A blind at the top of the main column.
• HOC Principles could have been applied.
• Design
g of SCSV
• Removing HC from MC
• Evaluate the use of modified HF

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Process Safety Management
• A safety management system
approach focused on the prevention
and mitigation of catastrophic
releases of chemicals or energy from
a process associated with a facility.
• Elements of PSM include:
– Process Hazard Analysis (PHA),
– Operating Procedures,
– Management of Change (MOC), and
– Employee Participation.
Participation

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California Process Safety
Management (PSM) Reform
• Some PSM failures would not have
been identified under the current CA
PSM regulation
regulation.
• Certain PSM elements fail to require an
assessment of their adequacy of
completion.
• Current PSM regulation
g also lacks keyy
process safety requirements
• CA draft PSM regulations will be discussed
i a llater
in t panell ttonight
i ht
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Previous CSB investigations
•Previous
Previous CSB reports have
identified similar regulatory gaps in
CA and other jurisdiction’s
jurisdiction s PSM
regulations
• Chevron
Ch R fi
Refinery Fi
Fire (2012)
• Tesoro Refinery Fatal Explosion
and Fire (2010)

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Additi
Additional
l Issues
I
•Organizational Failures
•ESP Siting
g
•Non-routine operating conditions
•Safety
S f t Critical
C iti l E
Equipment
i t
Management

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I
Investigation
ti ti Obstacles
Ob t l
•ExxonMobil refusing to provide
safety-related documentation
•ExxonMobil subpoena responses:
• 51%-Fullyy Responsive
p
• 24%-Partially Responsive
• 25%- Not Responsive

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P th Forward
Path F d
• Incorporate/Investigate Public Input from
this Meeting into the Investigation
• Finalize
Fi li Investigation
I ti ti and d Pl
Plan ffor R
Reportt
• Issue Report
p with Recommendations
• Safety Video
• PSM Advocacy Efforts

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B
Board
d Questions
Q ti for
f Investigation
I ti ti Team
T

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Break

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PSM Panel

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Bibli
Bibliography
h
http://2010.igem.org/User:Meagan/Oil_Sands (black oil picture)

"Electrostatic precipitator" by Evan Mason - Own work.

Licensed under CC BY-SA 3.0 via Commons -
https://commons.wikimedia.org/wiki/File:Electrostatic_precipitat
or.svg#/media/File:Electrostatic_precipitator.svg

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