2018 

PSM Moment
Process Safety Awareness
Valero Refinery Propane Fire
11th Anniversary
16th Feb 2007
 Incident Summary
• Propane release from dead leg pipe resulted in massive Fire.
• Three employees and contractor suffered from serious burn
injuries. Evacuation was ordered 15 minutes after the fire
ignited.
• The refinery was completely shutdown for two months.
Key Issues:
Leadership
Legal/Standards compliance
Hazard Identification
Standard and Practices
MOC
Emergency Preparedness
Inspection and Maintenance
References and Photos from www.csb.gov

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 Background
• Valero’s McKee Refinery was located in
Texas Panhandle, near the town of Sunray.
• The refinery processes 170,000 barrels of
crude oil per day, and distributes its
products by pipeline to customers.
• Control station of Propane De‐Asphalting
(PDA) unit was removed from active service in
the 1990s. The freeze‐related hazards of the
dead –leg formed were not identified.
• Cold weather froze the water, fracturing the
pipe elbow. Warmer weather melted the ice,
resulting in a release of highly pressurized
liquid propane through the fractured elbow.
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 Incident Event
1 2 3

Modification on the control station Line was not isolated or freeze‐ Due to 10” valve passing, water
by closing several valves to protected but left connected to the settling out of a propane stream
discontinue the mixed C3 inlet line. process, forming a dead‐leg which leaked and accumulated in the low
had not been used for 15 years. point formed.

4 5 6

In 2007, minimum temperature Water formed in the low point froze Ice sealing the failed pipe from the
recorded of 6 degree F in Texas. and cracked the pipe elbow. process melted, releasing 34kg/s of
liquid propane.

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 Incident Event

Large propane vapor cloud blown to the Boiler house nearby, ignited and
rapidly form the flame which flashed back to the cracked elbow. Propane
flew could not isolated due to no shutdown valves in the PDA skid.

Flame impingement on a non‐fireproofed structural

support caused a pipe rack to collapse. Large volume
of hydrocarbon from the pipe rack led to massive fire.

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 Near‐Miss Events
Four LPG spherical tanks were exposed to radiant
heat from the fire. Deluge valves were not able
to approach. Only sphere coating damaged.
Exposure to heating over a long period might
result in catastrophic consequences.
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The fire exposed the highly toxic liquid chlorine
containers nearby the pipe rack. 2415kg chlorine
released.
Persons left the area prior the release, otherwise
injured from toxic exposure might be possible.
Process Safety Management Failures 
According to 21 Process Safety Elements as specified in 11038-STD-SSHE-440-007

Process risk 
Process Safety  Risk Management Review and 
identification/ 
Leadership  Improvement
assessment

Leadership  Operating manuals  Process start‐up

and procedures
Incident Reporting 
Hazard  and Investigation
Identification Process and  Emergency 
Legal/standard  operational status  preparedness
compliance monitoring and 
handovers
Employee  Inspection and  Audit, Assurance, 
Management of  maintenance Management 
competency/ Review and 
operational 
assurance interfaces Management of 
Intervention
Safety Critical 
Workforce  Elements
Documentation,  Standards and 
involvement
Records & KM practices Process Safety Event 
Work control, PTW Indicators
Communication 
with stakeholders MOC
Contractor 
management

Note: Red: Ineffective barriers – details provided in the next slide.

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 Elements of Process Safety Management
1. Leadership: Leaders/Company ignored the recommendation to install shutdown valves in PDA unit which
handling large quantities of flammable materials. The action was incorrectly closed out.
2. Legal/Standards compliance: Neither API and Company standard specified sufficient protective distances for
fireproofing pipe rack support steel around the unit.
3. Employee Selection, Placement, Competency and Health Assurance:
4. Workforce Involvement:
5. Communication with Stakeholders:
6. Hazard Identification: The freeze‐related hazards of the dead‐leg formed were not identified after the
modification. Chlorine was selected in cooling water treatment unit instead of using safer biocides.
7. Documentation, Records & KM:
8. Operating Manuals and Procedures:
9. Process and Operational Status Monitoring and Handovers:
10. Management of Operational Interfaces:
11. Standards and Practices: Company had no written program to identify, review and ensure freeze protection at
dead‐legs or non used pipe. No using positive isolation at tie‐in point of unused equipment/pipe.
12. Management of Change: No MOC conducted or reviewed when the control station was removed.
13. Operational Readiness + Process Start‐Up:
14. Emergency Preparedness: Deluge system was not activated at LPG spheres due to fire at the deluge valve
location.
15. Inspection and Maintenance: No periodic inspection of long term isolation / unused piping.
16. Management of Safety Critical Elements:
17. Work Control, Permit to Work and Task Risk Management:
18. Contractor Selection and Management:
19. Incident Reporting and Investigation:
20. Audit:
21. Process Safety Event Indicators:
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 Lesson Learned
The lesson learned shall be applied:
• Effective Process Hazard Analysis shall be implemented with
following up on recommendations and appropriate close‐out.
• Inspection of dead‐legs and long term isolation equipment is
recommended.
• Ensure the proper Management of Change procedures are
followed before any modification works.
• Design of Deluge zone and activation location shall be ensured of
its usability in emergency scenarios.

Process Safety: Keep oil and gas in the pipe ! 
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