Investigation Report
Tesoro Martinez Sulfuric Acid Spill
Tesoro Martinez Sulfuric Acid Spill
- CSB
- Investigation Report
- Hazardous SubstancesProcess Safety
- Hazardous substancesLeadership and safety cultureLearning from incidentsLoss of containmentProcess safety
- Hot workInspection and maintenance
- Personal protective equipmentProcess pipework and pipelinesRespiratorValve
- Closed and remote samplingEnergy and process isolationPermit to workRisk assessment
- Downstream and process industries
Summary
CSB case study examines two sulfuric acid releases at the Martinez refinery in February and March 2014, injuring four workers. It analyses sampling-system integrity, protective equipment, pipe preparation and isolation, alongside process safety culture and missed incident learning. Comparisons with other refineries inform discussion of safer sampling arrangements.
Classifications: Hazardous substances; hazardous chemicals; chemical exposure.
Classifications: Leadership and safety culture; safety culture; safety leadership.
Classifications: Learning from incidents; incident learning; lessons learnt; lessons learned.
Classifications: Loss of containment; containment loss.
Classifications: Process safety; major accident hazards.
Classifications: Hot work; welding and cutting.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Personal protective equipment; PPE; personal protection equipment.
Classifications: Process pipework and pipelines; process piping.
Classifications: Respirator; respiratory protective equipment; RPE.
Classifications: Valve; valves.
Classifications: Closed and remote sampling.
Classifications: Energy and process isolation; isolation; energy isolation.
Classifications: Permit to work; PTW; work permit.
Classifications: Risk assessment; hazard assessment.
Classifications: Downstream and process industries; refining; petrochemicals.
Summary
An investigation into a sulfuric acid spill at an industrial facility.
Themes: hazardous substances, process safety.