On Friday April 19, 2013 during a public meeting at the Richmond Civic Center, the U.S. Chemical Safety Board (CSB) released its video animation of the August 6, 2012 incident at the Chevron Richmond Refinery. While the CSB has frequently garnered awards for its safety videos, this latest installment is not without controversy. On the same day, Chevron published the following statement on its Chevron Richmond Refinery Incident Response website:
“After we previewed the animation, we strongly urged the CSB not to release it. We informed the CSB that the animation contains numerous, material factual inaccuracies, the impact of which is to oversimplify, and in some instances trivialize, decisions that were made on that day. The animation also focuses on the actions of specific individuals, which we believe has the effect, surely not intended, of demeaning the challenges faced by the responding personnel. The reasons behind the incident are far more complex than depicted in the animation and we are disappointed with the CSB's decision to go forward with this unfair depiction.”
When viewing the animation in light of Chevron’s own internal investigation report, the animation all but ignores the precautions Chevron personnel undertook prior to the incident and at times appears to contradict the facts presented by Chevron’s Richmond Investigation Team. While any useful video animation of the incident would necessitate some measure of time compression, the omission of several precautions taken by Chevron personnel presents an inaccurate image to the public at large.
The video animation makes no mention of the gas testing conducted by Chevron Fire Department personnel prior to any maintenance/repair work – testing that determined the atmosphere around the leak was not flammable. Nor does the animation note the continuous monitoring of the area to ensure conditions did not change. In addition, at the 2:23 mark the CSB narrator states:
“The group discussed a recommendation from an operator to shut down the unit. But they decided to first try to pinpoint the leak by removing insulation from the pipe while the crude unit was still running.”
This seems to imply that management officials ignored the hourly worker’s safety suggestion opting to continue production while investigating the source of the leak. Chevron’s incident report reads differently noting that “[o]perations personnel directed a routine shutdown” of the unit to commence, an order that was given less than 20 minutes after the leak was first spotted. While the assembled team began preparing to remove the weather jacketing and insulation surrounding the pipe segment in question, feed rate to the unit was reduced according to the routine shutdown procedures, a fact omitted by the CSB narrator.
At the 2:42 mark of the animation, a fire fighter is depicted attempting to remove the weather jacketing and insulation from the pipe by using a fiberglass pike pole. While the use of the pike pole is undisputed, the CSB and Chevron appear to disagree as to where the pike was being used, a potentially important fact.
The animation depicts that the pike pole was being used to remove insulation from the piping where the pipe begins its downward slope and the CSB narrator states “the CSB later found that the tip of the pike likely caused a small puncture in the already thin pipe.”
Chevron’s report states otherwise noting that the attempted use of the pike was along the horizontal section of the pipe, a section which was downstream of the failure point. The report goes on to note that while “certain physical evidence suggests that there may have been contact between the tip of a pike pole and the failed piping component,” none of the witnesses interviewed “stated there was contact with the insulation-covered sloping section of pipe” (the section that ultimately failed).
Towards the end of the animation, the video depicts several workers being engulfed by the spreading vapor cloud and later states “fortunately all the workers would eventually flee to safety and there were no fatalities.” According to Chevron’s incident report, not only were there no fatalities, and no injuries to contractors, there were only six minor injuries reported ranging from abdominal discomfort to “a minor burn to a small area of the left ear,” and “[a]ll employees returned to work on the same shift.” This omission is quite glaring in light of the animated depiction of the incident with workers having to crawl blindly on hands and knees to escape certain death and one other having to run through a “wall of fire.”
The CSB serves an important role for industry but if the integrity of the Board’s work continues to be questioned by accusations of factual inaccuracies and omissions, both industry and the public will suffer.