Chemical Safety Board Report: Naphtha Release and Fire
The Chemical Safety Board has issued its final investigation report into the 2022 fire at the BP-Husky Refinery, near Toledo, Ohio. There were two fatalities ― the men who died were brothers.
The following safety issues were identified.
Liquid Overflow Prevention.
Abnormal Situation Management.
Alarm Flood.
Learning from Incidents.
Contributing to the incident were 1) the refinery’s failure to implement effective preventive safeguards for the overflow of towers and vessels in various pieces of equipment which led to an over-reliance on human intervention to prevent incidents; 2) the refinery’s failure to implement a shutdown or hot circulation through the use of Stop Work Authority or otherwise; 3) the refinery’s ineffective policies, procedures, and practices to avoid and control abnormal situations; 4) the refinery’s alarm system which flooded operators with alarms throughout the day resulting in poor decision making; and 5) the refinery’s failure to learn from previous incidents.
Lessons to be learned from this report are contained in the seven major recommendations.
