EPA Chemical Accident Investigation Report, Tosco Avon Refinery, Martinez, California   [open pdf - 2MB]

This document is a report from the Environmental Protection Agency, Chemical Emergency Preparedness and Prevention Office about an explosion and fire at the Tosco Avon Refinery in Martinez, California. "At approximately 7:41 p.m. on January 21, 1997 at the Tosco Avon Refinery in Martinez, CA, a section of effluent piping ruptured on the Hydrocracker Stage 2 Reactor 3. […] The excursion was not brought under control because the Stage 2 reactors were not depressured and shut down as required when the reactor temperatures exceeded the 800oF temperature limit specified in the written operating procedures." Investigators identified the causes and contributing factors of the explosion and developed recommendations to prevent similar occurrences at Tosco and other facilities. "EPA has a responsibility to investigate and understand why certain chemical accidents have occurred. A key objective of the EPA chemical accident investigation program is to determine and report to the public the facts, conditions, circumstances, and causes or likely causes of chemical accidents that result, or could have resulted, in a fatality, serious injury, substantial property damage, or serious off-site impacts, including a large scale evacuation of the general public. The ultimate goal of an accident investigation is to determine the root causes in order to reduce the likelihood of recurrence, minimize the consequences associated with accidental releases, and to make chemical production, processing, handling, and storage safer. This report is a result of an EPA investigation to describe an accident, determine its root causes and contributing factors, and identify findings and recommendations."

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United States Environmental Protection Agency: http://www.epa.gov/
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