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This checklist is designed to help you evaluate and strengthen your Process Hazard Analysis (PHA) program specifically in light of the CSB investigation report on the Marathon Martinez Fired Heater Incident. It is intended to help you proactively address key lessons learned from this specific incident and implement relevant CSB recommendations to prevent similar incidents in your operations. Are you truly addressing the identified gaps, or just hoping for the best?
Important Disclaimer: Scope and Limitations
This checklist is not a comprehensive or universally applicable PHA checklist. It is specifically focused on the key safety issues and recommendations arising from the CSB investigation into the Marathon Martinez Fired Heater Incident. While addressing these points is crucial, it does not replace the need for a thorough and comprehensive PHA tailored to your specific processes and hazards. This checklist should be used as a supplement to your existing PHA program, to help ensure you are incorporating the critical lessons from this particular incident. A complete PHA must consider a much broader range of potential hazards and scenarios relevant to your specific operations. Consult with process safety experts to ensure your PHA program is adequately comprehensive for your needs.
| Afterburning Safeguards (CSB Rec R1 & R6b): Does our PHA process explicitly analyze scenarios that could lead to afterburning in fired heaters (e.g., burner air supply blockage, incorrect fuel/air mixture, flow diversion)? (Based on CSB Findings: Afterburning was a key cause of the Marathon Martinez incident.) | |
| Combustibles Monitoring (CSB Rec R1 & R8c): Have we evaluated the necessity of implementing continuous combustibles monitoring (e.g., Tunable Diode Laser analyzers at the bridgewall) for fired heaters as a safeguard identified within our PHAs? (CSB Recommendation: Implement combustibles monitoring to detect afterburning.) | |
| Flame Detection (CSB Rec R1): Have we evaluated the necessity of flame detectors on all critical burners (not just a sampling) for fired heaters, as a layer of protection identified in our PHA? (CSB Recommendation: Implement flame detection to detect burner flameouts.) | |
| Tube Metal Temperature Monitoring (CSB Rec R1): Do our PHA recommendations include optimizing thermocouple placement to ensure comprehensive tube metal temperature monitoring, especially in convection sections prone to overheating? (CSB Finding: Overheating in convection section led to tube rupture.) | |
| NTE Limits for Tube Metal Temperature (CSB Rec R2 & R5): Does our PHA process rigorously define Not-to-Exceed (NTE) Limits specifically for tube metal temperature for fired heaters, going beyond generic process temperature alarms? (CSB Recommendation: Implement NTE limits for tube metal temperature.) | |
| Alarm Integration & Response Procedures (CSB Rec R2 & R5, R8a): Are PHA-defined NTE limits for tube metal temperature directly translated into high-priority alarms in our control systems, with pre-defined operator response procedures (including emergency shutdown and evacuation) clearly documented and trained on? (CSB Finding: Lack of proper alarms and response procedures contributed to incident severity.) | |
| PHA Analysis of Flow Diversion (CSB Rec R6a): Do our PHA studies for fired heater systems explicitly analyze potential flow diversion and bypass scenarios, especially those that could circumvent low-flow Safety Instrumented Systems (SIS)? (CSB Finding: Flow diversion defeated the SIS.) | |
| SIS Placement & Proof of Flow (CSB Rec R6a & R8b): Do our PHA recommendations address the optimal placement of flow meters for fired heater SIS to prevent bypass vulnerabilities? Do they consider "proof of flow" interlocks and valve position indication for critical valves to ensure flow integrity? (CSB Recommendation: Prevent flow diversions from defeating SIS.) | |
| Walk the Line Verification (Pre-Startup) (CSB Rec R3): Does our PHA process incorporate and recommend "Walk the Line" procedures, requiring field verification of critical valve alignments before ALL unit startup activities (and after maintenance/shutdowns)? (CSB Recommendation: Improve "Walk the Line" practices.) | |
| Human Factors in PHA (CSB Rec R3, R4, R7): Do our PHA methodologies systematically consider human factors and potential human error scenarios, especially regarding valve operations and complex startup procedures, as highlighted by the CSB report? (CSB Finding: Human factors and inadequate procedures contributed to the incident.) | |
| Corporate Oversight & PHA Gap Assessments (CSB Rec R4 & R7): Does our corporate process safety oversight program include regular gap assessments of facility PHA programs against corporate standards and industry best practices (like these CSB recommendations)? (CSB Recommendation: Improve corporate oversight and gap assessments.) | |
| PHA Action Item Tracking: Do we have a robust system for tracking PHA recommendations and ensuring their timely and effective implementation to close identified risk gaps? (General Best Practice: Effective PHA programs require robust follow-up.) |