Loading...
HomeMy WebLinkAboutMINUTES - 05222007 - D.3 TO: BOARD OF SUPERVISORS (�✓�/'�� ?—S L �F. Contra FROM: William Walker, M.D., Health Services Director noi, Costa By: Randall L. Sawyer, Hazardous Materials., . . 4c DirectorCo U n Ly DATE: May 22, 2007 SUBJECT: Root Cause Investigation Report on the January 15, 2007 Chevron Fire SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: Accept the root cause investigation report on the January 15, 2007 Chevron Fire FISCAL IMPACT: None BACKGROUND: On January 15, 2007 at approximately 05:18 a.m., a fire occurred at the Chevron Richmond Refinery#4 Crude Unit. Operators were in the process of shutting down the plant in preparation for scheduled maintenance and inspections. The City of Richmond's Industrial Safety Ordinance requires Chevron to perform a root cause analysis for this event. Health Services monitored the process that Chevron was following to perform this root cause analysis. Attached is the report of this effort and a copy of Chevron's Root Cause Analysis. CONTINUED ON ATTACHMENT: X .YES SIGNATURE: '�RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE L- AAPPROVE OTHER i SIGNATURE(S). ACTION OF BO ON ®�r2 2, APPROVE AS RECOMMENDED OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE _ UNANIMOUS (ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN AND ENTERED ON THE MINUTES OF THE BOARD AYES: NOES: OF SUPERVISORS ON THE DATE SHOWN. ABSENT: ABSTAIN: ATTESTED_QIcIZa JOHN CU LEN,CLERK OF THE BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR Contact Person: Randy .Sawyer (646-2286) CC: Health Services Hazardous Materials Cho Nai Cheung ` v Randy Sawyer BY: CC2 ,DEPUTY Root Cause Investigation for Crude Unit fire at Chevron on January 15, 2007 Incident Description On January 15, 2007 at approximately 05:18 a.m., a fire occurred at the Chevron Richmond Refinery #4 Crude Unit. Operators were in the process of shutting down the plant in preparation for scheduled maintenance and inspections. Initiating event - Fire began from a release of a swing out wash-oil pipe spool when a section of that spool failed. The pipe is located at the discharge of P-1165A (C-1160 Vacuum Column Bottoms pump) (Figure 1) and the material released was a mixture of wash oil, and partially processed crude oil. Wash oil is basically diesel fuel that is used to remove heavier crude oil residue from the internals of equipment in preparation for equipment clean up and maintenance. Due to the fire's potential off-site impact, Chevron initiated a Community Warning System Level 2 notification at 05:22. Shortly thereafter, at 05:30, a CWS Level 3 was issued to portions of the community alerting people to shelter in place. The main fire was extinguished at 07:00 and CCHS announced the CWS all clear at 08:40. For 'safety reasons (to not accumulate quantities of unburned vapor) several small fires were allowed to continue in a controlled manner until 14:14 on the same day. CCHS on-site inspection On January 18, 2007, Health Services representatives met with Chevron for an on-site inspection of the damaged unit and adjacent area. Health Services representatives noted the fire was constrained to a narrow and vertical area but high temperatures during the fire resulted in substantial damage to the immediate equipment and structure. Due to the potential unknown atmosphere of the immediate area, the site inspection was limited to elevated peripheral viewing. In addition, as a precaution, a fire engine was observed to be in the immediate area to suppress any possible re-ignition of materials at the time of the visit. Root Cause