The U.S. Chemical Safety and Hazard Investigation Board (CSB) released its final report* on the August 2012 fire at the Chevron refinery in Richmond, CA caused by a leaking pipe. In the discussion around the CSB’s interim incident report (see our April 16, 2013 post) the agency’s chairman said Chevron’s safety culture (SC) appeared to be a factor in the incident. This post focuses on the final report findings related to the refinery’s SC.
During their investigation, the CSB learned that some personnel were uncomfortable working around the leaking pipe because of potential exposure to the flammable fluid. “Some individuals even recommended that the Crude Unit be shut down, but they left the final decision to the management personnel present. No one formally invoked their Stop Work Authority. In addition, Chevron safety culture surveys indicate that between 2008 and 2010, personnel had become less willing to use their Stop Work Authority. . . . there are a number of reasons why such a program may fail related to the ‘human factors’ issue of decision-making; these reasons include belief that the Stop Work decision should be made by someone else higher in the organizational hierarchy, reluctance to speak up and delay work progress, and fear of reprisal for stopping the job.” (pp. 12-13)
The report also mentioned decision making that favored continued production over safety. (p. 13) In the report’s details, the CSB described the refinery organization’s decisions to keep operating under questionable safety conditions as “normalization of deviance,” a term popularized by Diane Vaughn and familiar to Safetymatters readers. (p. 105)
The report included a detailed comparison of the refinery’s 2008 and 2010 SC surveys. In addition to the decrease in employees’ willingness to use their Stop Work Authority, surveyed operators and mechanics reported an increased belief that using such authority could get them into trouble (p. 108) and that equipment was not properly cared for. (p. 109)
We like the CSB. They’re straight shooters and don’t mince words. While we are not big fans of SC surveys, the CSB’s analysis of Chevron’s SC surveys appears to show a deteriorating SC between 2008 and 2010.
Chevron says they agree with some CSB findings however Chevron believes “the CSB has presented an inaccurate depiction of the Richmond Refinery’s current process safety culture.” Chevron says “In a third-party survey commissioned by Contra Costa County, when asked whether they feel free to use Stop Work Authority during any work activity, 93 percent of Chevron refinery workers responded favorably. The overall results for the process safety survey exceeded the survey taker’s benchmark for North American refineries.”** Who owns the truth here? The CSB? Chevron? Both?
In 2013, the city of Richmond adopted an Industrial Safety Ordinance (RISO) that requires Chevron to conduct SC assessments, preserve records and develop corrective actions. The CSB recommendations including beefing up the RISO to evaluate the quality of Chevron’s action items and their actual impact on SC. (p. 116)
Chevron continues to receive blowback from the incident. The refinery is the largest employer and taxpayer in Richmond. It’s not a company town but Chevron has historically had a lot of political sway in the city. That’s changed, at least for now. In the recent city council election, none of the candidates backed by Chevron was elected.***
As an aside, the CSB report referenced a 2010 study**** that found a sample of oil and gas workers directly intervened in only about 2 out of 5 of the unsafe acts they observed on the job. How diligent are you and your colleagues about calling out safety problems?
* CSB, “Final Investigation Report Chevron Richmond Refinery Pipe Rupture and Fire,” Report No. 2012-03-I-CA (Jan. 2015).
** M. Aldax, “Survey finds Richmond Refinery safety culture strong,” Richmond Standard (Jan. 29, 2015). Retrieved Jan. 29, 2015. The Richmond Standard is a website published by Chevron Richmond.
*** C. Jones, “Chevron’s $3 million backfires in Richmond election,” SFGate (Nov. 5, 2014). Retrieved Jan. 29, 2015.
**** R.D. Ragain, P. Ragain, Mike Allen and Michael Allen, “Study: Employees intervene in only 2 of 5 observed unsafe acts,” Drilling Contractor (Jan./Feb. 2011). Retrieved Jan. 29, 2015.