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Motiva Enterprises Sulfuric Acid Tank Explosion

Delaware City, DE, Issued on August 28, 2002

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Summary
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.

Recommendations Listed by Recipient

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Occupational Safety and Health Adminstration (OSHA) 2001-05-I-DE-R1
Ensure coverage under the Process Safety Management Standard (29 CFR 1910.119) of atmospheric storage tanks that could be involved in a potential catastrophic release as a result of being interconnected to a covered process with 10,000 pounds of a flammable substance.

Status: Open - Awaiting Response or Evaluation/Approval of Response Either a recommendation has been issued and no substantive response was received from the recipient; or a response has been received from the recipient but the evaluation by CSB staff is pending or the Board has not yet acted on staff recommendation of status.

Delaware Department of Natural Resources and Environmental Control 2001-05-I-DE-R2
Ensure that regulations developed for the recently enacted Jeffrey Davis Aboveground Storage Tank Act require that facility management take prompt action in response to evidence of tank corrosion that presents hazards to people or the environment.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

Motiva Enterprises -- Delaware City Refinery 2001-05-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 The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board. 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 Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented. 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 The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board. 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 The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board. 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.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

Motiva Enterprises LLC 2001-05-I-DE-R8
In light of the findings of this report, conduct periodic audits of storage tank mechanical integrity and design, Unsafe Condition Reports, hot work, management of change, and accountability systems at Motiva oil refineries. Ensure that the audit recommendations are tracked and implemented. Share the findings with the workforce.

Status: Open - Acceptable Response or Alternate Response Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented. 2001-05-I-DE-R9
Communicate the findings and recommendations of this report to the workforce and contractors at all Motiva refineries.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

American Petroleum Institute (API) 2001-05-I-DE-R10
Work with NACE International (National Association of Corrosion Engineers) to develop API guidelines to inspect storage tanks containing fresh or spent H2SO4 at frequencies at least as often as those recommended in the latest edition of NACE Standard RP 0294-94, Design, Fabrication, and Inspection of Tanks for the Storage of Concentrated Sulfuric Acid and Oleum at Ambient Temperatures.

Status: Open - Acceptable Response or Alternate Response Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented. 2001-05-I-DE-R11
Revise API tank inspection standards to emphasize that storage tanks with wall or roof holes or thinning beyond minimum acceptable thickness that may contain a flammable vapor are an imminent hazard and require immediate repair or removal from service.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board. 2001-05-I-DE-R12
Ensure that API recommended practices address the inerting of flammable storage tanks, such as spent H2SO4 tanks. Include the following:

- Circumstances when inerting is recommended.

- Design of inerting systems, such as proper sizing of inerting equipment, appropriate inerting medium, and instrumentation, including alarms.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

National Association of Corrosion Engineers (NACE) 2001-05-I-DE-R14
Work with the American Petroleum Institute to develop API guidelines to ensure that storage tanks containing fresh or spent H2SO4 are inspected at frequencies at least as often as those recommended in the latest edition of NACE Standard RP 0294- 94, Design, Fabrication, and Inspection of Tanks for the Storage of Concentrated Sulfuric Acid and Oleum at Ambient Temperatures.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board. 2001-05-I-DE-R15
Communicate the findings and recommendations of this report to your membership.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

(PACE Local 2-898) Paper, Allied-Industrial, Chemical and Energy Workers International Union 2001-05-I-DE-R16
Work with Motiva management on the design and implementation of an improved Unsafe Condition Report program.

(PACE) Paper, Allied-Industrial, Chemical and Energy Workers International Union 2001-05-I-DE-R17
Communicate the findings and recommendations of this report to your membership.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

National Petrochemical and Refiners Association (NPRA) 2001-05-I-DE-R18
Communicate the findings and recommendations of this report to your membership.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

Building and Construction Trades Department, AFL-CIO 2001-05-I-DE-R19
Communicate the findings and recommendations of this report to your membership.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.