Safety Culture at Chevron’s Richmond, CA Refinery

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) 

Our Perspective

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.

Warning Shot for Chevron

White vapor and black smoke.  From CSB report.

On August 6, 2012 a leaking pipe at the Chevron refinery in Richmond, CA led to a fire that shut down a crude oil distillation unit and caused over 15,000 people to report to local hospitals seeking treatment for respiratory and other health issues.  This was not a Texas City.  About 20 of the 15,000 people were admitted to local hospitals and there were some minor injuries to employees in the area of the fire but no fatalities.  However, it should be a wake-up call for Chevron. 

The proximate cause of the leak was a pipe ("4-sidecut") that had corroded because of the fluids that flowed through it.  But the Chevron and Chemical Safety Board (CSB) investigations showed there was a ten-year trail of missed possibilities to identify and correct the problem, including the following: In 2002, an employee inspector had expressed concern about sulfidation corrosion in the 4-sidecut and recommended upgrading it but his recommendation was never implemented.  In the same year, an incident at another Chevron refinery led the company to recommend 100% inspection of pipes for corrosion but this was not implemented at Richmond.  In 2009 and 2010 Chevron promulgated new warnings about sulfur corrosion and reiterated the recommendation for 100% inspection but Richmond did not implement any remedial actions on the 4-sidecut.*  In 2011, after a fire in another pipe, Richmond employees complained to Cal/OSHA about the company ignoring corrosion dangers but Chevron rationalized their way out of the issue.**

Chevron's incident investigation, including a root cause analysis, resulted in multiple corrective actions that will ring familiar to our readers.  Summarized, they are: look harder for corrosion; upgrade the hardware reliability program and supporting procedures; increase oversight and training; implement new rules for evaluating leaks; and emphasize the importance of process safety in decision making.  In even fewer words, tweak the system and retrain.

There is no mention of safety culture (SC) but the odor of a weak or compromised SC wafts from the report.  In a strong SC, the 2002 inspector would have identified the potential problem, documented it in the corrective action program and monitored progress until the issue was resolved.  The corrective action program would have evaluated, prioritized and resourced the problem's resolution consistent with its safety significance.  Outside experience and directives (from other Chevron entities or elsewhere) would have been regularly integrated into local operating practices, including inspection, maintenance and process procedures.

We are not alone in recognizing the importance of SC.  The local county supervisor, who also chairs the Bay Area Air Quality Management District, said “We need to do a thorough review of the safety culture at the refinery.”***  The CSB's managing director said the company had a “tolerance for allowing piping to run toward failure” and “I think it points to a certain cultural issue.”****  The CSB's interim report says “After reviewing evidence and decisions . . . the CSB has determined that issues relating to safety culture are relevant to this incident. The CSB will examine the Chevron Richmond Refinery’s approach to safety, its safety culture and any organizational deficiencies, to determine how to best prevent future incidents.” (p. 61)

We'll see if Chevron gets the hint.


*  CUSA Richmond Investigation Team, “Richmond Refinery 4 Crude Unit Incident August 6, 2012” (April 12, 2013).  Attachment to letter from S. Wildman (Chevron) to R.L. Sawyer (Contra Costa County Health Services), “Seventh Update to the 30-Day Report for the CWS Level 3 Event of August 6, 2012” (April 12, 2013).  

U.S. Chemical Safety and Hazard Investigation Board, “Interim Investigation Report Chevron Richmond Refinery Fire” (April 15, 2013).  In addition to Chevron, the CSB also criticizes regulatory and other government agencies, particularly Cal/OSHA, for shortcomings in their oversight of refinery activities.

**  J. Van Derbeken, “Chevron ignored risk in '11, workers say” sfgate.com (Oct. 13, 2012).

***  J. Van Derbeken, “Chevron fire report shows troubled history” sfgate.com (April 13, 2013).

****  J. Van Derbeken, “Chevron fire sign of weak oversight” sfgate.com (April 15, 2013).