The U.S. Chemical Safety and Hazard Investigation Board (CSB) issues this Safety Bulletin to focus attention on the need for systematically managing the safety effects of process changes in the chemical industry. This bulletin discusses two incidents that occurred in the United States in 1998. Each case history 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.
Case No. 1
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.
Case No. 2
Background: On October 13, 1998, a reaction vessel explosion and fire at the CONDEA Vista Company detergent alkylate plant in Baltimore, Maryland, injured four
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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.