Unmasking the Mystery: Fire in Baton Rouge

Table of Contents:

1. Introduction
2. Incident Overview
3. Maintenance Activities at ExxonMobil Refinery
4. The Role of Management in Safety
5. The Sulfuric Acid Alkylation Unit
6. Equipment and Valve Operation
7. The Problem with the Gear Box
8. Critical Design Flaw in the Older Valves
9. Lessons Learned from the Incident
10. Importance of Detailed Procedures
11. Training for Hazard Awareness
12. The Hierarchy of Controls
13. The Need for Updated Valve Design
14. Applying the Hierarchy of Controls
15. Human Factors and Process Hazard Analysis
16. Conclusion

Incident at ExxonMobil Refinery: A Lesson in Safety Management

The incident that took place on November 22, 2016, at the ExxonMobil Refinery in Baton Rouge, Louisiana, serves as a stark reminder of the critical importance of safety management in industrial facilities. During routine maintenance activities, a fire broke out, resulting in severe burns to four workers. This unfortunate event highlighted several shortcomings in the safety practices and procedures followed at the refinery.

Incident Overview

The fire occurred when operators inadvertently removed bolts that secured a piece of pressure-containing equipment to a plug valve. As they attempted to open the valve, it came apart, releasing flammable isobutane and forming a vapor cloud that rapidly ignited. The operators were following accepted practices within the refinery but lacked a safety hazard analysis, which significantly increased the risk to the workers.

Maintenance Activities at ExxonMobil Refinery

The management of safety in any industrial facility is crucial to protect workers and ensure the integrity of operations. In the case of the ExxonMobil Baton Rouge refinery, the incident took place in the sulfuric acid alkylation unit. This unit plays a vital role in converting isobutane and olefins into a major component of gasoline. On the day of the incident, two operators were preparing to put a spare isobutane Pump into service. To do so, they needed to open the pump's inlet valve, which required manual operation.

The Role of Management in Safety

The incident investigation revealed that the ExxonMobil refinery management accepted the practice of operators removing malfunctioning gear boxes from plug valves without written procedures or adequate training. While operators did receive training on hard-to-operate valves, it did not specifically cover the removal of inoperable gear boxes from older plug valve models. This lack of comprehensive training and written procedures highlights the need for a more robust approach to safety management.

The Sulfuric Acid Alkylation Unit

Understanding the specific processes and equipment within the sulfuric acid alkylation unit is crucial to addressing safety concerns adequately. In this unit, the importance of valves, such as the plug valve involved in the incident, cannot be overstated. These valves control the flow of isobutane and other substances critical to the conversion process. It is essential to ensure that these valves are properly maintained and operated to prevent incidents like the one that occurred at the ExxonMobil refinery.

Equipment and Valve Operation

The gear box connected to the plug valve played a significant role in the incident. It enables operators to open or close the valve more easily by using gears to turn the valve stem. However, if the gear box malfunctions, it is an accepted practice in the alkylation unit for operators to remove it and use a pipe wrench to turn the valve stem directly. This procedure requires the removal of bolts that secure the support bracket to the valve body.

The Problem with the Gear Box

The issue lies in the design of the older plug valve models. Approximately 3% of the valves in the refinery's alkylation unit were designed to connect the gear box support bracket to a critical pressure-containing component known as the top cap. This design flaw, combined with the operators' improper removal of the bolts, led to the catastrophic failure of the valve. The majority of the valves, about 97%, had an updated design that eliminated this connection, reducing the likelihood of such incidents.

Critical Design Flaw in the Older Valves

Although the older valve design technically adhered to industry standards, it lacked explicit requirements for updating to the safer valve design. Current standards call for gear boxes to be removable without affecting pressure-containing parts, which can be achieved by removing two horizontal bolts. However, on the day of the incident, the operators did not remove the two horizontal bolts, leading to the valve failure. Updating all the older valves to the safer design could have prevented this incident altogether.

Lessons Learned from the Incident

The incident at the ExxonMobil Baton Rouge refinery offers several essential lessons for improving safety management in industrial facilities. First and foremost, detailed and accurate written procedures are crucial for performing potentially hazardous work. These procedures should address different types of equipment and configurations to prevent confusion among workers. Additionally, comprehensive training that focuses on processes and equipment is critical to enhance hazard awareness and prevent chemical incidents.

