corpus/source-0032.txt

U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD 
 
REGULATORY REPORT 
 
CHEVRON RICHMOND REFINERY 
PIPE RUPTURE AND FIRE 
 
 
CHEVRON RICHMOND REFINERY #4 CRUDE UNIT 
RICHMOND, CALIFORNIA 
AUGUST 6, 2012 
 
 
 
REPORT NO. 2012-03-I-CA 
OCTOBER 2014 

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Table of Contents 
Table of Contents .......................................................................................................................................... 3 
Acronyms and Abbreviations ....................................................................................................................... 5 
1.0 
Executive Summary ......................................................................................................................... 7 
1.1 Incident Summary ............................................................................................................................ 7 
1.2 Interim Report .................................................................................................................................. 7 
1.3 Background ...................................................................................................................................... 9 
1.4 Key Findings .................................................................................................................................. 10 
1.5 Regulatory Conclusions ................................................................................................................. 12 
1.6 Recommendations .......................................................................................................................... 13 
2.0 
Introduction .................................................................................................................................... 14 
3.0 
The Safety Case Regulatory Regime ............................................................................................. 21 
3.1 Introduction .................................................................................................................................... 21 
3.2 Initial Safety Case Implementation ................................................................................................ 22 
3.2.1 
United Kingdom .................................................................................................................... 22 
3.2.1.1 
Onshore .......................................................................................................................... 22 
3.2.1.2 
Offshore ......................................................................................................................... 25 
3.2.2 
Global Analysis of Safety Case Implementation .................................................................. 27 
3.2.2.1 
Australia ........................................................................................................................ 27 
3.2.2.1.1 
Offshore ................................................................................................................. 27 
3.2.2.1.2 
Onshore .................................................................................................................. 28 
3.2.2.2 
Norway .......................................................................................................................... 29 
3.2.2.3 
The United States........................................................................................................... 30 
3.2.2.3.1 
OSHA PSM Standard ............................................................................................ 31 
3.2.2.3.2 
U.S. Environmental Protection Agency Risk Management Program .................... 33 
3.2.2.3.3 
Safety Case in the United States ............................................................................ 35 
4.0 
Key Features of an Effective Safety Case Regulatory Regime ...................................................... 37 
4.1 Duty Holder Safety Responsibility, including a Written Case for Safety ...................................... 38 
4.2 Continuous Risk Reduction to ALARP ......................................................................................... 40 
4.3 Adaptability and Continuous Improvement ................................................................................... 44 
4.4 Active Workforce Participation ..................................................................................................... 53 
4.5 Process Safety Indicators that Drive Performance ......................................................................... 58 
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4.6 Regulatory Assessment, Verification, and Intervention ................................................................ 62 
4.7 Independent, Competent, Well-Funded Regulator ........................................................................ 66 
5.0 
Oversight of Petroleum Refineries in California ........................................................................... 70 
5.1 Cal/OSHA ...................................................................................................................................... 70 
5.1.1 
Background Information ....................................................................................................... 70 
5.1.2 
Analysis ................................................................................................................................. 76 
5.1.2.1 
ALARP .......................................................................................................................... 76 
5.1.2.2 
Adaptability and Continuous Improvement ................................................................... 78 
5.1.2.3 
Process Safety Indicators ............................................................................................... 80 
5.1.2.4 
Inspections ..................................................................................................................... 80 
5.1.2.5 
Workforce Participation ................................................................................................ 81 
5.1.2.6 
Funding and Regulator Competency ............................................................................. 83 
5.2 U.S. Environmental Protection Agency ......................................................................................... 85 
5.2.1 
Risk Management Plan (RMP) Program ............................................................................... 85 
5.2.2 
Implementation of the RMP Program ................................................................................... 86 
5.3 Unified Program ............................................................................................................................ 87 
5.3.1.1 
Contra Costa County Hazardous Materials Programs ................................................... 87 
5.3.1.1.1 
CalARP .................................................................................................................. 88 
5.3.1.1.2 
Industrial Safety Ordinance ................................................................................... 89 
5.3.1.1.3 
City of Richmond Industrial Safety Ordinance ..................................................... 90 
5.3.1.2 
Analysis ......................................................................................................................... 90 
6.0 
Conclusion ..................................................................................................................................... 92 
7.0 
Process Safety Management Reform at the Federal Level: A Path Forward ................................ 93 
8.0 
Recommendations .......................................................................................................................... 96 
References ................................................................................................................................................. 100 
Appendix A: Significant Petroleum Refinery Incidents in 2012 ............................................................. 103 
Appendix B: Regulatory Comparison Table ............................................................................................ 108 
Appendix C: Frequently Asked Questions (FAQs) Regarding the Safety Case Regulatory Approach ... 111 
Appendix D: CSB Staff May 2014 Response to the Board’s Motion to Postpone issued on January 15, 
2014 .......................................................................................................................................................... 121 
 
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Acronyms and Abbreviations 
ALARA 
 
