Chemical Safety Board issues report on 2015 flash fire that burned worker

CSB worker.
Delaware City refinery
CSB photo

The U.S. Chemical Safety Board (CSB) released its findings and recommendations after a fire that injured one worker at the Delaware City Refining Company in 2015.

CSB Chairperson Vanessa Allen Sutherland said, “More than a third of the incidents investigated by the CSB occurred during maintenance activities, ultimately resulting in 86 fatalities and 410 injuries.”

According to the report, on Nov. 29 of that year, alkylation unit operators at the Delaware City Refining Company, were preparing equipment for maintenance. Before performing the work, operators had to first drain and isolate a section of piping scheduled to be replaced by closing valves to block the flow of hydrocarbons into the piping.


Operators learned that a valve on one side of the pipe isolation was leaking and would not seal properly, which led staff to expand the isolation to a downstream block valve. That expansion did not trigger additional hazard review. The next available valve included additional equipment not involved in the original isolation plan which needed to be drained to ensure removal of flammable hydrocarbons.

That evening, shortly after opening the drain valve to the sewer system, the night shift operator recalled hearing a pop and suddenly seeing a wall of fire advancing toward him. He suffered second- and third-degree burns from the flash fire.

Supervisory Investigator Johnnie Banks said, “Prior to the incident, DCRC (the refinery) did not have general procedures for preparing equipment for maintenance or procedures for taking those pieces of equipment out of service. If DCRC had identified and addressed potential hazards before commencing this work, this incident would not have happened.”

Sutherland said, “Non-routine operations warrant careful attention. The five key lessons from this safety bulletin will help ensure that hazards are identified, and addressed to promote safer operations during similar activities.”

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents.

The board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA.

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