Overview

• The fire began on Feb. 1 during turnaround maintenance and burned for three days, prompting a four-hour shelter-in-place order and injuring six workers.
• A mistaken opening of the wrong flange caused a hydrocarbon leak that ignited flames and led to the release of about 7,140 gallons of fuel, most of which was consumed by the blaze.
• Investigators identified contributing factors including California’s local union hiring rules, small-font work permits, delays exceeding permit timing, inadequate contractor training and insufficient supervision.
• Contra Costa Health reported that smoke from the fire carried carcinogens and respiratory irritants but largely drifted away from populated areas.
• Consultant JEM Advisors will present its draft findings and permanent corrective-action recommendations to the Contra Costa Health oversight committee this afternoon.