On Tuesday, the Martinez Refining Company Oversight Committee will discuss a draft report regarding the February 1 fire at the Martinez Refining Company.
The report says the root cause is Operations Monitoring and Control of Work was inadequate for current Maintenance Contractor Organizational Capability. Four contributing causes were identified as well. Recommendations are developed to address all causal factors and prevent recurrence of such an incident.
According to the 21 page draft consultant’s report, provided by JEM Advisors, it highlights the incident which broke out February 1 and extinguished February 4 with six workers being evaluated by medical personnel before being released.
The flange tagged as #816 was within two isolation valves which had been closed and locked to remain closed. A drain valve within this double isolation valve installation had been previously opened, rodded out to confirm no drain valve plugging, and witnessed to confirm there was no pressure or valve leakage (confirmation of “zero energy”). However, the flange on the outside of the isolation valve was mistakenly opened by the contract workers. When opening the flange, hydrocarbon material started to leak. The two workers evacuated the area after seeing the leak, and the hydrocarbon material ignited within a minute of the initial release, resulting in a large fire in the CFH and the Cat Cracker Unit Gas Plant (CCUGP) units.
The investigation concluded that MRC procedures to positively identify work locations and to verify isolation and “zero energy” were not effective for the current Maintenance Contractor organizational capability, resulting in the workers opening a flange on the wrong side of the isolation valve, resulting in the loss of containment.
MRC cut out the double isolation valve assembly and sent to a mechanical and metallurgical laboratory for testing. A summary of breakaway torque measurement data from that testing was provided to JEM by MRC. Based on this preliminary information, JEM concluded the four bottom stud bolts on the incorrect flange (Flange #4 on Figure 1) and all of the stud bolts on the correct flange (Flange #3 on Figure 1) for blind #816 installation were loosened prior to the loss of containment and fire, indicating the workers started work on the correct flange and then began opening the wrong flange.
Causes and Factors:
- Contributing Cause #1 – Regulatory Issues
- Contributing Cause #2 – Work Processes and Procedures
- Contributing Cause #3 – Human Factors (Training)
- Contributing Cause #4 – Contractor Supervision
- Root Cause- Operations Monitoring and Control of Work was inadequate for current Maintenance Contractor Organizational Capability
JEM Advisors is set to present the report to Contra Costa Health’s (CCH) Martinez Refining Company Oversight Committee at its Tuesday meeting. For more information on the meeting, click here.
Related Stories:
- April 3 – Martinez Refining Company to Restart Refinery Process Units
- Feb 11 – Martinez Refinery Discloses Toxic Chemicals Released During Fire
- Feb 5 – Joint Statement on the Martinez Refinery Fire
- Feb 4 – Martinez Health Advisory Lifted
- Feb 4 – Scales-Preston Issues Statement on Martinez Refining Company Fire
- Feb 4 – Contra Costa Fire Releases Incident Report from Martinez Refinery Fire
- Feb 2 – Bay Area Air District Releases Report on Martinez Refinery Fire
- Feb 1 – Update: Martinez Refinery Fire Injures 3, Shelter-in-Place