Importance of Detailed Procedures

Detailed procedures provide clear guidance for workers, ensuring that they understand how to perform tasks safely. By establishing these procedures, companies can minimize the risk of accidents and injuries caused by confusion or ambiguity. Written procedures act as a reference point for employees and help maintain a consistent and safe work environment.

Training for Hazard Awareness

Providing adequate training is another crucial aspect of effective safety management. Workers need to be equipped with the knowledge and skills to perform their job tasks safely. Training programs should cover not only general safety practices but also specific processes and equipment Relevant to the job. This approach enhances hazard awareness and empowers workers to identify and address potential risks proactively.

The Hierarchy of Controls

The hierarchy of controls is a valuable framework for evaluating safeguards and minimizing risks. Engineering controls, such as improved valve designs, are more effective than administrative controls, like warning signs. By implementing engineering controls, companies can make it easier for workers to perform tasks correctly and minimize the chances of human error leading to incidents.

The Need for Updated Valve Design

The incident investigation highlighted the importance of updated valve designs that eliminate critical design flaws. The ExxonMobil refinery had updated approximately 97% of the valves in the alkylation unit, significantly reducing the risk of incidents like the one that occurred. Industry standards should explicitly address the need for updating older valves to safer designs to ensure a higher level of safety across industrial facilities.

Applying the Hierarchy of Controls

To mitigate identified hazards effectively, it is essential to Apply the hierarchy of controls. This approach involves systematically evaluating safeguards and implementing measures to reduce risks. By considering engineering controls as the most effective form of risk reduction, companies can prioritize investments in updated valve designs and other engineering solutions to prevent incidents.

Human Factors and Process Hazard Analysis

Inadequate consideration of human factors in the process hazard analysis can lead to potential safety hazards being overlooked. By involving workers in discussions about difficulties with equipment, such as the removal of plug valve gear boxes, companies can identify potential hazards and take proactive measures to address them. A comprehensive process hazard analysis should analyze the human factors associated with equipment operation and maintenance.

Conclusion

The incident at the ExxonMobil Baton Rouge refinery was a tragic reminder of the critical role of safety management in industrial facilities. By establishing detailed procedures, providing comprehensive training, and implementing updated valve designs, companies can significantly reduce the risk of incidents and protect workers' lives. It is crucial for companies to learn from this incident and share and implement the key safety lessons outlined in the CSB's Safety Bulletin to prevent future injuries and property damage.

Highlights:

• The incident at the ExxonMobil Refinery in Baton Rouge highlighted the importance of safety management in industrial facilities.
• The lack of a safety hazard analysis and inadequate procedures put workers at risk during routine maintenance activities.
• The design flaw in the older plug valve models and the improper removal of bolts led to the catastrophic failure of the valve.
• Detailed procedures and comprehensive training are crucial for performing hazardous work safely.
• The hierarchy of controls emphasizes the need for engineering controls, such as updated valve designs, to prevent incidents.
• Process hazard analysis should consider human factors to identify potential hazards and recommend necessary equipment replacements.

FAQ:

Q: How did the incident at the ExxonMobil Baton Rouge refinery occur? A: The incident occurred when operators inadvertently removed bolts securing a pressure-containing component to a plug valve, which led to the valve failure and the release of flammable isobutane, resulting in a fire.

Q: What were the factors contributing to the incident? A: The incident was primarily caused by the critical design flaw in the older plug valve models and the operators' improper removal of bolts. Additionally, the lack of a safety hazard analysis and inadequate written procedures played a significant role.

Q: How can incidents like this be prevented in industrial facilities? A: Prevention of similar incidents requires the establishment of detailed procedures, comprehensive training programs, and the implementation of updated valve designs. Companies should also apply the hierarchy of controls, giving priority to engineering controls over administrative ones.

Q: What lessons can be learned from the incident at the ExxonMobil refinery? A: The incident highlights the importance of detailed procedures, hazard awareness training, and the need for updated valve designs. Additionally, considering human factors in the process hazard analysis can help identify potential hazards and prevent incidents.

Q: What can companies do to improve safety management practices? A: Companies should ensure the implementation of detailed procedures, provide comprehensive training, and prioritize engineering controls. Sharing and implementing the key safety lessons outlined in the CSB's Safety Bulletin can also contribute to better safety management practices.