Investigation Report
Tosco Avon Refinery Petroleum Naphtha Fire — Final Investigation Report
Tosco Avon Refinery Petroleum Naphtha Fire — Final Investigation Report
- CSB
- Investigation Report
- CorrosionFireHydrocarbon releaseLeadership and safety cultureProcess safety
- Fluid transferInspection and maintenanceWorking at height
- Process pipework and pipelinesValve
- Energy and process isolationManagement of changePermit to workRisk assessment
- Downstream and process industries
Summary
Investigates the fatal naphtha fire during pipe replacement at Tosco’s Avon refinery while the crude unit remained operating. It examines corrosion, failed isolation and draining, work authorisation and management oversight. Timeline and logic-tree analysis underpin recommendations on hazard evaluation, shutdown decisions, management of change and corrosion control.
Classifications: Corrosion; corrosion damage.
Classifications: Fire; fire safety.
Classifications: Hydrocarbon release; hydrocarbon leak; oil and gas release.
Classifications: Leadership and safety culture; safety culture; safety leadership.
Classifications: Process safety; major accident hazards.
Classifications: Fluid transfer; fluid loading; fluid offloading.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Working at height; work at height.
Classifications: Process pipework and pipelines; process piping.
Classifications: Valve; valves.
Classifications: Energy and process isolation; isolation; energy isolation.
Classifications: Management of change; MOC; change management.
Classifications: Permit to work; PTW; work permit.
Classifications: Risk assessment; hazard assessment.
Classifications: Downstream and process industries; refining; petrochemicals.