Investigation Chevron is required by the Richmond Industrial Safety Ordinance to conduct a root cause analysis (RCA) for any Major Chemical Accident or Release Community Warning System Level 2 and Level 3 incidents. Investigation Methodology The investigation team followed a Health Services approved proprietary root cause analysis methodology, TapRooT®, developed by System Improvements, Inc. of Knoxville, TN. The TapRooT® investigation process requires a systematic evaluation of each causal factor against a structured hierarchy, called the Root Cause Tree®. The Root Cause Tree consists of a series of questions relating to individual performance, team performance and management systems, which then lead to a defined set of Basic Cause Categories. Within each Basic Cause Category are a number of unique root causes, as defined by the TapRoot®methodology(as identified by System Improvements, Inc.) Investigation Team The investigation was facilitated by a Chevron Corporate Fire and Process Safety Engineer and led by Chevron Pascagoula Refinery Area Business Leader with over 20 years of experience in crude operations. Other core team members included a Chevron Pascagoula Refinery Designs Team Leader and members from the Richmond Refinery including a plant Operating Assistant, two Head Operators, who are also United Steel Worker Union Health and Safety Representatives, and a Corporate Crude Unit subject matter expert. Additional experts were involved in the analysis of the incident and the investigation on an as needed basis (e.g. materials testing, corrosion engineer, etc.) Health Services Oversight On January 23, 2007, Health Services met with the Root Cause Analysis team at Chevron to discuss and review the investigation method to include: • Investigation team make-up, qualifications and experience. • Incident time line • Close-up photos of the equipment and adjacent area (not observed during earlier visit) • Review and discuss with investigation team members significant observations and findings that were available Chevron and Health Services set-up weekly telephone conference/updates with the investigation team or Chevron Process Safety Management team leader to keep track of the investigation progress and stay informed of any significant findings from the investigation. On February 1, 2007, Health Services met with the investigation team at the conclusion of the on-site participation of the off-site team leader and member before their departure from Richmond. At this point.of the investigation, the anticipated interviews of the incident related personnel were complete and the material evidence had been gathered and awaiting analytical results. Though the investigation was not fully complete, the team leader and member were informed of any additional results obtained by the Richmond investigation team members and they were involved in final preparation of the investigation report. Orr March 1, 2007, Health Services met with Chevron to review preliminary root cause . analysis findings and discuss recommendations for path forward to address the identified causes and prevent future recurrence of similar events. On April 26, 2007, Health Services visited the refinery to verify that the repairs had been made to the unit as presented in the root cause .analysis final report. Health Services observed that the area that was damaged had been restored and returned to normal operation. Additionally, Chevron evaluated similar pump/pipe spool arrangements in the Crude Unit to determine if the metallurgy should be upgraded to prevent future corrosion. Fourteen spools were