03 Jun Refinery Report Finds Blame for Three-Day February Fire

Flames and smoke billow from the Martinez Refining Company on Feb. 1. The fire broke out amid flaring at the oil refinery leading to a public health advisory from Contra Costa County Health for residents in the Martinez, Pacheco, and Clyde areas. Flaring is the burning of excess gas that occurs during equipment shutdowns or malfunctions. (Tony Hicks / Bay City News)

By Tony Hicks
Bay City News

A lack of qualified contract workers, inadequate training and supervision, and contractors exceeding the timing of a work permit were among factors leading to the Feb. 1 fire at the Martinez Refinery Company, according to a consultant’s draft report.

Part of the problem with the permitting timeline was reportedly with small font on work permits that made them difficult to read, the report said.

Consultant JEM Advisors will present the report to Contra Costa Health’s Martinez Refining Company Oversight Committee at its Tuesday meeting.

The Feb. 1 fire sent flames and enough black smoke into the air for the county to order nearby residents to shelter in place for more than four hours. Six workers were injured, though none seriously.

The fire, caused by a hydrocarbon leak during “turnaround” maintenance, burned for three days. A turnaround is a planned, periodic shutdown of a refinery, or part of it, for maintenance, upgrades, and repairs.

The Martinez refinery, which is owned by PBF Energy, has said 170 barrels — 7,140 gallons — of hydrocarbon materials were released during the fire, most of which they said were consumed by the flames.

Contra Costa Health has said chemicals and combustion byproducts from the fire included those that cause cancer, heart and lung disease, though most of the smoke was blown northeast, away from downtown and most residential areas.

The report says at 1:35 p.m. on Feb. 1, two contract workers began opening a flange to install an isolation blind to prepare for planned maintenance on one of the process units, which was shut down.

A flange is a protruded ridge in piping systems allowing easier access for maintenance, providing a means to connect or disconnect pipes without welding.

During the process, the workers mistakenly opened the wrong flange, causing fuel to leak.

The workers immediately evacuated the area, and the hydrocarbon material ignited within a minute of the initial release.

The report said loosened bolts indicated the workers started work on the correct flange but then moved to work on the incorrect one.

The investigation found four specific causes:

The first was California state laws requiring “contractor manpower to be sourced solely from the local union hall. As a result, past resources that included ‘professional shutdown execution’ personnel from other locations are no longer available for PBF to use on turnarounds.”

“Contracted experienced turnaround craftspeople are now more difficult to find and staff using the local union halls” the report said.

The second contributing cause was the work permits. The type of work being done requires work to be started within 90 minutes of the permit being issued, according to MRC guidelines, to ensure work conditions remain safe.

Work on this particular “blind installation” was started approximately 115 minutes after permit approval, without revalidation approval. It also says permits to work are difficult to read due to the small text font.

The third contributing cause was listed as “human factors (training),” and inadequate contractor training. It said “co-employment policies” have expanded beyond the need for the company to insert contract foremen between the contract workforce and company resources “which impedes clear communications regarding job details and safety hazards.”

“Current requirements include sharing safety training information with contractors, with the expectation that contractors train employees in the same manner that was previously done under direct company resources,” the report said. “As a result of this co-employment interpretation, there is a higher likelihood for human errors entering into maintenance work performed by contractor resources.”

The fourth contributing cause was inadequate contractor supervision, with supervisors not having adequate knowledge of PBF standards, procedures, requirements, and other factors.

“Contractor supervisors often manage multiple crews in multiple locations and are not always on jobsites during potentially hazardous maintenance steps,” the report said. “Even with ratios as low as 1:4 (supervisor to craftspeople), they cannot be in two locations at the same time as most crew teams are two-person teams.”

The report recommends many “permanent corrective actions,” including increased operator presence during contractor maintenance work and reviewing employment agreements to ensure workers understand the risks.

It also recommends providing “appropriate consequences” for poor performance and work excellence and the same level of oversight for contract workers as other workers.

The report can be found at https://bit.ly/3Hiwbcx.

The oversight committee meets from 3 p.m. to 5 p.m. Tuesday on Zoom, at https://bit.ly/4kF8gSS. Go to https://www.cchealth.org for more information.

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