The flash fire at the Delaware City Refinery Company could have been prevented if the refinery had been more proactive in identifying hazards before employees perform maintenance, a new report found.

That was the conclusions reached in findings released from the Chemical Safety Board’s (CSB) investigation into a 2015 flash fire at the refinery that left one worker severely burned.

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Maintenance is one of the leading causes of injury when working with chemicals, said CSB chairperson Vanessa Sutherland.

“More than one third of the incidents investigated by the CSB occurred prior to, during or immediately following maintenance activities,” she said.

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A night operator at the refinery suffered severe burns on his face, neck and wrists as the result of the flash fire.

He opened a leaky valve being used to isolate two pieces of equipment undergoing maintenance.

“Shortly after opening the drain valve to the refinery’s sewer system he recalled hearing a pop and seeing a wall of fire advancing toward him,” said CSB Supervisory Investigator Johnnie Banks. 

He said the worker had unknowingly released a backflow of gas that ignited in a nearby furnace and resulted in the wall of fire.

The CSB’s investigation identified five safety lessons that can apply to high hazard facilities:
• Non-routine operational tasks surrounding maintenance should have standard operating procedures, covering tasks such as emptying, decontaminating, washing, steaming, purging, and draining equipment and vessels.
• For all equipment preparation activities, develop a process that requires preplanning and hazard identification prior to initiating the work.
• When isolating equipment for emptying or decontaminating activities prior to maintenance work, avoid reliance on single block valves. Always consider more protective measures for isolation such as including double blocks or blinds.
• When an equipment preparation task or isolation plan needs to be modified or expanded due to leaking valves or changing conditions, evaluate the hazard.
• Use closed systems such as tanks, drums, flares, control the draining, or relieving of hazardous energy in preparation to isolate equipment for maintenance.

Since the fire, the Delaware City Refinery Company has developed procedures to ensure hazards are identified and mitigated before employees perform maintenance.

“We openly shared details of the actions taken by the refinery with CSB representatives and our workforce, and are distributing the CSB’s “Safety Bulletin” to our employees, to further reinforce our continuing commitment to safety, reliability, and regulatory compliance,” said officials at the refinery’s parent company, PBF Energy.

Click here for more details on the report.

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