Investigation into Refinery Spent Catalyst Accident Pins Blame on Training Lapses, Worker Fatigue, Inadequate Safeguards
Long-awaited independent analysis documents causes of November 2022 toxic dust incident, including failure to operate key piece of equipment properly, underestimating potential severity of release
Inadequate training, worker fatigue and a failure to implement adequate safeguards were among the key causes of the “spent catalyst” release by PBF Energy’s Martinez refinery in November 2022 that spewed at least 20 tons of toxic dust into the surrounding community.
Those were among the conclusions reached by the long-awaited independent root cause investigation into the incident that has left the refinery under a cloud of controversy and criticism ever since.
Scott Berger of Scott Berger and Associates delivered his draft report to the Martinez Refining Company Oversight Committee on Thursday morning. The Oversight Committee was established by Contra Costa Health in the wake of the incident, which left community members and public officials outraged, in large part because of the lack of prompt notification by the refinery to the release.
A key factor in the release, according to Berger, was the fact that an important piece of equipment designed to regulate the flow of catalyst was left in manual mode instead of being placed in automatic. This caused the catalyst (material that helps to “crack” large hydrocarbon molecules into smaller ones) to rise above safe levels and ultimately overwhelm the equipment designed to process it, resulting in the release.
Refinery personnel did not recognize the dust was being released into the community because no catalyst was found falling within the refinery grounds, which was the reason the refinery gave immediately after the incident as to why it didn’t activate the county’s Community Warning System. A slight wind that night blew the dust off refinery property, according to Berger’s report. The refinery received calls from the community about the dust after daylight Nov. 25; the incident began at around 8:30 p.m. the previous night (which was Thanksgiving).
Berger found that the refinery failed to properly train operators on the likelihood that excessive catalyst build-up in the Catalytic Cracking Unit (CCU) equipment designed to remove the dust would lead to a hazardous community release.
Berger’s highly technical report focused in large part on flawed processes and training that led to the sequence of events over multiple days that resulted in the release of the heavy metal-laded dust — though operator error itself was not identified as a root cause. However, following Contra Costa Health’s guidance, it did not specifically address the refinery’s failure to activate the Community Warning System and promptly notify health authorities and the public. That question was referred to the Contra Costa County District Attorney’s Office over a year ago for potential legal action; the D.A. has still not announced a decision on whether the refinery will face any charges over the failure.
Of particular note, Berger found that both PBF and the refinery’s previous owner, Shell, had previously analyzed the specific scenario that led to the Nov. 24-25 chemical accident and “underestimated the severity of (a) potential incident.”
“They didn’t realize it would be a major catalyst release,” Berger told the committee.
Berger also found that the process the refinery used for deviating from standard procedures “wasn’t as formal as it needs to be.” He faulted the refinery for not giving workers adequate “cautionary” statements explaining the importance of certain procedures, and failing to emphasize the need to pause and re-evaluate work “when things go differently than expected.”
Berger addressed a lingering question that has been speculated about in the months since the incident — whether a device known as a wet gas scrubber would have prevented the release. The refinery is currently fighting in court a new rule implemented by the Bay Area Air Quality Management District that would necessitate the implementation of a wet gas scrubber to meet new air quality emissions standards.
Berger’s investigation found that a wet gas scrubber would not have “reduced the incident severity significantly,” though it would have prevented “at least some” of the release in the early phase of the incident. He found that operators likely would have had to shut down a wet gas scrubber before the incident was over because of the limited capability of the device to capture high levels of catalyst.
“We may have seen the wet gas scrubber remove a few tons of the release, but the vast majority of the release would have continued, as was experienced,” Berger told the committee.
A slide from the presentation of the independent investigation by Scott Berger at Thursday’s MRC Oversight Committee meeting.
Some of the highlights from Berger’s investigation:
The sequence of events leading up to the catalyst release started three days before the release itself, on Nov. 21, when an air controller failed, prompting workers to shut down the CCU.
The unit’s electrostatic precipitators, which use electric sparks to remove small particles and control pollution, were de-energized as a safety precaution when the CCU shut down and was re-started. This became standard operating procedure following an explosion in 2015 at a refinery in Torrance.
A device known as a “stripper slide valve” was not in automatic mode, as it should have been, when feed was reintroduced into the CCU on Nov. 24 leading up to the release. As a result, the valve was not manually closed fast enough when reactor pressure surged. An engineer had told day shift operators not to reintroduce the feed unless the valve was in automatic mode, and that they were told to call an instrument technician if it could not be switched to automatic. The refinery’s representative to the committee, Ken Axe, disputed that operators were told not to operate the stripper slide valve in manual mode (Axe also raised several other objections to the report’s findings, many of which were technical in nature).
An unnamed refinery employee worked 20-plus hour shifts in the days after the shutdown on efforts to re-start the CCU. Berger’s investigation identified “gaps” in the refinery’s worker-fatigue management processes. “We believe that the fatigue of the worker played a role in why the procedure was not followed and why the decision was made to put that slipper slide valve in manual,” Berger told the committee.
