Massive Martinez Refinery Fire in February Caused by Human Error, Investigation Finds

Human error, worker inexperience and lack of supervision were at the root of early February’s massive fire at the PBF Energy refinery in Martinez, according to an independent investigation commissioned by Contra Costa County health officials that will be presented to the refinery’s oversight committee on Tuesday.

After starting on Feb. 1, the blaze burned for days, prompting a shelter-in-place advisory for surrounding neighborhoods. The subsequent two-month shutdown of the refinery, which produces more than 156,000 barrels of crude oil per day and accounts for nearly 10% of California’s total production, led to a surge in gas prices throughout the state.

According to the 21-page report by consulting firm JEM Advisors, the fire ignited when two contract union workers mistakenly loosened the bolts on a flange full of hot hydrocarbons during a routine but hazardous procedure called a turnaround, in which a piece of equipment or a processing unit is taken offline to be cleaned, inspected and repaired.

The workers fled the unit as the fluid started leaking and pooling on the ground, igniting within a minute and rapidly intensifying as other pipe systems failed, according to the report.

The main culprit, the investigation determined, was the “inadequate” supervision and training of the contract workers tasked with completing the critical operation. The report’s authors blame that deficit, in part, on “regulatory issues impacting contractor skill sets, selection and training,” noting that “there are few options to address the gaps brought about by the regulatory policies.”

In particular, the investigation singled out SB 54, a 2013 California law that requires refineries to hire many of their contractors from local union halls and ensure they are enrolled in or graduates of approved apprenticeship programs. As a result, the report said, the Martinez refinery is often unable to rehire the most experienced workers.

“Past resources that included ‘professional shutdown execution’ personnel from other locations are no longer available for PBF to use on turnarounds,” the report said. “There is no confirmation that contract workers understand the most significant process hazards and simultaneous operation hazards.”

Contra Costa County health officials declined to comment on the report ahead of Tuesday’s hearing.

JEM Advisors, which did not respond to requests for comment, is a private national firm of oil industry experts, many of whom previously worked for Chevron and other major oil companies.

The report additionally faulted California’s co-employment rules, in which two entities have some degree of control over the same workers — in this case, PBF Energy and TIMEC, the Texas-based company that employed the two contractors. Those regulations, the report said, preclude the refinery from directly approving contractor safety plans and providing critical safety training to those workers.

“As a result of these two regulations, there is now a higher likelihood for human errors entering into maintenance work performed by contractor resources,” the report said, also noting that one team of contract workers created the maintenance operation plan, while a different team executed it, without the necessary supervision.

TIMEC did not return a request for comment by publication.

Shortly after the Martinez refinery resumed operations in April, Valero announced it planned to close down its Benicia refinery, just across the Carquinez Strait, within a year, citing burdensome state regulations.

The report on the Martinez fire also emphasized that, despite these restrictions, PBF Energy must do more to ensure its operations are conducted safely.

The report noted that “operational presence from start of job until work is in a safe state is required but not always enforced, and was not in place.”

“As owners of the facility, operations cannot allow the poor performance of others to impact the safety and performance of the refinery,” it said, recommending that the refinery increase oversight of such operations and ensure that workers understand hazard risks before starting projects.

The February fire, which started around 1:30 p.m. on a Saturday, was the third major incident at the Martinez refinery since Shell sold it to PBF Energy in 2020 — including the release of nearly 50,000 pounds of powdered industrial chemicals into the air in 2022. The incident prompted a growing number of nearby residents to demand greater oversight of the facility, with some calling for it to be shut down altogether.

“It just seems like this kind of stuff is happening more and more, which is really scary,” Samantha Viano, who has lived in Martinez for 30 years, told KQED after the February fire. “How are they going to stop this from happening? Because I think the whole community is really scared now.”

KQED’s Katie DeBenedetti contributed to this report.