- ISHN GLOBAL
- EHS RESEARCH
The CSB issues urgent recommendations before completion of final investigation reports in cases where CSB Board Members determine an imminent hazard may be present and has the potential to cause serious harm unless rectified in a short timeframe.
On the day of the accident last July, hydrocarbons and hydrogen fluoride were suddenly released from the refinery’s HF alkylation unit. The hydrocarbons ignited, leading to a fire that burned for several days. The fire critically injured one employee and another was treated for possible hydrogen fluoride exposure.
CSB investigators determined that a blockage of liquid caused by the sudden failure of a control valve led to violent shaking within the process recycle piping. The shaking broke threaded pipe connections resulting in the release of hydrocarbons. The cloud of hydrocarbons reached an adjacent unit and ignited. The ensuing fire caused multiple additional fires and the release of approximately 42,000 pounds of hydrogen fluoride from equipment and piping within the unit.
The refinery used a water spray system to absorb the released HF, but the CSB cited scientific literature to conclude that at least 4,000 pounds of HF likely escaped from the unit into the atmosphere and left the facility. Investigators determined that during the first day of response efforts CITGO nearly exhausted the stored water supply for the water mitigation system. Approximately eleven-and-a-half hours after the initial release, before the water supply was completely exhausted, the refinery began pumping salt water from the ship channel into the refinery fire water supply. Multiple failures occurred during the salt water transfer including ruptures of the barge-to-shore transfer hoses and water pump engine failures.
CSB Chairman John Bresland said, “It is imperative that refineries have the proper emergency response resources available to control a release of hazardous materials and protect against impact on the surrounding community.”
The CSB’s urgent recommendations call on CITGO to develop and initiate plans within thirty days to ensure an adequate water supply to the refinery’s HF mitigation system. The company should also report planned or completed actions to the Refinery Terminal Fire Company and the Local Emergency Planning Committee every thirty days until all planned activities are fully implemented.
Investigations Supervisor Robert Hall, P.E., said, “Our investigation closely examined emergency response actions related to this accident. Investigators found that the CITGO water mitigation system serves as the last line of defense to protect the community from an HF release. The CSB’s urgent recommendation aims to improve the reliability of CITGO’s Corpus Christi, Texas, HF water mitigation system.”
A second urgent recommendation called on CITGO to commission independent, third-party audits of the safety of its two HF alkylation units at refineries in Corpus Christi and Lemont, Illinois. The audits should compare safety practices at the alkylation units to those recommended by the American Petroleum Institute (API). Investigators said that CITGO had never conducted such an audit of the units, despite an existing industry recommendation for audits every three years.
The CSB also released video of the initial pipe failure, release, ignition, and fire as captured by two refinery surveillance cameras. Chairman Bresland noted, “The camera footage shows the release and spread of the flammable vapor cloud and the moment when the flammable vapor was ignited. It shows just how severe the release and fire were during this incident.”
Chairman Bresland said, however, that the company had raised objections to the CSB’s release of the video, saying that doing so would “raise substantial issues of national security” and would “only sensationalize this unfortunate accident.” The CSB subsequently received affirmation from the Department of Homeland Security that the video did not fall under certain classifications requiring protection from disclosure. Chairman Bresland said, “We found this claim disturbing and believe that it is contrary to the intent of a recent law passed by Congress, following similar secrecy claims by Bayer CropScience in Institute, West Virginia. This law, the American Communities’ Right to Public Information Act, states that national security classifications may not be used to conceal corporate errors, prevent embarrassment, or improperly delay the release of information to the public. An important part of this CSB investigation is to ensure all relevant information and visual materials regarding this accident are made available to the residents of Corpus Christi.”
The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.