Final Investigation Report - US Chemical Safety and Hazard ...

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U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD INVESTIGATION REPORT REFINERY INCIDENT (1 Killed, 8 Injured, Offsite Environmental Impact) MOTIVA ENTERPRISES LLC DELAWARE CITY REFINERY DELAWARE CITY, DELAWARE JULY 17, 2001 KEY ISSUES MECHANICAL INTEGRITY ENGINEERING MANAGEMENT MANAGEMENT OF CHANGE HOT WORK SYSTEMS REPORT NO. 2001-05-I-DE ISSUE DATE: OCTOBER 2002
Page 1: KEY ISSUES: MECHANICAL INTEGRITY U
Page 6 and 7: EXECUTIVE SUMMARY .................
Page 8 and 9: Figures 1 Layout of Acid Storage Ta
Page 10: LEL Lower explosivity limit LLC Lim
Page 13 and 14: Spent H 2 SO 4 normally contains sm
Page 15 and 16: The design and implementation of th
Page 17 and 18: Sizing of inerting flow requirement
Page 19 and 20: On at least two previous occasions
Page 21 and 22: ES.6 Recommendations Occupational S
Page 23 and 24: Motiva Enterprises LLC 1. In light
Page 27 and 28: 1.3 Delaware City Refinery 1.4 Sulf
Page 30 and 31: B eginning in late June 2000, boile
Page 32 and 33: On July 17, 2001, four WGI boilerma
Page 34 and 35: Figure 2. Tank 393, collapsed at no
Page 36: The spill eventually reached both t
Page 39 and 40: Date Inspection Findings 3.1.1.1 Ta
Page 41 and 42: Figure 5. Elongated hole on roof of
Page 43 and 44: API 653 requires that “flaws, det
Page 45 and 46: Table 2 History of Motiva API 653 T
Page 47 and 48: In the presence of low concentratio
Page 49 and 50: . . . hydrocarbons produce a flamma
Page 51 and 52: 3.2 Engineering of Conversion From
Page 53 and 54:
CO 2 inlet Instead of having a dedi
Page 55 and 56:
The July 17 incident resulted in th
Page 57 and 58:
. . . there was no documented MOC r
Page 59 and 60:
. . . a prestartup safety review .
Page 61 and 62:
Each switchover represented an oppo
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3.5 Hot Work Motiva allowed hot wor
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3.6 Unsafe Condition Report followe
Page 67 and 68:
3.8 Review of Similar Incidents the
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. . . the DCR acid storage tanks we
Page 71 and 72:
The purpose of the Jeffrey Davis Ab
Page 74 and 75:
4.0 Root and Contributing Causes 1.
Page 76 and 77:
Ensure coverage under the Process S
Page 78 and 79:
1. Work with NACE International (Na
Page 80:
By the U.S. CHEMICAL SAFETY AND HAZ
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Lees, Frank P., 1966. Loss Preventi
Page 85 and 86:
A.3 1998- Shell Leak monitor corros
Page 87 and 88:
A.5 2000- Shell Leaks A.6 2001- She
Page 90 and 91:
Hot work conducted in vicinity of t
Page 92 and 93:
Accelerated localized corrosion of
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