The U.S. Chemical Safety Board (CSB) has released an eight minute safety video entitled “Fire in Baton Rouge” detailing the agency’s Key Lessons stemming from the 2016 fire at the ExxonMobil Refinery that seriously injured four workers. The video includes a new four minute animation explaining the events leading up to the incident.

The fire occurred when operators inadvertently removed bolts that secured a piece of pressure-containing equipment to a type of valve known as a plug valve. When the operators then attempted to open the valve, it came apart and released flammable isobutane, which formed a vapor cloud that quickly ignited.

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In the video CSB Chairperson Vanessa Allen Sutherland said, “During our investigation, the CSB learned that the operators attempting to open the plug valve were following accepted practices within the refinery. Our safety bulletin addresses the need for companies to be vigilant with their safety hazard and risk mitigation analyses. The management of safety is critical to the protection and safety of workers and integrity of facility operations.”

The CSB is issuing Key Lessons to address the shortcomings revealed by the investigation: 

1. Evaluate human factors - interactions among humans and other elements of a system - associated with operational difficulties that exist at a facility in relation to machinery and other equipment, especially when the equipment is part of a process covered by the Occupational Safety and Health Administration’s Process Safety Management (PSM) standard. Apply the hierarchy of controls - a method of evaluating safeguards to provide effective risk reduction -  to mitigate the identified hazards.
2. Establish detailed and accurate procedures for workers performing potentially hazardous work, including job tasks such as removing an inoperable gearbox.
3. Provide training to ensure workers can perform all anticipated job tasks safely. This training should include a focus on processes and equipment to improve hazard awareness and help prevent chemical incidents.

Chairperson Sutherland said, “The safety management practices outlined in our bulletin could have prevented the fire in Baton Rouge. We urge companies to share and implement our key safety lessons at their facilities in order to prevent future injuries and property damage.”

The CSB is an independent, non-regulatory federal agency charged with investigating industrial chemical accidents. The agency's board members are nominated by the president and confirmed by the Senate. The agency investigations examine all aspects of chemical accidents, including physical causes such as equipment failure or inadequacies in regulations, industry standards, and safety management systems.