"This investigation report examines a refinery incident that occurred on July 17, 2001, at the Motiva Enterprises LLC Delaware City Refinery in Delaware City, Delaware. One worker was killed, eight were injured, and there was significant off-site environmental impact. This report identifies the root and contributing causes of the incident and makes recommendations on mechanical integrity, engineering management, management of change, and hot work systems." Key issues discussed include: mechanical integrity, engineering management, management of change, and hot work systems.
Report No. 2001-05-I-DE
U.S. Chemical Safety and Hazard Investigation Board: http://www.csb.gov/