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Cal/OSHA Issues 20 Citations in Tosco Accident

SAN FRANCISCO -- The California Division of Occupational Safety and Health (Cal/OSHA) today cited Tosco Refining and Marketing Company for 22 alleged violations of state workplace safety regulations as a result of its investigation of the January 21, 1997 fatal explosion at the company's Martinez plant. One employee died as a result of the accident and 46 Tosco and contractor workers reported injuries.

"Our six-month inspection has shown us that Tosco has failed to use recognized and generally accepted good engineering procedures in the operation of the company's Hydrocracker Unit," Deputy Cal/OSHA Chief Mark Carleson said. "The Process Safety Management (PSM) regulations that Tosco has allegedly violated are intended to prevent a catastrophic incident, such as what happened in January, thereby minimizing the risks that employees are exposed to in the petroleum refinery industry."

The total amount of the penalties was $277,750. A review of Cal/OSHA inspections through 1990 show that the fine represents the highest penalty levied against a petroleum refinery company in California.

Sixteen of the alleged violations were classified as serious under California's Code of Regulations and carried penalties totaling $66,375. Three general violations were cited, carrying a total penalty of $1,375. Three additional violations were classified as willful serious and carried the maximum penalties allowed of $70,000 each.

Specifically, Cal/OSHA found violations for:

• Tosco's process hazard analysis failed to: Identify depressuring as a control measure associated with reactor temperature increases ($625), record supplemental training to employees of the Hydrocracker Unit ($500), promptly report a January 19 incident in the unit or investigate a January 10 incident ($250);

• Failed to effectively communicate key safety elements to employees concerning the company's Process Safety Management of Acutely Hazardous Materials program ($3,125);

• Temperature indicators inside the Hydrocracker Unit were removed for modification on January 10 and January 20 with no interim system installed ($2,500);

• The company's process hazard analysis was not appropriate for the operation as it existed inside the Hydrocracker Unit ($2,500);

• A hazard analysis performed by the company did not consider the failure of an important part of the operation, or the consequences of the failure of the unit's emergency depressuring systems ($2,500);

• Written operating procedures did not provide proper instructions on safely conducting several emergency adjustment functions ($3,125);

• Written instructions did not address the consequences of deviation from certain operating limits ($7,000);

• Employer created a hazard to employee by requiring them to a "zone of danger" under the reactor to obtain critical supplemental temperature data ($7,000).

• Employer failed to assure that the operating procedures reflected safe operating practices through regular and necessary updates ($7,000);

• Failing to develop and implement safe work practices to provide for the control of hazards during operations ($1,875);

• Employees assigned to the Hydrocracker Unit did not receive required supplemental training at least every three years ($7,000);

• Proper pre-startup safety review was not performed ($2,500);

• Inspection and testing procedures did not follow recognized and generally accepted good engineering practices ($7,000);

• The frequency of inspections and tests were inconsistent with good engineering practices ($7,000);

• Employer failed to establish and implement written procedures to manage changes to the facility ($1,875);

• Changes to process chemical, technology and equipment were not amended in the company's process safety information ($2,500);

• A change in operating procedures was required but not reflected in the company's written procedures ($1,875);

• Machinery and equipment in service was not kept in a safe operating condition ($70,000);

• Employer failed to have proper written procedures to address emergency operations, including emergency shutdowns ($70,000);

• Employer failed to respond or take action in a timely manner regarding written concerns of the Hydrocracker Unit expressed by employees ($70,000).OSHA defines a willful violation as one in which the employer either knew that a condition constituted a violation or was aware that a hazardous condition existed and made no reasonable effort to correct it. A serious violation occurs when there is a substantial probability that death or serious physical harm could result from a hazardous condition and that the employer knew or should have known of the hazard.

The Cal/OSHA investigation found that the explosion and fire was caused when the temperature inside the Hydrocracker Unit passed 1,700 degrees Fahrenheit, exceeding the reactor's maximum safety level of 800 degrees Fahrenheit. Temperature inside the reactor rose due to the process instability and was initially undetected by internal thermostats. While the investigation does not rule out the possibility of some aspect of operator error, it is clear that there remains a serious failure on the part of Tosco's management to implement the company's own internal safety policies.

California law provides that a company may appeal Cal/OSHA citations and penalties within 15 working days to the Occupational Safety and Health Appeals Board in Sacramento.

The Cal/OSHA investigation team coordinated on-site investigations with the Federal OSHA, Bay Area Air Quality Management District, Contra Costa County Department of Health Services, and the U.S. Environmental Protection Agency. The division has a concurrent criminal investigation underway through its Bureau of Investigation. The findings from that investigation, which focuses on possible criminal liability involved in the accident, will be handed over in a confidential report to the local district attorney's office for a determination as to whether criminal charges are appropriate.