(BCN) – The lack of qualified contract workers, insufficient training and supervision, and contractors who exceed the timing of the work permit were among the factors that lead to the February 1 fire at Martinez Refinery Company, according to the draft advisor.
It is said that part of the problem in the timetable to allow it was with a small line on work permits that made it difficult to read, Report He said.
Counselor JEM Advisors will present the report to the Martinez Health (CCH) supervision committee (CCH) at Contra Costa Health (CCH) at its meeting on Tuesday.
The February 1 fire sent a sufficient black flame and smoke in the air to the boycott to ask the nearby residents in place for more than four hours. Six workers were injured, although he was seriously.
Fire, caused by hydrocarbon leakage during maintenance “transformation”, burned for three days. The transformation is to close a patrol scheme for a refinery, or part of it, for maintenance, promotions and repairs.
Martinez refinery, owned by PBF Energy, said that 170 barrels – 7,140 gallons – were launched from hydrocarbon materials during the fire, most of which said the fire.
The Costa Health Costa Hilth said that the chemicals and secondary combustion of the fire included those that caused cancer, heart and lung, although most smoke was detonated in the northeast, away from the city center and most of the residential areas.
The report says at 1:35 pm on February 1, two workers began opening a lip to install a blind insulation to prepare for the planned maintenance on one of the operation units, which were closed.
The edge is a series of hills flying in pipeline systems, which allows easily access to maintenance, providing a way to connect or separate pipes without welding.
During this process, the workers are wrongly opened the wrong edge, causing fuel leakage.
The workers immediately evacuated the area, and the hydrocarbon caught within a minute of the initial version.
The report said that the whipped screws indicate that the workers started working on the right edge, but then moved to work on one incorrect.
The investigation found four specific reasons:
The first was the laws of the state of California that require “the workforce to be obtained only from the local union hall. As a result, the previous resources that included” implementing professional closure “from other sites available for PBF to be used in the transformation.”
“It has become difficult to find experienced handicrafts with experienced and employees who use local union halls,” the report said.
The second contributing reason is work permits. The type of work that is done requires the start of work within 90 minutes of the permit issued, according to MRC instructions, to ensure that the working conditions remain safe.
Work on this “blind installation” began about 115 minutes of approval of the permit, without re -verification approval. It also says that work permits are difficult to read due to the small text line.
The third contributing reason was included as “human factors (training)”, and insufficient training in the contractor. “Joint Employment Policies” expanded beyond the need to include Forms between the workforce in the contract and the company’s resources, which hinders clear contacts regarding job details and safety risks. “
The report said: “The current requirements include the participation of safety training information with contractors, with the expectation that the contractors will train employees in the same way that was previously conducted under the company’s direct resources.” “As a result of the interpretation of this joint employment, there is a greater possibility to enter human errors in maintenance work performed by contractor resources.”
The fourth contributing reason was insufficient supervision of the contractor, as supervisors had no sufficient knowledge of PBF standards, procedures, requirements and other factors.
The report said: “Contractors often run multiple sets in multiple locations and are not always on work sites during possible dangerous maintenance steps,” the report said. “Even with ratios of up to 1: 4 (the supervisor of the craftsmen), they cannot be in two sites at the same time because most of the crew teams are two people.”
The report recommends many “permanent corrective procedures”, including increasing the presence of the operator during the contractor’s maintenance and reviewing employment agreements to ensure workers understand the risks.
It also recommends providing “appropriate consequences” for poor performance and excellence at work and the same level of supervision of workers as other workers.
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