Investigation Report
ExxonMobil Baton Rouge Refinery Chemical Release and Fire
ExxonMobil Baton Rouge Refinery Chemical Release and Fire
- CSB
- Investigation Report
- Hazardous SubstancesHot Work and FireProcess Safety
- FireHuman factorsHydrocarbon releaseLeadership and safety cultureMechanical failure
- Inspection and maintenance
- Valve
- Competence and trainingHuman-centred designOperating and work proceduresRisk assessment
- Downstream and process industries
- Onshore facility
Summary
This safety bulletin examines an isobutane release and fire at ExxonMobil’s Baton Rouge refinery that seriously injured four workers. It analyses plug valve gearbox removal, pressure-retaining bolt arrangements, design ambiguity and organisational practices. Lessons address safer valve designs, human-factors hazard analysis, written removal procedures and operator training.
Classifications: Fire; fire safety.
Classifications: Human factors; human performance; ergonomics.
Classifications: Hydrocarbon release; hydrocarbon leak; oil and gas release.
Classifications: Leadership and safety culture; safety culture; safety leadership.
Classifications: Mechanical failure; equipment failure.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Valve; valves.
Classifications: Competence and training; competency assurance; safety training.
Classifications: Human-centred design.
Classifications: Operating and work procedures.
Classifications: Risk assessment; hazard assessment.
Classifications: Downstream and process industries; refining; petrochemicals.
Classifications: Onshore facility; onshore plant.
Themes: hazardous substances, hot work and fire, process safety.