Overview

• A consultant-led investigation cited lack of qualified contract workers, inadequate supervision and work permits started 25 minutes past their allowed window as key factors in the Feb. 1 fire during refinery maintenance.
• Inspectors found two contractors mistakenly opened the wrong flange, triggering a hydrocarbon leak that ignited within minutes and sustained a three-day blaze.
• California laws requiring contractor hires to come solely from local union halls reduced access to experienced turnaround craftspeople, the report says.
• The fire consumed an estimated 170 barrels (7,140 gallons) of hydrocarbons, injured six workers and prompted a four-hour shelter-in-place order over toxic emissions.
• Recommendations include boosting operator oversight on maintenance jobs, clarifying safety responsibilities in contracts and enforcing uniform supervision for all crews.