Report: Martinez refinery fire caused by inadequate training and monitoring of contractors, California workplace rules
A new report on the fire and chemical release at the Martinez Refinery Company in February blames inadequate training and supervision of contractors, as well as regulatory hurdles that created a lack of qualified workers.
Contra Costa Health hired an independent firm to perform a root cause analysis to determine why the fire happened and how it can be prevented from happening again. The Feb. 1 fire lasted for three days, injured six workers, and emitted a host of harmful chemicals, prompting a shelter-in-place alert and public health advisory for the surrounding communities.
Consultant JEM Advisors was set to present the report to the CCH's Martinez Refining Company Oversight Committee at its meeting on Tuesday. The report determined that the fire at MRC began when workers mistakenly opened a flange on the wrong side of an isolation valve during maintenance work, leading to the release of hydrocarbon material, which quickly caught fire.
Contractor issues resulting from California workplace rules
The report concluded that the root cause of the fire was inadequate oversight of the operations and work of the contractors, who had limited organizational capability to perform the work. Their limited capability required increased monitoring and operator oversight, the report said.
The report also listed four contributing causes, one of which was regulatory restrictions due to , passed in 2013, and , passed in 2019.
SB 54 requires companies to use source contractor manpower from local union halls, meaning personnel experienced in refinery unit maintenance from other locations cannot be used, and experienced workers are more difficult to find, the report said.
Meanwhile, co-employment rules for contractors prevent MRC from approving contractor safety plans and providing safety training directly to contractors. Instead, the rules require sharing such safety training with contractor company leaders, "with the expectation that contractor employees are fully trained in these prior to working on the refinery site," according to the report.
"As a result of these two regulations, there is now a higher likelihood for human errors entering into maintenance work performed by contractor resources," the report stated.
Other contributing causes were faulty work procedures, inadequate contractor training because of co-employment rules, and inadequate or missing contractor supervision. Among the issues affecting contractors' ability to perform was the small font on work permits, making them difficult to read, and inadequate procedures to mark or tag locations where work is to be done.
Previous incidents at the Martinez Refinery Company
New Jersey-based BPF Energy acquired MRC from Royal Dutch Shell in 2020. Since then, there have been three major incidents at the refinery as well as other spills and chemical releases.
On Thanksgiving Day in 2022, the refinery mistakenly released more than 20 tons of chemicals into the air, covering cars and homes in metallic dust. In July 2023, the refinery spewed petroleum coke dust, also known as petcoke, prompting a hazardous materials investigation.
In February, CCH said the chemicals and combustion byproducts from February's fire and release included those that can cause cancer, and heart and lung disease.
issued at the time, county health director Dr. Ori Tzvieli said it was fortunate the wind blew most of the toxic smoke north of the refinery and away from populated areas.
"This could have been much worse," Tzvieli said. "We got lucky this time. But our community shouldn't have to rely on luck."
that concentrations of chemicals in the air from the fire were mostly below the threshold considered dangerous, but there was a brief period when the particulate matter near the refinery was at a high level.
The agency said it was working with toxicologists to determine whether there were any long-term health impacts from the release, including potential impacts to soil and water.
The report from JEM Advisors said MRC has already implemented some changes recommended in the report, such as increasing company personnel presence during contractor maintenance work and reinforcing adherence to existing procedures.
Other recommendations include increasing operations oversight, closely reviewing and endorsing safety assessment permits to ensure contractors are aware of risks, and providing consequences for poor performance as well as for excellence.
