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CSB ISSUES URGENT RECOMMENDATIONS TO CITGO; FINDS 

INADEQUATE HYDROGEN FLUORIDE WATER MITIGATION SYSTEM 

DURING CORPUS CHRISTl REFINERY FIRE LAST JULY 

Houston, TelUIS, Da:ember 9, 2009-The 

U.S. Chemical Safety Board 

(CSB) today issued ur:gc:nt safety 

nlCOIIIIIleDdatons camng on CITOO to 

immediately improve its emezgency water 

mitigation system in the event of anothtll' release 

of potentially d&adly hyd!ogo.n flumide (HF) 

vapor, u ocam:ed following an explosion and 

fire July 19,2009, atCITOO's Coxpus Christi 

refinery. The Board also call~!d on CITOO to 

pe1fonn thir:d-party audits to eruJlln'l the safety of 

its hydrogen fluoride llllits at its COlpiiS Christi, 

TC!XU, and Lemont, Illinois, refineries. 

The CSB issues urgcmt rec:ommsda1ions before completion of final investigation up:u ts in 

CII!KIS wh~!re CSB Board Members datmnine an imminst hazard may be present and has the 

po1ell1ial to cause serious lwm unl&SS rec:tified in a short lime&ame. 

On the day of the accidmrt last July, hydrocarbons and hyd!ogen ftuoride Wl!re suddenly 

n!leased. ftom the refinery's HF alkylation uniL The hydrocarbon!~ ignited, leading to a fire lhat 

b'II!Ud. for several day!. The tire critically injured one ~!mployee and anoth« Wll8 treated for 

possible hyd!og1111 fluoride C!XpOIIIIRI. 

CSB investigators detamined that a blockage of liquid caused by the sudden failure of a 

control valve led to violmrt shaking within tho process recycle piping. Tho shaking broke tlmiaded. 

pipe conni!Cti.ons resulting in tho reloaso ofhydrocarbons.. Tho cloud ofhydrocalbons IeaChod an 

adjaclll.t unit and ignited. The llll.&uing tire caused. multiple additional tires and the reloaso of 

approximately 42,000 pounds ofhydmgen fluoride from equipment and piping within 1M unit. 

Tho refinery used a water spray system to absorb tho released HF, but the CSB cillld 

&cillll.tific literatun.~ to conclude that at least 4,000 pounds ofHF lilcely escaped fimn 1M unit into 

1M atmosph~~~:e and left the mcility. Investigators dllterminM that during the first day of response 

efforts CITQO n&arl.y C!Xhausllld the Stultd water supply for tho water mitigstion S)'!tem. 

Apprt-ximately eleven..and-a-halfhO'Ill'S after the initial nllease, befoxe the watrr supply was 
11/1312015 CSB Issues Urgent Recommendations to CIT GO; Finds I~ Hydrogen Fluoride Wfilli!r Mitigation System duri~ Corpus Christi Refinery Fire L. .. 

completely exhausted, the refmery began pumping salt water from the ship channel into the 

refinery fire water supply. Multiple failures occurred during the salt water transfer including 

ruptures of the barge-to-shore transfer hoses and water pump engine failures. 

CSB Chairman John Bresland said, "It is imperative that refineries have the proper 

emergency response resources available to control a release of hazardous materials and protect 

against impact on the surrounding community." 

The CSB's urgent recommendations call on CITGO to develop and initiate plans within 

thirty days to ensure an adequate water supply to the refinery's HF mitigation system. The 

company should also report planned or completed actions to the Refinery Terminal Fire Company 

and the Local Emergency Planning Committee every thirty days until all planned activities are fully 

implemented. 

Investigations Supervisor Robert Hall, P.E., said, "Our investigation closely examined 

emergency response actions related to this accident. Investigators found that the CITGO water 

mitigation system serves as the last line of defense to protect the community from an HF 

release. The CSB's urgent recommendation aims to improve the reliability ofCITGO's Corpus 

Christi, Texas, HF water mitigation system." 

A second urgent recommendation called on CITGO to commission independent, third-party 

audits of the safety of its two HF alkylation units at refineries in Corpus Christi and Lemont, 

Illinois. The audits should compare safety practices at the alkylation units to those recommended 

by the American Petroleum Institute (API). Investigators said that CITGO had never conducted 

such an audit of the units, despite an existing industry recommendation for audits every three years. 

The CSB also released video of the initial pipe failure, release, ignition, and fire as captured 

by two refinery surveillance cameras. Chairman Bresland noted, "The camera footage shows the 

release and spread of the flammable vapor cloud and the moment when the flammable vapor was 

ignited. It shows just how severe the release and fire were during this incident." 

Chairman Bresland said, however, that the company had raised objections to the CSB's 

release of the video, saying that doing so would "raise substantial issues of national security" and 

would "only sensationalize this unfortunate accident." The CSB subsequently received affirmation 

from the Department of Homeland Security that the video did not fall under certain classifications 

requiring protection from disclosure. 

Chairman Bresland said, "We found this claim disturbing and believe that it is contrary to 

the intent of a recent law passed by Congress, following similar secrecy claims by Bayer 

CropScience in Institute, West Virginia. This law, the American Communities' Right to Public 

Information Act, states that national security classifications may not be used to conceal corporate 

errors, prevent embarrassment, or improperly delay the release of information to the public. An 

important part of this CSB investigation is to ensure all relevant information and visual materials 

regarding this accident are made available to the residents of Corpus Christi." 

The CSB is an independent federal agency charged with investigating industrial chemical 

accidents. The agency's board members are appointed by the president and confirmed by the 

Senate. CSB investigations look into all aspects of chemical accidents, including physical causes 

such as equipment failure as well as inadequacies in regulations, industry standards, and safety 

management systems. 

http:llwww.csb.gav/csb-issues-urgent-recommendations-to-citgo-finds-i ~hydrogen-II uoride-wfilli!r-miligation-system-d.Jring-corpus-ciTisti-refinery-fi... 213 
1111312015 CSB Issues Urgllllt Recommenci&lions ID CITGO; Finds lnader.JIIIB HyWogen Fluoride Wa Mitigation SystBm vi~ Carpus Christi Refinery Fire L •.• 

The Board does not issue citations or fines but does make safety recommendations to plants, 

industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Please visit 

our website, www.csb.gov. 

For more information, please contact Hillary Cohen (202) 446-8094 cell or Dr. Daniel 

Horowitz, (202) 441-6074 cell. 

Back 

@SB 

2175 K. st....t,. NW, Suite 400 I W..hlngtan, DC 20037·1808 

Phane: (202) 281·7800 I Fax: (202) 281-7850 I Emili: n~meOcAp 

02015 CSB.OOV. ALL RIOH'I'S RESERVED 

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