Investigation Report
BP - Husky Oregon Chemical Release and Fire
BP - Husky Oregon Chemical Release and Fire
- CSB
- Investigation Report
- Hazardous SubstancesHot Work and Fire
- FireHuman factorsHydrocarbon releaseLearning from incidentsProcess safety
- Fluid transfer
- Pressure vesselProcess pipework and pipelinesValve
- Alarm managementOperating and work proceduresRisk assessmentStop-work authority
- Downstream and process industries
- Onshore facility
Summary
Investigates the fatal naphtha release and flash fire at the BP-Husky Toledo Refinery in Oregon, Ohio. Examines cascading process disturbances, vessel overflow, manual draining, misleading level indications and alarm overload. Recommendations address engineered overfill safeguards, abnormal-situation procedures, stop-work practice and alarm performance, alongside shortcomings in applying earlier incident lessons.
Classifications: Fire; fire safety.
Classifications: Human factors; human performance; ergonomics.
Classifications: Hydrocarbon release; hydrocarbon leak; oil and gas release.
Classifications: Learning from incidents; incident learning; lessons learnt; lessons learned.
Classifications: Process safety; major accident hazards.
Classifications: Fluid transfer; fluid loading; fluid offloading.
Classifications: Pressure vessel; pressure vessels.
Classifications: Process pipework and pipelines; process piping.
Classifications: Valve; valves.
Classifications: Alarm management.
Classifications: Operating and work procedures.
Classifications: Risk assessment; hazard assessment.
Classifications: Stop-work authority; stop work; stop-work intervention.
Classifications: Downstream and process industries; refining; petrochemicals.
Classifications: Onshore facility; onshore plant.
Summary
Investigation into a chemical release and fire at an industrial facility.
Themes: hazardous substances, hot work and fire.