STUDY CASE

2015 Explosion at ExxonMobil Refinery

May 3, 2017, Torrance, CA, -- Today, the U.S. Chemical Safety Board (CSB) released its final
report into the February 18, 2015, explosion at the ExxonMobil refinery in Torrance,
California. The blast caused serious property damage to the refinery and scattered catalyst
dust up to a mile away from the facility into the nearby community. The incident caused the
refinery to be run at limited capacity for over a year, raising gas prices in California and
costing drivers in the state an estimated $2.4 billion.

The explosion occurred in the refinery’s fluid catalytic cracking (FCC) unit, where a variety of
products, mainly gasoline, are produced. A reaction between hydrocarbons and catalyst
takes place in what is known as the “hydrocarbon side” of the FCC unit. The remainder of
the FCC unit is comprised of a portion of the reaction process and a series of pollution
control equipment that uses air and is known as the “air side” of the unit.

The Torrance Refinery is a 750 acre facility, located just outside of Los Angeles, California. At
the time of the explosion, the refinery was owned by ExxonMobil.An important part of the
refining process takes place in the facility's fluid catalytic cracker, or FCC Unit.In the FCC
Unit, heavy hydrocarbons from crude oil are broken or cracked into smaller hydrocarbons,
which can then be processed into gasoline and other fuel products. The heavy hydrocarbons
are first fed into a reactor, where they mix with a catalyst. The heavy liquid hydrocarbons
are converted into lighter hydrocarbon vapors, as they travel up the reactor. At the top of
the reactor, the lighter hydrocarbon vapors are separated from the catalyst. The
hydrocarbon vapors then flow to the main distillation column. The catalyst falls down the
side of the reactor, where it moves through a slide valve, to a piece of equipment called the
regenerator. During the reaction, a layer of carbon, called "coke" forms on the catalyst, that
must be removed.

Inside the regenerator, air is added and the coke on the catalyst is burned off. The catalyst is
then fed back to the reactor through a slide valve and the cycle is repeated. When the coke
is burned off the catalyst, this creates products of combustion called "flue gas". The flue gas
flows out the regenerator and enters a system comprised of multiple pieces of equipment,
which remove any remaining catalyst particles present.

The regenerator and flue gas system comprise the air side of the FCC Unit. The last piece of
equipment in the flue gas system is called the "electrostatic precipitator" or ESP. The ESP
removes small catalyst particles, using static electricity. While the ESP is energized, it creates
sparks, which are sources of ignition. It is critical that the flammable hydrocarbons in the
reactor do not flow into the air side of the FCC Unit, as this could create an explosive
atmosphere.

To avoid this hazard, the two slide valves connecting the reactor and regenerator are used
to maintain a catalyst barrier between the pieces of equipment. The sequence of events
that eventually led to the explosion at the refinery began on Monday, February 16th, 2015,
when a piece of equipment in the air side of the FCC Unit, called the "expander" vibrated
forcefully enough that the refinery's control system automatically transitioned the FCC Unit
to a standby mode known as "safe park".

During safe park mode, the flow of hydrocarbons into the reactor is turned off.The flow of
air into the regenerator is also stopped. The two slide valves connecting the reactor and
regenerator are closed, to ensure a catalyst barrier is maintained. Steam is then forced into
the reactor to prevent hydrocarbons in the main distillation column from flowing back
inside. The ESP remains energized during safe park. One slide valve, however, had eroded
over six years of operation. And even though it closed, it could not maintain a catalyst
barrier in the reactor. Within seven minutes of the unit going into safe park, all of the
catalyst in the reactor fell through the slide valve, into the regenerator. A direct pathway
was created for hydrocarbons to flow between the reactor and the regenerator. But the
pressure of the steam flowing into the reactor as part of safe park mode was high enough to
prevent hydrocarbons in the main column from flowing back inside. With the Unit in safe
park mode, operators attempted to restart the expander several times, but were unable to
do so. Refinery personnel met to identify a strategy to repair the expander and bring the
FCC Unit back online. Operations personnel predicted the expander could not restart,
because catalyst had likely accumulated inside.

