Group 07

Case Study Report

Pipe Rupture and Fire

Chevron U.S.A. Inc. Refinery, California
August 6, 2012

Submitted by

Kaiying Wang
&
Sukanta Mondal

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 Contents
Introduction 4

Background Information 5

Events Leading up to Incident 6

Incident Description 7

Incident Analysis 8

Conclusions

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Incident Description
The Richmond, California Chevron Refinery’s #4 Crude Unit (Crude Unit) experienced a catastrophic pipe
rupture on August 6,2012. The #4 Crude Unit performs the initial processing step in the refining process.
Raw crude oil stored in storage tanks is pumped to the Crude Unit. After an initial “cleaning” of the oil
through the use of a desalter, which removes corrosive salts, solids, and water, the oil is pre-heated and
enters the C-1100 Crude Unit Atmospheric Column (Crude Column) where the incident occurred. The
pipe rupture occurred on a 52-inch long component of the 4-sidecut 8-inch line (the 52-inch
component). At the time of the incident, light gas oil was flowing through the 8-inch line at a rate of
approximately 10,800 barrels per day (bpd).
In a short time, flammable and high temperature light gas oil released from the ruptured pipe. Then the
released gas partially vaporized into a large, opaque vapor cloud that engulfed 19 Chevron U.S.A. Inc.
(Chevron) employees. After two minutes’ release, the leaked process fluid ignited. Fortunately, eighteen
of the employees safely escaped from the vapor cloud just before ignition. A Chevron refinery
Firefighter was able to make his way through the flames safely since he was wearing full-body fire-
fighting protective equipment. However, there were still six Chevron employees suffered minor injuries
during the incident and subsequent emergency response efforts.
What is worse, the release, ignition, and subsequent burning of the hydrocarbon process fluid resulted
in a large plume of vapor, particulates, and black smoke, which traveled across the surrounding area.
This chain of events resulted in a Community Warning System (CWS) Level 3 alert, and a shelter-in-place
advisory (SIP) was issued at 6:38 p.m. for the cities of Richmond, San Pablo, and North Richmond. It was
lifted later that night, at 11:12 p.m., after the fire was fully under control. In the weeks following the
incident, approximately 15,000 people from the surrounding communities sought medical treatment at
nearby medical facilities for ailments including breathing problems, chest pain, shortness of breath, sore
throat, and headaches. Approximately 20 of these people were admitted to local hospitals as inpatients
for treatment.
Incident Analysis
How does this happen? What should we do to avoid this terrible accident? An accident map was
developed for the Chevron investigation, which can be seen in Fig 1.

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 Fig 1. Acci-Map of August 6, 2012, Chevron Refinery Fire.

The diagram includes the following five levels.

1. Outcomes: the impact of the August 6, 2012, event to workers present and the surrounding

community;

2. Physical Events and Conditions: the immediate causes of the incident as displayed in a traditional logic
tree;

3. Chevron: company rules and policies; conduct of turnarounds; risk management; identification of

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hazards and evaluation of safeguards; adoption of internal recommendations; safety programs; and

emergency response;

4. Industry Codes and Standards: good practice guidelines that provide safety requirements and

recommendations on topics including mechanical integrity and emergency response; and

5. Government: laws and legislation developed to regulate process safety at refineries.

First, we can tell that the accident seriously affected not only the people in the company but also people
surrounding the company. Second, we can find the main reason causing the rupture from Physical
Events and Conditions. The rupture of the 4-sidecut piping resulted from the 52-inch component being
extremely thin due to a damage mechanism known as sulfidation corrosion. This damage mechanism
causes pipe walls to gradually thin over time. The Chevron Richmond Refinery 4-sidecut piping was
constructed of carbon steel, which corrodes at a much faster rate from sulfidation than other typical
alternative materials of construction. Also, carbon steel experiences significant variation in corrosion
rates due to possible variances in silicon content. However, there is no minimum silicon content
requirements for carbon steel piping so that the level of silicon in the carbon steel pipe manufacturing
process are different. Unfortunately, the Chevron Richmond Refinery 4-sidecut piping circuit containing
the 52-inch component that failed had no minimum specification for silicon content, which shows
considerably less thinning.

