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The CSB investigated a fire at an oil refinery, Tosco Avon, in Martinez, CA. Investigators found that the root causes of the incident were the refinery management system's failure to recognize hazards posed by performing non routine maintenance, and their safety management oversight did not detect or correct serious deficiencies in the execution of maintenance and review of process changes. Contributing causes included: the management did not conduct a management of change review of operational changes that led to piping corrosion, and the crude unit corrosion control program was inadequate. The CSB issued safety recommendations based on these root and contributing causes.
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