New reports out now are claiming that an aging, failed elbow pipe appears to be the initial cause of a June 21 fire and subsequent explosions that injured five people at the largest oil refinery on the East Coast, federal investigators said.
The U.S. Chemical Safety and Hazard Investigation Board released a preliminary factual findings report which discoveries the remnants of the failed elbow pipe, had worn to .012 inches (about the thickness of paper) likely contributing to the release of the flammable vapor. After the elbow pipe failed around 4 a.m., a cloud of flammable vapor ignited. Investigators said there were three explosions that followed including the last explosion of a surge drum around 4:22 a.m. that sent three large chunks of debris weighing between seven and 17 tons (15 metric tons) flying into the air. The five workers injured in the fire received treatment on scene for minor injuries, and company officials said the explosions caused severe damage to the 150-year-old site, which could have been much worse.
However, this situation also is easily avoidable, and it all depends on a site’s “Safety Culture.” Not only does each company, but each site has a different and individual “Safety Culture.” There can be differences between site training, site procedures and simply the attitude on safety along with other variables. For example, one site could be very strict on when and how to proof test and assess end of life, where its sister site, may be more relaxed and push the test off a few more months. We have seen differences between 2x-6x the amount of failures on the same device depending on each site’s “Safety Culture.”
exida defines the safety culture variable in a four level model called the “Site Safety Index (SSI).
SSI is a quantitative model that allows the impact from what many people call “safety culture.” SSI can provide a way to show the cost impact of alternative operational and maintenance processes.
| Level | Description |
|---|---|
| SSI 4 | Perfect - Repairs are always correctly performed. Testing is always done correctly and on schedule, equipment is always replaced before end of useful life, equipment is always selected according to the specified environmental limits and process compatible materials, electrical power supplies are clean of transients and isolated, pneumatic supplies and hydraulic fluids are always kept clean, etc. This level is generally considered to be extremely hard to achieve, but possible in some organizations. |
| SSI 3 | Almost Perfect - Repairs are correctly performed. Testing is done correctly and on schedule, equipment is normally selected based on the specified environmental limits and a good analysis of the process chemistry and compatible materials. Electrical power supplies are normally clean of transients and isolated, pneumatic supplies and hydraulic fluids are mostly kept clean, etc. Equipment is replaced before end of useful life, etc. |
| SSI 2 | Good - repairs are usually correctly performed. Testing is done correctly and mostly on schedule, most equipment is replaced before end of useful life, etc. |
| SSI 1 | Medium - Many repairs are correctly performed. Testing is done and mostly on schedule, some equipment is replaced before end of useful life, etc. |
| SSI 0 | None - Repairs are not always done. Testing is not done, equipment is not replaced until failure, etc. |
SSI can be comprehensively evaluated with an on-site third party audit.
If the safety culture or SSI was evaluated and addressed at the largest oil refinery on the East Coast, it is possible that this aging pipe would have been exposed before the leak and explosion occurred. Thinking about maintenance and operations, before an accident, could have prevented the damage which caused the company to close down the refinery, declare bankruptcy and start laying off workers in August 2019.
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