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Contractor Safety, Oversight and Management in CSB Investigations
Reepa Shroff, MS; Vidisha Parasram, MPH; Johnnie Banks, CFEI
United States Chemical Safety and Hazard Investigation Board

Partridge Raleigh Oilfield, 2006

Donaldson Enterprises, Inc., 2011
Contractor management and oversight issues have played a causal
role in many of the incidents that CSB has investigated. Contractors
Introduction must be adequately managed by the owner of the facility or third party
management companies that are delegated oversight responsibilities.
Conclusions
Prudent company controls are required to ensure hazards associated
CSB Background with contractor’s services are identified, evaluated, and controlled.1 A company’s inactive participation in contractor selection, and
Company controls involve “Implementing practices to ensure that oversight, coupled with a lack of communication can contribute to an
The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an Motiva Enterprises, 2001
unsafe working environment and lead to catastrophic incidents.
contract workers can perform their jobs safely, and that contracted
independent federal agency charged with investigating industrial
chemical accidents. Headquartered in Washington, DC, the agency's
services do not add to or increase facility operational risks.1” Often,
third party management companies fail to adequately manage the
Results Partridge Raleigh Oilfield, 2006 Through its investigations, CSB has found that by managing its
contractors a facility owner must effectively and comprehensively
board members are appointed by the President and confirmed by the CSB Investigation2 Date Fatalities Injuries
Type of
Activity evaluate a contractor’s entire safety record. A review such as this can
contractors on behalf of the owners of the facility. The failures are Incident
Senate. 1. Sonat Exploration
Oil and Refining- Vessel lacked a pressure relief system and ruptured
help the facility owner identify past incidents involving substantially
created by tasking individuals with completing dangerous work without 3/4/1998 4 (2 contractors) 0 Explosion and due to over pressurization during start-up, releasing
The CSB conducts root cause investigations of chemical accidents at Company
Fire flammable material which ignited. similar work. In addition, developing a process safety management
being familiar with the hazards associated with the work. The use of 2. Union Carbide Nitrogen Nitrogen asphyxiation during inspection of a pipe in
refineries, chemical plants, and fixed industrial facilities. Root causes Corporation
3/27/1998 1 Employee 1 Contractor
Asphyxiation a confined space system requiring a formal process hazard assessment could likely
contractors can place personnel who are unfamiliar with the facility's
are usually deficiencies in safety management systems, but can be any 3.
Tosco Avon Refinery 2/23/1999 4 (3 Contractors) 1 Employee Fire Petroleum naphtha fire prevent incidents from occurring by identifying the hazards before the
hazards and protective systems into locations where they could be
factor that would have prevented the accident if that factor had not 4.
Bethlehem Corporation 2/2/2001 2 (1 Contractor) 4 Employees Fire
Flammable liquid released and ignited in the furnace
work is to be done. It is also prudent for a facility owner to actively
affected by process hazards. Conversely, as a result of their work area of a plate mill
occurred. Other accident causes often involve equipment failures, 5.
Hot Work-
discuss safety elements related to specialized tasks and equipment
activities, the contractors may expose facility personnel to new Motiva Enterprises 7/17/2001 1 Contractor 8 Contractors Explosion and Sulfuric acid tank explosion from hot work.
human errors, unforeseen chemical reactions or other hazards. The Fire with employees and contractors during scheduled training and regular
hazards, such as those associated with the use of specialized 6. Kaltech Industries Explosion and
agency does not issue fines or citations, but does make Group, Inc.
4/25/2002 0 36 (2 Contractors)
Fire
Chemical waste-mixing
safety meetings. To name a few, safety topics should include topics
equipment.
recommendations to plants, regulatory agencies such as the 7. Georgia- Pacific
Naheola Mill
1/16/2002 2 Contractors 8 Contractors Reactives
Hydrogen sulfide exposure from sodium hydrosulfide
and sulfuric acid reaction such as JHAs, hot work permits, hazard awareness, stop work
Occupational Safety and Health Administration (OSHA) and the
Environmental Protection Agency (EPA), industry organizations, and Methods 8.

