CSB Releases Final Report on Acid Releases at California Refinery

By Chemical Processing Staff

Aug 05, 2016

On August 2, the U.S. Chemical Safety Board (CSB) issued its final report on releases of sulfuric acid that occurred in 2014 at the Tesoro refinery in Martinez, Calif., that led to the burning of four workers. The report cites deficiencies in safety culture and safety indicators, and says the failings point up the continued need for a proactive regulator to conduct preventive inspections.

In early 2014,the Tesoro refinery suffered two events at its alkylation union that released sulfuric acid, burning two workers each time. In February, an incident led to the release of 84,000 lb of the acid; less a month later, removal of piping caused a spray of sulfuric acid.

The report lists nine key failings in safety culture, including mischaracterization of the February incident as minor, site-specific safety policies that were less protective than corporate policies and industry good practices, and not developing an action plan to address safety culture flaws identified in a 2007 survey.

“The CSB urges all refineries to review the key findings and conclusions of the board’s case study and to apply those learnings to their own facilities. It is imperative that companies continually work toward improving their operations in an effort to prevent future incidents and ensure the safety of their workforce,” noted CSB chair Vanessa Sutherland. (For details on her plans and goals for the CSB, see: “Chemical Safety Board Opens Up.”)

“The continued recurrence of sulfuric acid incidents demonstrates the need for improvements at the Tesoro refinery. We recommend that the refinery report process safety indicators to the regulator,” said lead investigator Dan Tillema. “Regulators should monitor these indicators and conduct preventive inspections that lead to corrective actions — this is a critical component of an effective safety program — the ultimate goal is to ensure that risk is continually reduced.”

Click here more details on the report; the complete report is available via: www.csb.gov/assets/1/19/Tesoro_Martinez_Final_Case_Study1.pdf.

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  • The report talk a lot about the safety culture at the Tesoro Martinez Refinery not being good, but it contains no specific advice about how to create a good safety culture. Maybe the CSB is not allowed to provide such advice, but I still believe it should. Also in report after report the CSB calls for better regulatory efforts. This has been the case for many years. But more regulation cost more money, and unfortunately there is only the costumer to pay for that. I would very much like to seem the Baker Report recommendations turned into law, i.e. that a refinery's upper management is personally responsible for the safety in the plant, and that it is the duty of the company board to ensure that their manager can do that job.


  • CP has published a number of articles about creating an effective and enduring safety culture, e.g., "Process Safety Begins in the Boardroom" and "Achieve Effective Process Safety Management." CP also has had a recent article on combatting complacency, "Stimulate a Sense of Vulnerability."


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