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Final Investigation Report of Chevron August 6, 2012 Crude Unit Fire From 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 Draft for Public Review Chevron Richmond Refinery Investigation Report January 2015 [This page intentionally left blank.] ii U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD Draft for Public Review 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 Draft for Public Review 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 Draft for Public Review
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