The lethal naphtha launch and fireside that killed two staff on the BP-Husky refinery near Toledo, US, in September 2022 was the outcomes of ‘a group of cascading events’ over the day before today, the US Chemical Safety and Hazard investigation Board (CSB) has concluded in its final report. These included an ‘alarm flood’, the place larger than 3700 alarms went off inside the 12-hour interval sooner than the incident, which overwhelmed and distracted BP’s operators and led to delays in responding to essential alarms, the CSB found. The corporate moreover determined that the refinery did not implement a shutdown in time to cease the catastrophic launch.
Liquid naphtha was launched from a pressurised vessel, making a vapour cloud that ignited and led to a flash hearth. The CSB well-known that there was a earlier incident on the BP Toledo refinery in 2019 the place naphtha began to fill the vessel after a refinery-wide course of failure, and that BP had missed the possibility to behave on its investigation to reinforce safety and forestall one different incident.
Based on its findings, the CSB has made fairly a number of solutions, along with that that the subsidiary of Cenovus Energy that now operates the refinery (since shopping for it in February 2023) must revise safeguards in course of hazard analyses for positive conditions, and develop protection that clearly offers staff the authority to stop work that is perceived to be unsafe.
‘Virtually each little factor that might go improper did go improper all through this incident,’ acknowledged CSB’s chairman Steve Owens. ‘The tragic lack of life ensuing from this fireplace underscores the importance of placing within the devices that staff should perform duties safely, equal to stop work authority, and having sufficient insurance coverage insurance policies, procedures, and safeguards in place to efficiently deal with extraordinarily anxious irregular situations, along with alarm floods,’ he added.