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CSB Investigation:
Chevron Refinery Pipe Rupture and Fire
Richmond, California
Southern California Society For Risk Analysis
26th Annual Meeting
May 30, 2013
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Chevron Refinery Pipe Rupture and FireRichmond, California
Background
Incident Review
Sulfidation Corrosion
Review of Findings and Recommendations
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Chevron Richmond Refinery
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Atmospheric
Crude Column
8-inch
“ 4-sidecut” line
Line Constructed
of Carbon Steel
Process Fluid is
Light Gas Oil
P = 55 psigT = 640 ⁰F
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ccuMechanics of Sulfidation Corrosion
Occurs in high temperature process fluidSulfur Compounds React with Iron Contained in Steel
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Sulfidation Rates of Various Alloys
25Curves can be found in API RP 939-C
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Carbon Steel Corrosion Rate Variability
26Graph from API RP 939-C
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Low-SiliconCarbon Steel
>.1% Silicon
Carbon Steel9-Chrome Stainless Steel
INHERENTLY SAFER
90 % Wall Loss 65% Wall Loss 9% Wall Loss < 1% Wall Loss
Chevron 4-sidecut
Material of Construction
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Inherently Safer Materials of ConstructionThinning resulting from 15 years of operation (Estimated)
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Corrosion Monitoring of Carbon Steel Piping
http://ftp2.bentley.com/dist/collateral/docs/plantspace_isometrics/PlantSpace_Isometrics_3D_Pipe.jpg
Measurement
Location
Straight-Run
Components
Elbow
Components
Generic Piping Configuration
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http://ftp2.bentley.com/dist/collateral/docs/plantspace_isometrics/PlantSpace_Isometrics_3D_Pipe.jpg
Generic Piping Configuration
http://ftp2.bentley.com/dist/collateral/docs/plantspace_isometrics/PlantSpace_Isometrics_3D_Pipe.jpg
Measurement
Location
Measurement
Location
Measurement
Location
Measurement
Location
MeasurementLocation
Measurement
Location
Measurement
Location
Measurement
Location
Measurement
Location
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100 Percent Component Inspection Identifies
Low-Silicon Components
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Inherently Safer Metallurgy Reduces Hazard
http://ftp2.bentley.com/dist/collateral/docs/plantspace_isometrics/PlantSpace_Isometrics_3D_Pipe.jpg 30
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Low-Silicon 4-Sidecut Component Not
Monitored
Measurement
Location
WeldHigh-Silicon
Elbow Component
Low-SiliconPipe Component
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Low-Silicon 4-Sidecut Component Not
Monitored
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Many Chevron Recommendations
to Inspect or Upgrade 4-Sidecut
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Pipe Ruptures
Recommendations to 100 Percent Inspect 4-Sidecut
Recommendations to Upgrade Metallurgy of 4-Sidecut
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Process Hazard Analysis
Process Hazard Analysis Required by OSHA PSM Program
– Enforceable by Cal/OSHA and City of Richmond
PHA team DID evaluate “leak or rupture” of 4-sidecut line
PHA team did not identify 4-sidecut Sulfidation vulnerabilities – PHA team not knowledgeable of 4-sidecut corrosion hazards
– PHA team did not seek out additional corrosion expertise
No PHA recommendations to improve 4-sidecut safeguards
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Damage Mechanism Hazard Reviews
These hazard reviews:
– Analyze all process equipment failure mechanisms including:• Corrosion
• Cracking
– Identify potential safeguards to control or eliminate hazard
Not required by regulators or by current Chevron standards
May have prompted PHA team to recommend replacing 4-sidecut line
CSB recommended to Chevron and State of California to require
Damage Mechanism Hazard Reviews as part of PHA cycle
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Adequacy of PHA Safeguards
Safeguard Evaluation Methodologies; accepted methods include:
– Quantitative, e.g., Quantitative Risk Analysis
– Semi-Quantitative, e.g., Layers of Protection Analysis, and
– Qualitative, e.g., NFPA Fire Codes
Chevron PHAs do not use these safeguard evaluation methodologies
– Reliability of safeguards were not adequately verified
– Rely on PHA team experiences, beliefs, and areas of expertise
CSB recommended to California Regulators to require a fullydocumented, rigorous analysis of safeguards using established
methods such as LOPA
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Implementation of Inherently Safer Systems
(ISS)
Contra Costa County process facilities are required consider inherently
safer design opportunities in PHAs and for new construction
But many more opportunities exist:
– Management of Change (MOCs)
– Process Unit Rebuilds
– Major Repairs
– Corrective actions from incident investigation recommendations
Chevron did not document the analysis of ISS alternatives.
CSB recommended more rigorous ISS requirements by:
– City of Richmond / Contra Costa County
– State of California
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Multi-Agency Regulatory Approach Needed
Program will improve public
accountability and process safety
performance
Sharing of data and operational
coordination will help regulators
prevent major incidents
Regulators have cited the need for
greater multi-agency cooperation
CSB recommended multi-agency
regulatory cooperation
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Transparency Drives Process Safety
Transparency is the public disclosure of process safety information
Minimal transparency exists
between refineries, regulators,
and the public
The CSB recommended that
the multi-agency group
establish procedures for
greater transparency betweenlocal officials, regulators, the
workforce, and the public.
Tawanda Kanhema/Richmond Confidential
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Many Factors Contributed to Incident
Immediate Causes
– Failure caused by sulfidationcorrosion in low-silicon carbon steel
– Chevron failed to shut down unit
when leak was found
Latent Causes
– Chevron never fully inspected or
replaced the 4-sidecut despite
many recommendations
– Chevron PHA process failed to
identify sulfidation corrosion hazard
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Many Factors Contributed to Incident
Regulations did not require rigorous
ISS implementation
Regulations did not require damage
mechanism hazard review
Regulations did not require evaluation
of safeguard effectiveness
Multi-agency cooperation andtransparency needed in California
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Additional Items Still Under Investigation
California
– Refinery regulatory regime
Chevron
– Safety culture
– Management system
– Mechanical integrity systems
– Emergency planning,
notification, and response
– Process safety indicators
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CSB Investigation:
Chevron Refinery Pipe Rupture and Fire
Richmond, California
Southern California Society For Risk Analysis
26th Annual Meeting
May 30, 2013