9.
BLSR Operating, LTD

Hayes Lemmerz
1/13/2003 3 (1 Contractor)
Vapor Cloud
4 (1 Contractor) Deflagration and
Pool Fire
Aluminum Dust
Release of hydrocarbon vapor during unloading from
vacuum trucks into an open area collection pit.
authority, pre-task planning, fire prevention and gas detection. The
siloing of tasks, unclear responsibilities, a checklist mentality and
labor groups. Congress designed the CSB to be non-regulatory and 1. Conducted a comprehensive review and analysis of CSB International
10/29/2003 1 Employee 6 (1 Contractor)
Explosion
Dust explosion in a scrap re-melting system.
inadequate management can contribute to failures in contractor safety
independent of other agencies so that its investigations might, where investigative reports from 1998 to present 10.
BP Texas City 3/23/2005 15 Contractors 180 Workers
Fire and
Explosion
Restarting a hydrocarbon isomerization unit and may lead to incidents involving contractor injuries and fatalities.
appropriate, review the effectiveness of regulations and regulatory 2. Qualitatively analyzed each investigation report for contractor 11.
Valero Refinery 11/5/2005 2 Contractors 0 Asphyxiation Nitrogen asphyxiation during maintenance work CSB has found these to be recurring contractor safety themes
enforcement. fatalities and injuries, type of incidents, and activities involved Hot Work-
Weld piping to oil production tanks when a welding throughout its investigations.
12. Partridge Raleigh
6/5/2006 3 Contractors 1 Contractor Explosion and
A History of Contractor Safety 3. Evaluated for emerging contractor safety themes Oilfield
Fire
tool likely ignited flammable vapor from the tanks.
Contractor
13. Liquid propane release from cracked control station
BP, Texas City 2005 Valero McKee Refinery 2/16/2007 0 4 (1 Contractor) Fire Selection and
The CSB has had a long history of investigating incidents involving piping
Evaluation
contractor-related injuries and fatalities. The CSB has analyzed the Xcel Energy, 2007
14.
Allied Terminals, Inc. 11/12/2008 0 2 Contractors Tank Failure Liquid fertilizer release from failed tank

root and contributing causes of these incidents, addressing issues 15.

10/2/2007 5 Contractors 3 Confined Space
Flash fire erupted inside a drained penstock at the Deviations Dangerous
Xcel Energy
hydroelectric power plant from Policies and/or
involving contractor oversight, contractor selection processes, 16. Combustible Accumulations of combustible sugar dust in and Procedures Specialized Job
2/7/2008 14 (2 Contractors) 36 Workers
communication, training and hazard awareness. In the CSB’s 19 year
Imperial Sugar
Dust packaging building led to explosion and fire
Oil and Refining-
history, the agency has deployed to over 130 chemical incidents and 17.
Silver Eagle Refinery 1/12/2009 0 4 (2 Contractors) Explosion and
flammable vapor cloud was released from an Contractor
atmospheric storage tank Injuries and
Fire
issued more than 800 recommendations that have led to numerous 18. Macondo-Deepwater
Oil and Refining- Fatalities Lack of Hazard
4/20/2010 11 Contractors 17 Contractors Explosion and Explosion and fire on an oil rig. Contractor
safety improvements across a wide variety of industries. CSB has Horizon
Fire Oversight
Awareness by
Hot Work Contractors
conducted many investigations that involved incidents resulting in the 19. E.I. DuPont de
11/9/2010 1 Contractor 1 Contractor Explosion and
Repairing the agitator support atop an atmospheric
Nemours & Co. Inc. storage tank containing flammable vinyl fluoride.
death or injury of contractors. These 26 investigations are Fire
Metal Dust
20. Particulates ignited in the blender processing
summarized in the results table. AL Solutions, Inc. 12/9/2010 3 Employees 1 Contractor Explosion and
zirconium
ExxonMobil Baton Rouge Refinery, 2016 Fire
21. Donaldson Enterprises, Inadequate Poor
4/8/2011 5 Contractors 1 Contractor Reactives Explosion in a fireworks storage facility Safety Training Communication
Inc.
Industry often relies upon contractors for very specialized skills and, Chemical
Equipment rupture, explosion, and fire during non-
sometimes, to accomplish particularly hazardous tasks - often during 22. Williams Geismer
Olefins
6/13/2013 2 Employees
167 (164
Contractors)
Manufacturing
Fire and
routine operational activities that introduced heat to
an offline reboiler.
periods of intense activity, such as maintenance turnarounds. These
considerations, coupled with the potential lack of familiarity that 23. Tesoro Martinez
Refinery
3/10/2014 0 2 Contractors
Explosion

Sulfuric Acid
Release
Sulfuric acid sprayed workers while they conducted
planned non-routine maintenance work to remove
Resources
contractor personnel may have with facility hazards and operations, Explosion and
piping in the alkylation unit.
24. Sunoco Logistics
8/12/2016 0 7 Contractors Hot work on crude oil pipeline in a terminal 1. Center for Chemical Process Safety, “Guidelines for Risk Based Process
pose unique challenges for the safe utilization of contract services.1 Partners Fire
Chemical Release Isobutane release and fire in the sulfuric acid Safety,” 2007. Section 13.1.2.
25. ExxonMobil Baton
11/22/2016 0 4 (3 Contractors)
As a result of the nature of many of these hazardous tasks there have Rouge Refinery and Fire alkylation unit 2. U.S. Chemical Safety and Hazard Investigation Board http://www.csb.gov/
been many incidents involving fatal injuries or injuries to contractors.
26. Packaging Corporation
of America
2/8/2017 3 Contractors 7 Contractors
Explosion and
Fire
Hot work near tank containing flammable
atmosphere 2017. www.csb.gov