identified to have'this corrosion potential and were upgraded even though none of the removed spool piece showed indication of corrosion. Chevron is now in the process of examining other units in the entire facility for operations that may be susceptible to this type of corrosion and upgrade any piping as needed. Health Services will continue to monitor what Chevron is discovering in the other units in the refinery and what actions Chevron is taking to address them. This will be done during regular audits or unannounced inspections. Fig. 1 Simplified Drawing of Vacuum Column Bottoms Pump P-1165A and Piping Gude ra tC"Cnaa Lm c Unit rK-Iur Vacuum a'V4'cah as Lne Pmm Column - x.xnaur,E,i �a rx-tam C-1160 t:»,Pi.Aa R 4� f 8hinj out,'!-Mme Gi!agaU „ � 1165A .< 1 �L/ � CIosN.ake mxa na aorta Vacuum Column Bottoms Pump REQUEST TO SPEAK FORM (3 Minute Limit) I wish to sneak on Agenda Item #: 3 Complete this form and place it in the upright box near the Date: .51zZ10 speaker's podium, and wait to be called by the Chair. —� Cf7' Personal information is optional. This speaker's card will be My comments will be: General incorporated into the public record of this meeting. ❑ For ❑ Against Name: ❑ I wish to speak on the subject of: Address: City: r Phone: Z yL — Z S/P i i I am speaking for:. ❑ Myself C Organization: ❑ I do not want to speak but would like to leave comments for the Board to consider (use the back of this form) n ` ,3 I REQUEST TO..SPEAK.FORM (3 Minute Limit) I wish to speak on Agenda Item#:. Complete this form and place it in the upright box near the Date: <P j ?.2 speaker's podium, and wait to be called by the Chair. al Personal information is optional. This speaker's card will be My comments will be: Gene incorporated into the public trecord of this meeting. ElFor IRA. i Name (PRINT): `A. 1Qh too i MCLS ❑ Against To entire your nante is atnvounced con-ectly,you inav want to inchtde its phonetic spelling /. Xr I wish to speak on the subject o£ Address: cO �-'� S�-A ea'S/j 5a 97 �t S �rc`J 3 OW<qw City: Phone: I am speaking for: ❑ Myself _ Organization: F6't*-7 9g2p ❑ I do not want to speak but would like to leave comments for the Board to consider Val IPA 624�-r2i M''r'''\ (Use the back of this form) V CL D W L W. Q L o 4mJ Ln cn cn 2 � w CL ?� O O p � ..�..J �.. �� 0 a) to CL. N ° w J u� a 4-J n N T�3 N V Q H k i`t' . _ N O o r�� •~ O a� ■mmm� 4-J . 0) 4-J ® •Oc p -� > � olco rill zit 4—J CL ru 4 C O � Q) E c Com -' 4-J u E- O U � cea: CL N ® ■ ro a' yvj' 141- O o M Up CP cle) ,., . , U- c� � CP co , NSU o ca Oco un U °y t4 co Lf) C, O V ` ' o o V UO) O ® a co � •� cv S � oSoo a COs .$ ca N o v ` ' O orn . ' N Ln o 3s ♦ � �g fin, ws� T � l �l �3 ti Ns a-' cU � . 4� �U k � (n ra cn4--J ru N a) �" . . N N a No . w U CD E Lu Ln U Q cn C: �' I tta CDCL E fa p (a C:C: � '�' � W U O V) Q) (Y Q Q) EC� Ln fB �' •(ll s- U N i� CL CL z � =3 0Ln0cLn =; r%, Cr Ln (31 ON o C�� ,�' �` tQ c' E 2 Co U)Q) fu E U tv � � U 0Q) L. tt3 � to c.1 L- a � N o E •— � c) f> N � MM fl, i +'=t fa Q) CD Ln ,1 (a E fa (a t2 •— a) fa =3 4-J fU O �. MMO mo f6 i N (_n L. ® . C: fu (n 0 .- i C: fa N V Q •- 4--J ca '_ a-' 4J O } ._ I� fa - � ¢ w - � v •�" fa o > Llf) C: QTS 4-J z fa 4O O :3 "mJ � 1 N CL O O OCA O 0 ca. E •� ra O MMO fu Q) N 4-J 0. 4— o u ■ ■ ■ �. u f11 roMs . c I I. i 110 4-J (U mo O Q V ® o i 0 (1) •cn 0 �. 0 4"' O � • ra � U �— cn U) ra a >� Q) 0 u ro co ra o > O 04.o 4. U Ln � o > 00 N C: _ fu I L •� U) ol¢ 4-J a..i 0 Ln vlz � a-J 4- V) .V 'v� cnro N fa 0 g 0 An •> r8 �� Cr U 0 co fu V ■ ° ■ N N 3a k �. vi, i I i f I I C: fu n °— (n . —' o m E � cn fo fu a� Q Lo x ® M Q V) O (1) . .