CSB Video Depicts Fatal 2022 Fire at Ohio Refinery
An animated video released by the Chemical Safety and Hazard Investigation Board (CSB) explains the series of malfunctions and errors that preceded the flash fire at the BP Husky refinery in Oregon, Ohio, on Sept. 20, 2022. Two workers died in the incident.
The refinery processes crude oil and pumps it into a tower where it is separated into several products, including naphtha, a highly flammable liquid. The night before the fire, a control room operator made adjustments to a drum in which naphtha condenses prior to being routed to other areas of the plant. These changes eventually led to an increase in pressure and vibrations in pipes that caused a leak of liquid naphtha on Sept. 20. Refinery operators quickly contained the leak.
Control room personnel responded to the leak by shutting down equipment and putting an area of the refinery into bypass mode. These actions produced “process upsets” that continued for several hours, the video explains. Attempts to manage the situation caused liquid naphtha to flow into areas intended only for vapors. Responding to instructions from the control room, two operators released liquid naphtha onto the ground from an overfilling drum. A large cloud of naphtha vapor formed and ignited a flash fire that killed the two operators. The fire burned for more than two hours.
CSB investigators found that the refinery did not have engineering controls to prevent liquid naphtha from overflowing, instead relying on operators' actions. Contributing to the incident was an “alarm flood” that exposed operators to more than 3,700 alarms across nearly 12 hours, according to CSB. The agency also found that refinery personnel had successfully managed a similar liquid overflow in 2019, which may have been misinterpreted to mean that engineering controls were not necessary.
The video is available on YouTube. For more information, including specific recommendations that CSB made to prevent similar incidents, refer to the agency’s final report (PDF).