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Final Investigation Report U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD FINAL INVESTIGATION REPORT CHEVRON RICHMOND REFINERY PIPE RUPTURE AND FIRE CHEVRON RICHMOND REFINERY #4 CRUDE UNIT RICHMOND, CALIFORNIA KEY ISSUES: AUGUST 6, 2012 CHEVRON PROCESS SAFETY PROGRAMS CHEVRON EMERGENCY RESPONSE MECHANICAL INTEGRITY INDUSTRY STANDARD DEFICIENCIES LEAK EVALUATION AND RESPONSE INDUSTRY STANDARD DEFICIENCIES REPORT NO. 2012-03-I-CA JANUARY 2015 Chevron Richmond Refinery Investigation Report January 2015 [This page intentionally left blank.] ii U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD Chevron Richmond Refinery Investigation Report January 2015 Table of Contents 1.0 Executive Summary ......................................................................................................................... 1 1.1 Incident Summary .............................................................................................................................. 1 1.2 Chevron Interim Report ..................................................................................................................... 2 1.3 Chevron Regulatory Report .............................................................................................................. 4 1.4 Chevron Final Investigation Report ................................................................................................... 5 1.4.1 Technical Findings .................................................................................................................... 5 1.4.2 Organizational Findings ............................................................................................................ 7 1.4.3 Emergency Response Findings ............................................................................................... 12 1.4.4 Safety Culture Findings .......................................................................................................... 13 1.4.5 Industry Codes and Standards Findings .................................................................................. 14 1.4.6 Regulatory Findings ................................................................................................................ 14 1.5 Recommendations ............................................................................................................................ 15 2.0 Richmond Refinery Process Description ..................................................................................... 17 2.1 Chevron Background ....................................................................................................................... 17 2.2 Richmond Refinery .......................................................................................................................... 17 2.3 #4 Crude Unit ................................................................................................................................... 18 2.4 4-Sidecut Line .................................................................................................................................. 19 3.0 The Incident .................................................................................................................................... 22 3.1 Leak Discovery ................................................................................................................................ 22 3.2 Leak Response ................................................................................................................................. 25 3.3 Consequences ................................................................................................................................... 29 4.0 Technical Analysis ......................................................................................................................... 34 4.1 Sulfidation Corrosion ....................................................................................................................... 34 4.2 Sulfidation Corrosion Inspection Techniques .................................................................................. 41 4.3 Silicon Characterization Techniques ............................................................................................... 43 4.4 Inherently Safer Design ................................................................................................................... 45 5.0 Incident Analysis ............................................................................................................................ 48 5.1 Organizational Analysis ................................................................................................................... 50 5.1.1 Chevron Energy Technology Company .................................................................................. 53 5.1.1.1 ETC Sulfidation Failure Prevention Guidance ................................................................... 54 5.1.1.2 Chevron ETC Conclusions .................................................................................................. 56 5.1.2 Chevron Turnaround Management ......................................................................................... 58 iii U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD Chevron Richmond Refinery Investigation Report January 2015 5.1.2.1 2007 Crude Unit Turnaround .............................................................................................. 59 5.1.2.1.1 Recommendations Regarding 4-Sidecut Line for 2007 Turnaround .......................... 60 5.1.2.2 2011 Crude Unit Turnaround .............................................................................................. 64 5.1.2.2.1 Recommendations Regarding 4-Sidecut Line for 2011 Turnaround .......................... 65 5.1.2.3 Chevron Richmond Refinery Turnaround-Planning Conclusions ...................................... 66 5.1.3 Chevron Unit Reliability Improvement Process ..................................................................... 68 5.1.4 Chevron Fixed Equipment Reliability Business Improvement Network ................................ 71 5.1.5 Chevron Minimum Pipe Thickness Program .......................................................................... 74 5.1.6 Chevron Process Safety Indicators Program ........................................................................... 78 5.1.7 Stop Work Authority ............................................................................................................... 79 5.1.8 Chevron Organizational Conclusions ..................................................................................... 83 5.2 Industry Sulfidation Corrosion Guidance ........................................................................................ 85 5.2.1 API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries ....................................................................................................................................... 85 5.2.2 API RP 571: Damage Mechanisms Affecting Fixed Equipment in the Refining Industry ..... 89 5.2.3 API 570: Piping Inspection Code: In-Service Inspection, Rating, Repair, and Alteration of Piping Systems ........................................................................................................................ 90 5.2.4 API RP 578: Material Verification Program for New and Existing Alloy Piping Systems .... 91 5.2.5 API RP 574: Inspection Practices for Piping System Components ........................................ 91 5.3 Chevron Emergency Response to Process Leaks ............................................................................. 92 5.3.1 Area Control and Hazardous Area Assessment ...................................................................... 92 5.3.2 Miscommunication regarding 4-sidecut properties ................................................................. 93 5.3.3 Leak Mitigation and Discovery Attempts Worsened Leak ..................................................... 94 5.3.4 Chevron’s New Leak Response Protocol ................................................................................ 97 5.3.5 Leak Response Conclusions .................................................................................................. 100 5.4 Industry Leak Response Guidance ................................................................................................. 100 5.4.1 API RP 574: Inspection Practices for Piping System Components ...................................... 100 5.4.2 API RP 2001: Fire Protection in Refineries ......................................................................... 101 5.4.3 API 570: Piping Inspection Code: In-Service Inspection, Rating, Repair, and Alteration of Piping Systems ...................................................................................................................... 103 5.4.4 ASME PCC-2-2011: Repair of Pressure Equipment and Piping .......................................... 103 5.4.5 Industry Leak Response Guidance Conclusions ................................................................... 104 5.5 Chevron Richmond Refinery Safety Culture ................................................................................. 104 5.5.1 Normalization of Deviance ................................................................................................... 105 iv U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD Chevron Richmond Refinery Investigation Report January 2015 5.5.2 Chevron Richmond Refinery
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