On 22 November, 2016 a fire broke out during maintenance activities at the Exxon Mobil refinery in Baton Rouge, Louisiana, leaving four people with severe burns. Operators inadvertently removed bolts that attached pressurised equipment to a plug valve. Unfortunately, they were working on an old model of this type of equipment – only 3% of the facility’s valves still used this technology. Although operators followed the refinery’s accepted practices, the lack of a hazard analysis exposed them to greater risk. In particular, employees did not report the problem of removing gear boxes from plug valves, which would have identified potential hazards.
Lack of procedures, a lack of appropriate training when different types of parts or models were installed, and a lack of hazard awareness. We can also see that there is a lack of a hierarchy of controls, which aim to significantly reduce risks, and an under-evaluation of the contribution of human factors.