On June 24, 2024, the U.S. Chemical Safety and Hazard Investigation Board (CSB) released its final report on the fatal naphtha release and fire at the BP-Husky Toledo Refinery in Oregon, Ohio, which occurred on September 20, 2022. The incident led to the deaths of two BP employees, who were brothers, and caused approximately $597 million in property damage. During an emergency at the refinery, liquid naphtha was released from a pressurized vessel, forming a vapor cloud that ignited into a flash fire. This incident is the largest fatal event at a BP-operated refinery in the U.S. since the 2005 Texas City disaster.

The CSB’s investigation revealed that a series of cascading failures contributed to the incident. On the day of the accident, a process upset in the naphtha hydrotreater unit led to a loss of containment, shutting down other refinery units and resulting in liquid naphtha filling a vessel designed to hold only vapor. This abnormal situation caused an alarm flood, overwhelming operators with over 3,700 alarms in 12 hours, leading to delays and errors in managing the crisis. BP employees mistakenly believed the liquid was an amine-water solution and released it, creating a vapor cloud that ignited and caused the fatal fire.

The CSB identified critical safety issues and made seven recommendations to Ohio Refining Company LLC, the American Petroleum Institute (API), and the International Society of Automation (ISA). Recommendations included revising process hazard analyses, abnormal situation management policies, and alarm system guidelines. The CSB emphasized the importance of implementing tools like stop work authority and improving safety procedures to prevent similar incidents. Notably, the CSB made no recommendations to BP, as they no longer operate the refinery. The Board’s role is to make safety recommendations rather than issue citations or fines.

For more details on this news, visit the  CSB’s official release.