A February explosion and massive fire at a Martinez refinery happened because there were not enough number of contracted workers and insufficient training and supervision for those who were hired to do the work, according to the draft report submitted to the county’s health department by a consultant.
Contractors also exceeded the timing of a work permit, another reason the Feb. 1 blaze at the Martinez Refining Company began, according to the report. The refinery is located on Pacheco Avenue.
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Six workers required medical treatment. All of them were treated at the scene and released without being hospitalized, according to that same report. The chemicals released in the fire included those that cause cancer, heart and lung disease, according to the Contra Costa Health Services Department.
The company is owned by PBF Energy, Inc., and has faced much scrutiny in recent years. In October 2023, the refinery released petroleum coke dust on the city of Martinez. It also leaked coke dust in July of that year, and came under scrutiny on Thanksgiving 2022 when it leaked material containing aluminum, barium, chromium, nickel, vanadium and zinc in higher levels than are safe, officials said.
Consultant JEM Advisors prepared the latest report and presented it to the Contra Costa Health’s Martinez Refining Company Oversight Committee on Tuesday.
According to the report, the root cause of the fire was because “operations monitoring and control of work was inadequate for [the] current contractor organizational capability.” That root cause was created by three underlying causes, according to the report.
Regulatory issues were the first contributing cause. The report states that California Senate Bill 54 requires contractor manpower to be sourced solely from the local union hall, a requirement that made past resources including those trained in “professional shutdown execution” no longer available. As a result, the refinery was short of manpower.
That factor came into play about 1:35 p.m. on Feb. 1, when two contract workers began opening a flange to install an isolation blind to prepare for planned maintenance on one of the process units, according to the report. A flange is a protruded ridge in piping systems that provides a way to connect or disconnect pipes without welding, thus making it easier to access for maintenance.
Contract workers mistakenly opened the wrong flange, causing fuel to leak, the report said. The hydrocarbon material ignited within a minute as the workers evacuated the area.
“The investigation concluded that that MRC procedures to positively identify work locations and to verify isolation and ‘zero energy’ were not effective for the current Maintenance Contractor organizational capability, resulting in the workers opening a flange on the wrong side of the isolation valve, resulting in the loss of containment,” the report said.
The report also indicated that that the company’s work processes and procedures led to the root cause. According to the report, the MRC requires Permits to Work to be re-validated if the work has not started within 90 minutes of the issuance. This is supposed to ensure that safe work conditions still exist.
In this case, the work on the isolation blind started about 1 hour, 55 minutes after the permit approval, and the re-validation process didn’t take place, the report said. The small font of text also was part of the problem, because it made “permits to work difficult to read,” according to the report.
Human factors — specifically the lack of contractor training — was the third underlying cause, the report said. The lack of a contract foreman impeded clear communications regarding job details and safety hazards and created a “higher likelihood for human errors,” the report said.
Inadequate contractor supervision was the fourth underlying cause listed in the report. It summarized that supervisors did not have adequate knowledge of procedures, requirements and standards.
“Contractor supervisors often manage multiple crews in multiple locations and are not always on jobsites during potentially hazardous maintenance steps,” the report said. “Even with ratios as low as 1:4 (supervisor to craftspeople), they cannot be in two locations at the same time as most crew teams are two-person teams.”
In the report, JEM Advisors recommends the company increase its operations oversight for maintenance work and that it revises the PBF MRC Permit to Work form to include improvements, including a larger font size. The report stated that the company already had implemented some of the recommendations prior to the investigation, including increasing company presence during contractor maintenance work.
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