An independent consultant said Thursday there were several main factors contributing to the release of up to 24 tons of chemicals at the Martinez Refining Company on a day in 2022.
The consultant also mentioned an operator who had been on the job 20 hours a day for multiple days before the incident.
Another problem was a unit was left on manual for hours that day, Nov. 24, 2022, when it should’ve been on automatic.
During a meeting of the Martinez Refining Company Oversight Committee, a panel created by the Contra Costa County Board of Supervisors in the wake of the chemical release, consultant and refining expert Scott Berger unveiled his preliminary investigative report, which hasn’t been released to the public.
On Thanksgiving night 2022, a chemical release began in the refinery’s cracking unit that lasted into the following morning.
MRC didn’t report the release of 20 to 24 tons of spent catalyst into the community. Contra Costa Health only found out about it two days later from residents on social media commenting on dust falling onto their front yards and vehicles.
A root cause of the release, according to Berger’s preliminary report, was an inadequate process hazard analysis regarding the catalyst release. Spent catalyst is a byproduct of the refining process.
There was a “practice of deviating from procedures without managing field changes,” Berger wrote.
An “operating procedure managing system failed to ensure cautionary statements were adequate.”
The report said there was a policy of not pausing to reevaluate work when things go differently than expected.
It said the refinery should require “just in time” training to deal with incidents before they become a problem.
The report said the refinery should also require alarms for potential catalyst releases.
“Operator training didn’t address instrument failure modes, troubleshooting, and when to call (an) instrument technician,” Berger’s report said.
Berger also found the company’s site fatigue management system problematic. The system is meant to keep workers from staying on the job too long.
Berger said MRC, which is owned by PBF Energy Inc., has already addressed many of these problems, though he did say there were some he believes need more attention.
Contra Costa Health and the Bay Area Air Quality Management District began a surprise inspection of the refinery Dec. 26 of last year that is ongoing.
A letter from CCH chief executive officer Anna Roth in December addressed a number of flaring incidents and dust releases since the Thanksgiving 2022 incident. Roth called them “unacceptable” and said they’ve “compromised health and safety at your facility, and in our community.”
“In the past year, CCH has documented 21 releases or spills of hazardous materials at the Martinez refinery,” the letter said. “According to the County’s Community Warning System records, PBF also reported using flares — devices that should only be used as an emergency safety measure to prevent more serious incidents — at a rate of nearly once per week. CCH has documented 46 flaring incidents at the refinery since November 2022.”
A community risk assessment report will be released by Contra Costa Health on Feb. 22. The public will then have 45 days to make comments on the report before a final report will be released to the Contra Costa County Board of Supervisors and the Martinez City Council.
Would rather have wisdom teeth pulled without anesthetic than participate in another root cause analysis investigation.
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Is critical those writing process control software to fully understand the process and what variables could cause problems. Monitoring process and variables in refining process prevents smouldering craters.
When building control system you first idiot proof it then take it one further step and operator proof it. When the dumbest operator or a new hire fresh off the street can’t bugger it up, then your control system is ready to use. Built control systems using relay logic when one of the bosses was too cheap to buy a PLC (programmable logic controller). Our primary process line had a downtime cost of $100 per minute which motivated aids in troubleshooting, video screens (HMI) calling out fault conditions as starting point for trouble shooting.
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Always has to happen, Safety of people, protecting equipment an process from failure and production of a salable product. In our automated processes local remote selector switch position were always monitored, any switch in local would be called out and prevent process line from starting. Familiar with distances involved in refining, wifi or radio links could be installed and software updated.
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Found best way to improve processes and Safety was to involve operators, mechanical and electrical maintenance along with person writing computer code controlling process.
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Just because it’s be done that way for 44 years doesn’t mean improvements can’t be made.
“The consultant also mentioned an operator who had been on the job 20 hours a day for multiple days before the incident.”
Twenty (20) hours a day for multiple days! Only a profit-seeking-above-all-else corporation would think that’s appropriate staffing, let alone safe. I guess we should be thankful the whole plant didn’t blow up.