The re-introduction of feed into the CCU is an infrequent procedure; Berger said the Nov. 24 event was the first time it had been done in over a year. However, the refinery failed to provide “just-in-time” training for operators prior to the work beginning.
There were two “flaring” events in the CCU on Nov. 24, one of which was related to the surging reactor pressure during the re-start efforts. The employee noted earlier who had been working 20-plus-hour days told staff that there should be no further flaring or use of propane, which was approaching minimum inventory levels, that day. Berger cited the directive against flaring/using propane as a possible “contributing cause” to the incident.
The catalyst levels became increasingly elevated and ultimately the dust passed through the unit’s carbon monoxide boilers and de-activated precipitators, before spreading off site. The vast majority of the catalyst was released before 11:30 p.m. that night. Berger said the highest level of catalyst release ended when the slipper slide valve was finally placed in automatic mode around 11:30 p.m. Catalyst continued to be released, however, until about 4:30 a.m., when the unit’s catalyst separators were finally drained.
Berger found that engineering designs not present in PBF’s refinery, but common in others in the industry, “may have helped avoid (the) incident.”
The report found that “console operators who normally would have worked the evening shift took time off (on Thanksgiving), leaving a shift supervisor and a production specialist to operate the CCU.” Berger disputed the refinery’s characterization of the staffing situation that night: “While MRC personnel stated that holidays were like any other operating day, this was clearly not the case,” he wrote.
As expected based on his findings, Berger recommended the PBF review and clarify its processes for analyzing potential problems as occurred during the spent catalyst accident, and shore up its training standards and worker-management and fatigue procedures to address the flaws he identified.
Berger also contrasted his findings with PBF’s own root cause analysis of the incident from last February, noting that in cases where the refinery blamed worker error, Berger cited procedure- and training-related causes that were the responsibility of refinery management.
Next up, a 45-day public comment period will be held for Berger’s report, which is expected to begin at the end of February when the report is updated. A public meeting on the report is expected to take place in March.
The draft report can be viewed at this link: https://www.cchealth.org/home/showpublisheddocument/29419
The video of Thursday’s Oversight Committee meeting can be viewed at the link below:
Storm preparations
With another big storm expected to hit the area this weekend, here are some handy storm tips from the city’s website:
“When the Alhambra Watershed comes alive with the winter rains – we all need to be smart about working with our local environment. Localized flooding, power outages, and downed trees/debris can all be expected as our local soil is already saturated. Preparation is key to weather the weather!
How to Prepare
Charge your phone(s).Keep flashlights handy and skip the candles.
Visit Ready.gov for information on storm preparedness.
Stay home and off the roadways if possible.
The American Red Cross is always a great disaster preparedness and response resource at 1-800-RED-CROSS.
Stay Informed
Follow the City of Martinez & Martinez Police Department on Facebook where routine updates are posted.
Register at the Contra Costa County Community Warning System for emergency alerts.
If safe, clear storm drains on your property, and surrounding area.
Sandbags and Sand
This winter season, the City has already provided over 14,000 sandbags to the community this storm season. Empty sandbags are available in two locations – and sand in four others. Home Depot and Ace Hardware are alternatives.
Empty Sandbags (limit 10):
City Hall – 525 Henrietta Street
City Corporation Yard – 300 Alhambra Avenue
Sandbag Filling Stations (bring your own shovel):
Church Street (located in the church parking lot)
Rankin Aquatic Center (located in the upper parking lot)
Ferry & Allen Street
F Street (west end of F Street off Alhambra Ave)
Who to Call
Life/Safety Emergencies
Call 911.
Downed Power Lines and Gas
If you smell natural gas, see downed power lines, or suspect another emergency, leave the area immediately and call 911. Then, call PG&E at 1-800-743-5000.
Downed Trees in Public Right of Way
Tree limbs and other large debris in roadways and sidewalks should be reported to the Martinez Police Department non-emergency line at 925-372-3440.
Power Outages
Outage information is available on PG&E's outage map and emergency preparedness safety tips available through PG&E's Safety Action Center.
Driving Safely
Driving through a flooded area puts your vehicle at risk for stalling out and becoming stuck in the water. Do not drive through standing water!
If you are driving and begin to hydroplane in ponding water, immediately take your foot off the accelerator and let your vehicle slow until you regain control. When driving in heavy storm conditions, give yourself plenty of extra time and maintain a safe distance in front of you. If your windshield wipers are on, your headlights MUST be on as well.
Downed Trees
Property owners are reminded that clean-up of privately owned trees and branches is the owner's responsibility, whether the clean-up is on the owner's property or neighboring property, including city property. City trees that have fallen on private property are the responsibility of the city to clear.
Property owners should contact private tree trimming/removal companies, their insurance companies, and utilities directly if their private tree falls and causes damage to their property. Private trees should be properly trimmed and maintained in advance of storm season to prevent tree failure and serious damage to private property during storms.”
Thank you for following this investigation.
And a big Thank You for posting the storm information. Your efforts result in a prepared and informed community.
Thanks for this, Craig. I missed going to the Oversight Committee meeting so your review brings me up to snuff!
So an employee working 20 hr shifts seems to be an OSHA violation, right?