Coker Management of Change

CSB Safety Bulletins offer advisory information on good practices for managing chemical process hazards. Actual CSB case histories provide supporting information. Safety Bulletins differ from CSB Investigation Reports in that they do not comprehensively review all the causes of an incident.

U.S. Chemical Safety and Hazard Investigation Board
Office of Investigations and Safety Programs
2175 K Street NW, Suite 400
Washington, DC 20037
202-261-7600
http://www.chemsafety.gov

www.coking.com

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The U.S. Chemical Safety and Hazard Investigation Board (CSB) issues Safety Bulletins to focus attention on the need for systematically managing the safety effects of process changes in the chemical industry. This bulletin discusses an incident that occurred at a delayed coker in 1998. The case offers valuable insights into the importance of having a systematic method for the management of change (MOC). An MOC methodology should be applied to operational deviations and variances, as well as to preplanned changes—such as those involving technology, processes, and equipment.

Background	. . . . . . . . . . . . . . . . . . . . . . . .	. . . . . . . . . . . . .
On November 25, 1998, a fire at the Equilon Enterprises oil refinery delayed coking unit in Anacortes, Washington, caused six fatalities. A loss of electric power and steam supply approximately 37 hours prior to the fire had resulted in abnormal process conditions.

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The complete U.S. Chemical Safety and Hazard investigation Board Safety Bulletin can be found at www.chemsafety.gov/safety_publications/docs/moc082801.pdf or www.coking.com/safety/moc/MOC_Equilon.pdf The bulletin includes a second case study for a reaction vessel explosion and fire at a detergent alkylate plant.

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