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The CSB investigated an explosion at the Motiva Enterprises refinery in Delaware City, DE. The investigation found that the Motiva refinery management systems for mechanical integrity, management of change, and hot work did not adequately prevent and address safety and environmental hazards. Furthermore, the system for investigating "Unsafe Condition" reports at the refinery was inadequate. The investigation also found that corporate management oversight was inadequate. The CSB issued safety recommendations based on these root and contributing causes.
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