Even though several Chevron personnel with knowledge and understanding of sulfidation corrosion
recommended on several occasions either a one-time inspection of every component within the 4-
sidecut piping circuit 10 years prior to the incident, Chevron did not take these recommendations, which
failed to perform internally recommended 100 percent component inspections. Besides, Chevron’s Fixed
Equipment Reliability Business Improvement Network (FER BIN) program did not effectively gain the
necessary commitment from refinery management to implement the ETC Sulfidation Failure Prevention
Initiative or other ETC recommendations to upgrade susceptible carbon steel piping to inherently safer,
higher chromium steel. To make things worse, Chevron did not effectively identify in the Incident
Command structure the damage mechanisms that could have caused the 4-sidecut piping leak on the
day of the incident. On the day of the incident, Chevron had no leak response guidance or formal
protocol for operations personnel, refinery management, emergency responders, or the Incident
Commander to refer to when determining how to handle a process leak.

If Chevron took the recommendations, made the proper risk management, followed the safety
requirements, or inspected the rupture more carefully, the accident can be avoided.

Conclusion
The main reason for the rupture is the sulfidation corrosion, which leads to the following fire and
explosion. However, this accident can be avoided if Chevron checked the pipe more carefully and
followed the safety design. The government should make strict laws and regulations to regulate the
process at refineries.

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References

[1] L. Grim, D. Tillema, S. Cutchen, M. Wingard, A. Johnson, CSB investigation of Chevron Richmond
refinery pipe rupture and fire, Process Safety Progress, 34 (2015) 355-359.

[2] U.S. Chemical Safety and Hazard Investigation Board, Chevron Richmond Refinery Pipe Rupture and
Fire, Final Investigation Report (2012).

[3] Chevron could have prevented Richmond refinery accident: CSB, Industrial Safety & Hygiene News,
(2013).

[4] Mike Wilson, Case Study: The Richmond, Chevron Refinery Fire, NIEHS & UCLA LOSH, (2013).

[5] J. Tepperman, Chevron Management Failures Led to Massive August 2012 Explosion in Richmond,
East Bay Express, (2015).

[6] A. Khan, Corporate Social Responsibility and its Effects on Corporate-Community Relationships: A
Case Study of Chevron's Richmond Refinery Fire in 2012, (2013).

[7] P. Thammongkol, The system theoretic accidental analysis of a crude unit refinery fire incident,
DSpace at Massachusetts Institute of Technology, (2014).

[8] S. Greene, Officials: Chevron failed to replace corroded pipe that caused Aug. fire, Richmond
Confidential, (2013).

[9] abc7news, Chevron ordered to pay up for 2012 refinery fire,

https://abc7news.com/business/chevron-ordered-to-pay-up-for-2012-refinery-fire/2247343/,
(2017).

[10] Wikipedia, Chevron Richmond Refinery,

https://en.wikipedia.org/wiki/Chevron_Richmond_Refinery#2012_fire.

[11] Kristin J. Bender, Massive fire at Chevron refinery in Richmond fully contained; shelter in place lifted
The Mercury News, (2012).

https://www.mercurynews.com/2012/08/06/massive-fire-at-chevron-refinery-in-richmond-fully-
contained-shelter-in-place-lifted/

[12] S. Wildman, Sixth Update to the 30-Day Report for the CWS Level 3 Event of August 6, 2012, Contra
Costa Health Services, ( 2013) p. 4.

https://cchealth.org/hazmat/pdf/2012_0806_chevron_30day_report_6th_Mar29.pdf

[13] USCSB, Animation of Fire at Chevron's Richmond Refinery, August 6, 2012,

https://www.youtube.com/watch?v=QiILbGbk8Qk, (2013).

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