WASTE MANAGEMENT INDUSTRIAL SERVICES, INC.
ACCIDENT INVESTIGATION INTO THE
TOSCO REFINERY 50 UNIT FIRE OF 02/23/99
SUMMARY
On February 23, 1999, a fire in a crude oil processing unit at
Tosco Refining Company’s SFAR-Avon Refinery resulted in four worker fatalities
and one serious injury. The incident
was investigated by Tosco, its on-site union, the Paper Allied Industrial
Chemical & Energy Workers (P.A.C.E.) and various state and federal agencies: The Division of Occupational Safety &
Health (DOSH/Cal OSHA), Bureau of Investigations (BOI), federal OSHA, Contra
Costa Health Services (CCHS), United States Chemical Safety and Hazard
Investigation Board (CSB), and the Bay Area Air Quality Management District
(BAAQMD). Waste Management Industrial
Services, Inc. was present at the site the day of the accident, but none of its
employees was injured.
Cal OSHA performed an opening conference with Waste Management
Industrial Services, Inc. the day of the incident in order to initiate a formal
investigation. Cal OSHA requested,
received, and reviewed various documents to evaluate employer’s compliance with
pertinent Title 8 regulations. These
included training, general safe practices, and implementation of the employer’s
Injury and Illness Prevention Program at the client’s worksite. An interview was conducted with the employee
who had been present onsite at the time of the accident.
Incident Summary
On 02/23/99, a fire occurred at the fractionator tower in the 50
crude oil processing unit at the Tosco “Avon” refinery in Martinez,
California. Both refinery employees and
contractor employees were engaged in a maintenance activity to remove and
eventually replace the naphtha draw piping in which a leak had been detected on
02/10/99. Subsequent inspection of the
entire line revealed it to be significantly corroded, and Tosco decided to
replace the entire pipeline.
Waste Management Industrial Services, Inc. Summary
Tosco decided that it was safe to effect the repair while the
process unit remained in operation.
Tosco failed to isolate the naphtha piping from the operating process
prior to cutting into and removing a portion of the line. Failure to isolate the line or to empty its
contents allowed naphtha ( a highly flammable, gasoline-like benzene-containing
hydrocarbon) to flow through openings in the line and onto hot surfaces in the
operating unit. The naphtha ignited,
causing a fire near the bottom of the tower, which then spread up and down the
tower, engulfing the four workers.
Tosco emergency response personnel extinguished the fire in 20 minutes.
Waste Management Industrial Services, Inc. was hired by Tosco to
provide a vacuum truck for the removal of naphtha from the naphtha draw
line. The vacuum truck operator
remained on the ground at the base of the fractionator tower while the naphtha
was drained from the piping into the vacuum truck.
Although Tosco was determined to be directly responsible for the
fire and ensuing tragedy, Waste Management Industrial Services was found to be
in violation of Cal OSHA regulations, violations which contributed to creating
an unsafe work environment.
Waste Management Industrial Services was issued three citations
alleging violations of the California Code of Regulations, Title 8. Citations were classified as follows: 1 General
citation; 2 Serious citations. The total monetary penalty was $10,780.00.
A summary of citations follows.
Waste Management Industrial Services Summary
Summary of Citations
Citation 1, Item 1
Regulation: 5218(e)(2)(A)
Description: Failure to
perform initial benzene exposure monitoring
Classification: General
Penalty: $165.00
Citation 2
Regulation: 1509(a)
Description: Failure to
implement Injury & Illness Prevention Program
Classification: Serious
Penalty: $5,250.00
Citation 3
Regulation: 1510(c)
Description: Failure to
instruct employees in recognition and protection from hazards
Classification: Serious
Penalty: $5,250.00
TOTAL: $10,780.00