� 4mJ V i 0 L � ^ M. 4-J 4 CL cn N = f . O ® O E •— �. ii V ClyLL � L N4..J o Q •- C > � 0 ow o (nom fu ' Z . clfa :3 L. ca. V °0 Q O v Cl) U o ca .� r > + � .V i mo rZj® a � 4-°, U „�,_y o >e L o O L L L LL w J V a V O N N j ra I II li I 4 `x 4 V { co W 4-J N ,� r fu N c�a f U 4fo Q O O -o� p C: U) O O N 4-J o_ to � . � �+ ca = � E O E C U a� U 4-' U N C > '0 O . m � O p -O U �Ir O N 0 ro N 4-J = o p O 01 cn O N C: N 0 CP U _ . .�.� L. � f6 U ® a) CL i , S2 u U (n Orn ' (Q f^a, U a z s ,rt t t YI I 1 a ` 1 Cl ifs .Y = I t i v— 5k q�I III — _ 'I YIITi ,� s u5 Iit� w � O an a o� � o � f c ^ S9 i-1 V] La i s C. Q y Uw ✓ � U tfi D I x sj ------------ E CL O 7 � o ZI-d .,w e-a d 7 � r-E U 7 > U U _ O O N N N ,. as vs U) fa ® O fu La O i Q 4-J C. Cn CDo � � i E E - fu Q fu f a-J fo C: O O V N '0 N [a Q O 0) 4-J E O .E cafu � x 4=J c� Q M O U Q, ■ � � -a�aF��+ 4�`�i v�' ���^'t 4t �< �✓�t"9"ew 4'y n �+.��� un�»4w� u ru � O �V1 hi ,fie 'cam �:. ✓5� � N CU Co O O N — 4-a CD C6 CU -. Q) p Q- L c/) E (a cn ( O Cll N CU u (nE CU N E OU cn cn 4 JOcr Ca CU C_ L CU N Co � ■ P Q L U Ca of — U Co X i .� E c 'n CU p N 0 O Ca E O ¢ w Cv _ U) 0 N ' '� a® CU n w U m L (/1 IXO OU C a m O olz 4=J C: U 4J ■ A 511, E�Q`�w ® ?n'C a O N � ,"• N 1 w I I V IO fa •— Er .. O 4-J 0— � 4-J � O l e ii •V i O � •- .- L O -6j Q E 41 V 70 fc$ � ui " a� > 4-J z � o�Q i � w 9 ' 3{gbis� bm A hmb t O a ' I I to -p L L v L . . NCL .� U V) fQfu 4-J N L fu ru 0 � � � _� fl. c °' O . .o L O C O (� 4 -+ > oL u cin fa 4-J N L L - • Zj � o : © v o .o O fo U fu CL U O 'r u N n O : . E �` E o �, U > � > OUB o > ar CL ry 0 w ry H Ln C D U CL > L U . .... 0 ¢ 4mJ 4�J q r, a {b CV ti r4 ro t a ' �d pti a � s h kPoWd� dfi� i W k E Ln IOL O ; c `. ■o O V � � .— U O O [a Z E N fu �o (n .— a-J U O =3Ul t:o u FIU w O 'Lu O • CY — L .� > L o Q 4-J fa W S O L -y O Q � � Q) l flo '0 1' 4) 4-' O v a--� fo, .— a s O L 4�J or fa 0 0 4f I,=I ■ ■ ■ Q No N x cu � C I • I ;pec ; „,.. Y PP 3y 4a cC3 � k � r--,41 ^y. i ct 4-4 CE � r--4 N m _ '-� csE Ct n'fie ct /�Z • T'�� ice,. a4w�+:�"°` vct �.,. ECS I Imp WINE p �1 1 ADDENDUM to D.3 May 22, 2007 On this day, the Board of Supervisors considered accepting the root cause investigation report on the January 15, 2007 Chevron Fire. Randy Sawyer, Health Services Department, introduced the item and began a PowerPoint presentation [attachment]. Cho Nai Cheung, Health Services Department,picked up narration of the PowerPoint presentation to explain the cause of the fire as outlined on slides 9 through 14. Supervisor Piepho noted that'lessons have been learned from this by Chevron, but asked if the information had been broadcast to other refineries. Mr. Sawyer responded that meetings are held where such information is shared between facilities. Supervisor Gioia asked if there was a timeframe for the ongoing upgrade. Mr. Sawyer said there is no timeline but the progress will be continually monitored. The Chair called for public comment and the following people spoke: ■ Dean O'Hair, Chevron Richmond, said that Chevron can get back to the Board with a timeline and noted that they will be looking for similar conditions that will be mitigated; Ralph Hoffman, District III resident, said he is a�retired Chevron employee and noted that during his tenure at no point was government involved in root cause analysis committees, and added that when government is involved there is an opportunity for bureaucracy. By a unanimous vote with none absent, the Board of Supervisors took the following action: ACCEPTED the root cause investigation report on the January 15, 2007 Chevron Fire. i I