On Tuesday, February 17th, a meeting took place involving a group of refinery personnel.
The group discussed a similar expander outage that occurred in 2012, for which the refinery
had developed what is called "a variance". A variance is a management approved deviation
from procedure. The group decided to use the 2012 variance,which allowed a departure
from the typical requirements for isolating the expander. Part of that process involved
installing a blind in one of the expander's outlet flanges. On the morning of Wednesday,
February 18th, ExxonMobil maintenance attempted to install that blind, but were unable to
do so, because steam was escaping through the open flange. Steam from the reactor had
traveled through the leaking slide valve, into the air side of the FCC Unit. Using the variance
as a guide, the flow of steam into the reactor was decreased in an attempt to reduce the
amount escaping from the expander. But the variance did not evaluate whether this flow
rate was sufficient to prevent hydrocarbons from flowing into the reactor, from the main
distillation column. And unknown to the operators, light hydrocarbons from a separate Unit
had flowed through a leaking heat exchanger into the main column, increasing pressure
inside. With the steam reduced and less pressure in the reactor, nothing could prevent the
hydrocarbons from flowing back from the main distillation column. The hydrocarbons
flowed into the reactor, where they escaped through the leaking slide valve, into the air side
of the FCC Unit.

At 8:07 a.m., a maintenance supervisor, working in the FCC Unit, received an alarm on his
personal hydrogen sulfide monitor, warning him that hydrocarbons were leaking nearby. By
8:40 a.m., multiple workers around the expander received the same alarm and the FCC was
evacuated.In an attempt to mitigate the problem, a supervisor ordered the flow of steam to
the reactor to be increased, but it was too late. A flammable hydrocarbon mixture was
flowing through the air side of the FCC Unit and moving toward the ESP, with it’s multiple
ignition sources. There, the flammable hydrocarbon mixture violently exploded.

CSB Chairperson Vanessa Allen Sutherland said, “This explosion and near miss should not
have happened, and likely would not have happened, had a more robust process safety
management system been in place. The CSB’s report concludes that the unit was operating
without proper procedures.”

In its final report, the CSB describes multiple gaps in the refinery’s process safety
management system, allowing for the operation of the FCC unit without pre-established
safe operating limits and criteria for a shut down. The refinery relied on safeguards that
could not be verified, and re-used a previous procedure deviation without a sufficient
hazard analysis of the current process conditions.

Finally, the slide valve - a safety-critical safeguard within the system - was degraded
significantly. The CSB notes that it is vital to ensure that safety critical equipment can
successfully carry out its intended function. As a result, when the valve was needed during
an emergency, it did not work as intended, and hydrocarbons were able to reach an ignition
source.

The CSB also found that in multiple instances leading up to the incident, the refinery directly
violated ExxonMobil’s corporate safety standards. For instance, the CSB found that during
work leading up to the incident, workers violated corporate lock out tag out requirements.

In July 2016, the Torrance refinery was sold by ExxonMobil to PBF Holdings Company, LLC,
which now operates as the Torrance Refining Company. Since the February 2015 explosion,
the refinery has experienced multiple incidents.

Chairperson Sutherland said, “There are valuable lessons to be learned and applied at this
refinery, and to all refineries in the U.S. Keeping our refineries operating safely is critical to
the well-being of the employees and surrounding communities, as well as to the economy.”

The CSB investigation also discovered that a large piece of debris from the explosion
narrowly missed hitting a tank containing tens of thousands of pounds of modified
hydrofluoric acid, or MHF. Had the tank ruptured, it would have caused a release of MHF,
which is highly toxic. Unfortunately, ExxonMobil, the owner-operator of the refinery at the
time of the accident, did not respond to the CSB’s requests for information detailing
safeguards to prevent or mitigate a release of MHF, and therefore the agency was unable to
fully explore this topic in its final report.

Chairperson Sutherland said, “Adoption of and adherence to a robust safety management

The CSB is an independent, non-regulatory federal agency charged with investigating serious
chemical incidents. The agency's board members are appointed by the president and
confirmed by the Senate. CSB investigations look into all aspects of chemical accidents,
including physical causes such as equipment failure as well as inadequacies in regulations,
industry standards, and safety management systems.