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