The U.S. Chemical Safety and Hazard Investigation Board (CSB) has released a safety video examining the September 2022 fire at the BP-Husky refinery in Oregon, Ohio, that killed two refinery employees.

The incident occurred after highly flammable liquid naphtha was released from a pressurized vessel during an abnormal operating situation. The naphtha vaporized and formed a flammable cloud that traveled to a nearby furnace, where it ignited.

According to the CSB, the incident followed a series of process upsets that caused liquid naphtha to enter and fill a fuel gas mix drum that normally contained only fuel gas vapor. As the drum filled, liquid overflowed into downstream piping serving furnaces and boilers. Operators subsequently directed employees to drain the vessel, and the naphtha was released directly to the ground.

The CSB's investigation identified several factors that contributed to the incident, including ineffective management of an abnormal operating situation, an alarm flood, inadequate safeguards to prevent liquid overflow and failures to communicate decisions made during a process engineering and refinery leadership meeting.

The CSB reported that control-room operators received 3,712 alarms during the approximately 12-hour period preceding the fire. The agency said the alarm flood contributed to delays and errors in responding to critical alarms and communicating information among refinery personnel.

The CSB's safety video, “Alarming Mistakes, Deadly Decisions: Fatal Fire at BP-Husky,” uses animation to reconstruct the events leading to the fire and includes commentary from CSB Board Member Sylvia Johnson and agency investigators.

The video focuses on four safety issues identified by the CSB: liquid overflow prevention, abnormal situation management, alarm flooding and learning from incidents. It also highlights recommendations the agency made to the American Petroleum Institute and the current refinery owner, Ohio Refining Co. LLC.

The video is the latest in a series of recent CSB safety videos and investigation activities. In August, the agency released a video examining the January 2021 liquid nitrogen release at the Foundation Food Group poultry processing plant in Gainesville, Georgia. That incident killed six workers and seriously injured three others. The video highlighted issues involving single points of failure, atmospheric monitoring and alarms, emergency preparedness, process safety management and product stewardship.

Earlier this year, the CSB also released a safety video on the 2017 combustible-dust explosion at Didion Milling's facility in Wisconsin, which killed five workers and injured 14.