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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.
Motiva Enterprises -- Delaware City Refinery2001-05-I-DE-R3
Implement a system to ensure accountability for mechanical integrity decision making. Include the following specific items:
- Review of inspection reports by subject area experts, such as metallurgists or equipment design engineers, to ensure adequate analysis of failure trends and suitability for intended service.
- Establishment of a planning system to ensure the timely repair of equipment.
The Center for Chemical Process Safety (CCPS) publication, Plant Guidelines for Technical Management of Chemical Process Safety, Chapter 3, “Accountability Objectives and Goals,” presents a model for such a system.
Status: Closed - Acceptable Action
2001-05-I-DE-R4
Review the design of existing tankage that contains or has the potential to contain flammables to ensure that, at a minimum::
- Inerting systems are installed where appropriate and are adequately sized and constructed.
- Emergency venting is provided.
Status: Open - Acceptable Response or Alternate Response
2001-05-I-DE-R5
Ensure that management of change reviews are conducted for changes to tank equipment and operating conditions, such as:
- Tank service and contents
- Tank peripherals, such as inerting and venting systems.
Status: Closed - Acceptable Action
2001-05-I-DE-R6
Revise the refinery hot work program to address the circumstances that require use of continuous or periodic monitoring for flammables.
Status: Closed - Acceptable Action
2001-05-I-DE-R7
Upgrade the refinery Unsafe Condition Report system to include the following:
- Designation of a specific manager with decision-making authority to resolve issues.
- Establishment of a mechanism to elevate attention to higher levels of management if issues are not resolved in a timely manner.
- Identification of a means to ensure communication of hazards to all potentially affected personnel.
- Work with the Paper, Allied-Industrial, Chemical & Energy Workers International Union (PACE) Local 2-898 to design and implement the improved system.
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