Why We Still See Refinery Fires - More Than 30 Years After OSHA 1910.119

OSHA's Process Safety Management (PSM) standard, 29 CFR 1910.119, was issued in 1992 to prevent catastrophic releases of highly hazardous chemicals. Yet refinery and chemical plant fires continue to make headlines. How can that be?

Below is a chart compiled by AOC:

Figure 1. Significant US Refinery Incidents vs Fatalities and Injuries

We researched all published data on the internet related to fires and/or explosions. My expectations before doing this research were:

1. The trend of the number of injuries would be flat.
2. The trend of the number of fatalities would be flat.
3. The trend of the number of incidents would be flat.

Given the current media coverage of the subject, my perception is that the industry has not learned any lessons regarding PSM. The injury trendline shows a slight decrease. I can't say what caused this decrease, but I don't believe it necessarily illustrates learning.

Therefore assuming we haven't learned, here's why these incidents persist despite PSM:

1. Compliance ≠ Risk Elimination

Many facilities have focused on compliance-based PSM, checking boxes to satisfy OSHA rather than performance-based safety management.

• Procedures exist, but are not always followed or kept current.
• PHA (Process Hazard Analysis) studies are sometimes treated as static documents, rather than living risk assessments.
• Mechanical integrity programs often emphasize inspection frequency rather than true condition or risk-based prioritization.

Result: Systems appear compliant, but underlying risk remains unmanaged.

2. Aging Infrastructure

Refineries are decades old, many built in the 1950s-1970s, and continue to operate far beyond their original design life.

• Corrosion, metal fatigue, and obsolete equipment designs introduce hazards.
• Legacy materials and layouts are hard to retrofit with modern safety systems.
• Even with inspection, degradation can be missed or underestimated.

Result: Equipment failures, leaks, and fires continue despite formal MI programs.

3. Human and Organizational Factors

Human error remains a leading cause of incidents, but often it's systemic, not individual.

• Inadequate training, handover, or operating discipline.
• Workforce turnover and contractor reliance reduce institutional knowledge.
• Complacency sets in when a plant operates for years without a major event.

Result: Safe work practices erode, and small deviations compound into major accidents.

4. Weak Safety Culture

A strong process safety culture is crucial but difficult to sustain

• Pressure to maintain production often outweighs safety priorities.
• Employees may feel unsafe reporting near-misses or mechanical issues.
• Leadership sometimes focuses more on personal safety metrics than process safety indicators.

Result: Early warning signs go unaddressed until a loss of containment event occurs.

5. Reactive, Not Predictive, Risk Management

Even after incidents, corrective actions often address symptoms rather than root causes.

• Many facilities lack integrated risk-based inspection (RBI) and management of change (MOC) programs.
• PHA revalidations are performed every 5 years as required, but may not be updated when process changes occur in between.
• Learning across the industry (sharing lessons from incidents) remains inconsistent.

Result: The same failure modes repeat at different sites.

6. Regulatory and Enforcement Limitations

• OSHA's resources for process safety inspections are limited; few inspectors specialize in PSM.
• Enforcement actions are often after-the-fact, and penalties may not deter large corporations.
• PHMSA and EPA RMP overlap in some areas, creating jurisdictional gray zones.

Result: Inconsistent regulatory oversight and uneven implementation across the industry.

7. Complex, Dynamic Operations

Refineries are among the most complex industrial systems on Earth. Even with robust safeguards:

• Changing feedstocks, variable operations, and non-routine work create dynamic risk.
• Control systems and human-machine interfaces can fail under upset conditions.
• Emergency isolation and mitigation may not act fast enough to prevent escalation.

Result: Work process breakdown

In Short

Fires and explosions persist because PSM is a framework - not a guarantee. Effective safety requires leadership commitment, culture, and continuous risk reduction, not just compliance.

REFERENCES

1. "Process Safety Management (PSM) of Highly Hazardous Chemicals", Occupational Safety and Health Administration (OSHA), https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.119
2. "Incident Reports Volume 1", 1/14/2025, US Chemical Safety and Hazard Investigation Board,https://www.csb.gov/assets/1/6/csb_incident_reports_volume_one_2025-01-14_rev_1.pdf
3. "Incident Reports Volume 2", 3/12/2025, US Chemical Safety and Hazard Investigation Board,https://www.csb.gov/assets/1/6/incident_reports_volume_2_2025-03-12.pdf
4. "Incident Reports Volume 3", 7/22/2025, US Chemical Safety and Hazard Investigation Board,https://www.csb.gov/assets/1/6/incident_reports_volume_3_2025-07-22.pdf
5. "'I thought we got nuked or something.' Massive explosion, fire at Chevron refinery rocks El Segundo", 10/2/2025, Los Angeles Times, Clara Harter, Grace Toohey, Ruben Vives, Tony Briscoe and Connor Sheets, https://www.latimes.com/california/story/2025-10-02/la-me-fire-refinery
6. "Marathon Refinery Fire", South Coast Air Quality Management District, https://www.aqmd.gov/home/news-events/community-investigations/marathon-refinery-fire?utm_source=chatgpt.com
7. "Magellan Explosion: 2 workers released from hospital, 5 in stable condition", 12/5/2020, Mariah Gallegos, Michael Gibson, James Ayala, KIIITV, https://www.kiiitv.com/article/news/local/fire-at-magellan-plant-in-corpus-christi/503-9db7daed-2dad-4418-b60c-920c21f9db12?utm_source=chatgpt.com

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