HSSE Date:

Alert No.:
Apr 24, 2021
003
ALERT Source: CSB

Chevron Refinery Fire Incident - (Richmond, USA)

INCIDENT SUMMARY: On August 6, 2012 at about 6:31pm, Chevron Refinery in Richmond, California, experienced
a catastrophic pipe failure in the #4 Crude Unit. The piping referred to as the “4-sidecut” stream ruptured, releasing
flammable, hydrocarbon process fluid (high temperature light gas oil) which partially vaporized into a large vapor
cloud that engulfed nineteen Chevron employees. All of the employees escaped, narrowly avoiding serious injury.
The flammable portion of the vapor cloud ignited just over two minutes after the pipe ruptured.
In the weeks following the incident, approximately 15,000 people from the surrounding area sought medical treatment
due to effects from the release.
Eighteen (18) of the employees safely escaped from the vapor cloud just before ignition; one (1) employee, a Chevron
refinery firefighter, was inside a fire engine that was caught within the fireball when the process fluid ignited. Because
he was wearing full-body fire-fighting protective equipment, he was able to make his way through the flames to safety.
Six (6) Chevron employees suffered minor injuries during the incident and subsequent emergency response efforts.

FINDINGS FROM INCIDENT INVESTIGATION

• Chevron did not effectively implement internal recommendations to help prevent pipe failures due to
sulfidation corrosion. Sulfidation corrosion causes pipe walls to thin, which eventually leads to the need to
replace the thinned piping.

• Failure to Invoke Stop Work Authority.

The CSB learned that some personnel participating in the insulation removal process while the 4-sidecut
line was leaking were uncomfortable with the safety of this activity because of potential exposure to the
flammable process fluid and recommended that the Crude Unit be shut down, but they left the final decision
to the management personnel present. No one formally invoked their Stop Work Authority due to issue of
decision making as they believed the Stop Work decision should be made by someone else higher in the
organizational hierarchy and fear of reprisal for stopping the job.

• The CSB found that the Richmond refinery’s turnaround planning group rejected the recommendations to
100 percent component inspect or replace the portion of the 4-sidecut piping that ultimately failed.

• A Crude Unit metallurgical analysis recommendation to perform 100 percent volumetric inspection of the 4-
sidecut line submitted for the 2007 turnaround was approved by the Crude Unit’s Area Business Unit (ABU)
Manager. Chevron installed experimental “Guided Wave bracelets” which were designed to continuously
perform 100 percent volumetric inspection. However, the guided wave bracelets were only installed on a
small portion of the 4-sidecut line which did not include the 52-inch component that ultimately failed.

• Chevron’s Fixed Equipment Reliability Business Improvement Network (FER BIN) program did not
effectively gain the necessary commitment from refinery management to implement the Sulfidation Failure
 Prevention Initiative or other recommendations to upgrade susceptible carbon steel piping to inherently
safer, higher chromium steel. The FER BIN is intended to be a “best practice” network across all Chevron
refineries for bringing up-to-date changes in industry standards and best practices into the organization.

• Reluctance among employees to use their Stop Work Authority. Recent safety culture surveys performed at
the refinery indicate that employees had become less willing to use their Stop Work Authority between 2008
and 2010.

• Substandard equipment maintenance practices. Those same surveys indicate that Chevron Richmond
Refinery employees saw increased problems in how the refinery maintained its equipment between 2008
and 2010.

• Effectively implementing inherently safer design provides an opportunity for preventing major chemical
incidents. The August 6, 2012, incident at Chevron and other incidents throughout the refining industry
highlight the difficulty in preventing failure caused by sulfidation corrosion in low-silicon carbon steel piping
solely through inspection, a procedural safeguard that is low on the hierarchy of controls. Using inherently
safer design concepts to eliminate the hazard of variation in corrosion rate in carbon steel piping due to
hard-to-determine silicon content will prevent future similar failures in refineries.

KEY ACTIONS TAKEN

• The chain of events of the incident 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. However, it was lifted later

• The CSB investigation team developed an accident map (AcciMap) for the Chevron investigation.

• After the Interim Investigation report was developed, the CSB release a comprehensive Final Investigation
Report later in 2013 that included analyses and recommendations relating to technical and regulatory
investigation findings which were not included in the interim report.

ROOT CAUSES
• Poor management of sulfidation corrosion on the piping.

• “Stop Work” not called.

• Piping was constructed with variable corrosion rate-prone carbon steel.

• Thorough inherently safer systems analysis not conducted in PHA.

• No Damage Mechanism Hazard Review Performed.

• Chevron reliability programs not effective to implement Sulfidation Failure Prevention Initiative.

• No guiding emergency leak response protocol in place.

INCIDENT INVESTIGATION RECOMMENDATIONS
• Develop an auditable process for all recommended turnaround work items related to inspection or mechanical
integrity recommendations that are denied or deferred. This process shall provide the submitter of the denied
or deferred recommendation with a mechanism to further elevate and discuss the recommendation with
higher level management. – (Chevron USA)

• Develop an approval process that includes a technical review that must be implemented prior to resetting the
minimum alert thickness to a lower value in the inspection database. – (Chevron USA)

• Develop an accountability method at Chevron to identify and track effective implementation of Chevron or
industry best practices to ensure process safety or employee personal safety. – (Chevron USA)

• Refer users to follow the leak response guidance developed by the American Petroleum Institute prior to
conducting leak repairs. – (ASME)

• Revise API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries to
establish minimum requirements for preventing catastrophic rupture of low-silicon carbon steel piping. – (API)

• Revise API RP 574: Inspection Practices for Piping System Components (3rd edition) to incorporate as a
normative reference API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil
Refineries and to follow the leak response protocol requirements established in API RP 2001: Fire Protection
in Refineries. – (API)

• Revise API RP 2001: Fire Protection in Refineries to require users to develop a process fluid leak response
protocol specific to their own facility that must be followed when a process fluid leak is discovered.
Recommend users to incorporate key actions into their leak response protocol to effectively manage response
to potential sulfidation corrosion piping failure. – (API).

KEY LESSONS LEARNED

• Best industry practices for the management of sulfidation corrosion on piping must be duly followed.

• Inherently safer systems analysis must be conducted in PHA.

• Damage Mechanism Hazard Review must be Performed.

• Reliability programs must be effective to implement Sulfidation Failure Prevention Initiatives.

• Emergency leak response guidance protocol must be in place.

• “Stop Work Authority” must be invoked as and when due.

• There is a need for thorough analyses of process safeguards.

Compiled By:
Engr. Osedebamen Itua Irabor Kelly