As Low As Reasonably Achievable 
ALARP 
 
As Low As Reasonably Practicable 
ALJ 
 
 
Administrative Law Judge 
ANPRM 
 
Advance Notice of Proposed Rulemaking 
APA 
 
Administrative Procedure Act 
API 
 
 
American Petroleum Institute 
ASARP 
 
As Safe As Reasonably Practicable 
BSEE 
 
Bureau of Safety and Environmental Enforcement 
CA 
 
 
Competent Authority 
CAA 
 
Clean Air Act 
CAAA 
 
Clean Air Act Amendments 
CalARP 
 
California Accidental Release Prevention 
Cal/EPA 
 
California Environmental Protection Agency 
Cal/OSHA 
 
California Division of Occupational Safety and Health 
CAPA 
 
California Administrative Procedure Act 
CCHMP 
 
Contra Costa Health Services’ Hazardous Materials Program 
CCPS 
 
Center for Chemical Process Safety 
CCR 
 
California Code of Regulations 
CERCLA 
Comprehensive Environmental Response, Compensation, and Liability 
Act 
CFR 
 
 
Code of Federal Regulations 
Chevron ETC 
Chevron Energy Technology Company 
CIMAH 
 
Control of Industrial Major Accident Hazards 
COMAH 
 
Control of Major Accidents Hazards Regulations 
CSB 
 
 
U.S. Chemical Safety and Hazard Investigation Board 
CSHO 
 
Compliance Safety and Health Officer 
CUPA 
 
Certified Unified Program Agency 
DIR 
 
 
California Department of Industrial Relations 
DNV 
 
Det Norske Veritas 
EA 
 
 
Environment Agency 
EPA 
 
 
U.S. Environmental Protection Agency 
FSA 
 
 
Formal Safety Assessment 
FY 
 
 
Fiscal Year 
GAO 
 
U.S. Government Accountability Office 
HSC 
 
California Health and Safety Code 
HSE 
 
 
Health and Safety Executive 
HTHA 
 
High Temperature Hydrogen Attack 
ISO 
 
 
Industrial Safety Ordinance 
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ISOM 
 
Isomerization 
LOHP 
 
Labor Occupational Health Program 
MOC 
 
Management of Change 
MOOC 
 
Management of Organizational Change 
NASA 
 
National Aeronautics and Space Administration 
NDU 
 
Naphtha Desulfurization Unit 
NEP 
 
 
National Emphasis Program 
NOHSC 
 
Australia National Occupational Health and Safety Commission 
NOPSEMA 
Australian National Offshore Petroleum Safety and Environmental 
Management Authority 
NPRM 
Notice of Proposed Rulemaking 
NRC 
U.S. Nuclear Regulatory Commission 
OERI 
Operational Excellence and Reliability Intelligence 
OIG 
Office of Inspector General 
OMB 
Office of Management and Budget 
OSHA 
 
U.S. Occupational Safety and Health Administration 
OSHAct 
 
Occupational Safety and Health Act 
PHA 
 
Process Hazard Analysis 
PHMSA 
Department of Transportation, Pipeline and Hazardous Materials Safety 
Administration 
PQV 
Program Quality Verification 
PSA 
Petroleum Safety Authority 
PSI 
Process Safety Information 
PSLA 
Petroleum Submerged Lands Act 
PSLG 
Process Safety Leadership Group 
PSM 
Process Safety Management 
QRA 
Quantitative Risk Assessment 
RAGAGEP 
Recognized and Generally Accepted Good Engineering Practices 
RFI 
Request for Information 
RISC 
Risk-Informed Safety Case 
RISO 
City of Richmond Industrial Safety Ordinance 
RLOP 
Richmond Lube Oil Plant 
RMP 
Risk Management Plan 
RP 
Recommended Practice 
SEPA 
Scottish Environmental Protection Agency 
SFAIRP 
So Far As Is Reasonably Practicable 
SOP 
Standard Operating Procedure 
UK 
 
 
United Kingdom 
USCG 
 
U.S. Coast Guard 
USW 
 
United Steelworkers Union 
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1.0 Executive Summary 
1.1 
Incident Summary 
On August 6, 2012, the Chevron U.S.A. Inc. Refinery in Richmond, California, (“the Chevron Richmond 
Refinery”) experienced a catastrophic pipe failure in the #4 Crude Unit (“the crude unit”). The pipe, a 52-
inch long carbon steel piping component of the #4 sidecut line, ruptured and released flammable, 
hydrocarbon process fluid, which partially vaporized into a large vapor cloud that engulfed 19 Chevron 
employees and ignited. All of the employees escaped, narrowly avoiding serious injury. The ignition of 
the flammable portion of the vapor cloud and subsequent continued burning of the hydrocarbon process 
fluid resulted in a large plume of particulates and vapor traveling across the Richmond, California area. 
Approximately 15,000 people from the surrounding area sought medical treatment due to the release. 
1.2 
Interim Report 
The CSB released an Interim Report on the Chevron incident in April 2013 (“the Interim Report”), which 
highlighted technical findings and safety system deficiencies. Testing conducted on the ruptured pipe 
determined that it had experienced extreme thinning near the rupture location due to sulfidation 
corrosion.1 Sulfidation corrosion is a damage mechanism that causes thinning in iron-containing 
materials, such as steel, due to the reaction between sulfur compounds and iron at temperatures ranging 
from 450 °F to 800 °F.2 This damage mechanism3 causes pipe walls to gradually thin over time, and is 
common in crude oil distillation4 where naturally occurring sulfur and sulfur compounds found in crude 
oil feed, such as hydrogen sulfide,5 are available to react with steel piping and equipment. The Interim 
Report stated that virtually all crude oil feeds contain sulfur compounds and, as a result, sulfidation 
corrosion is a damage mechanism present at every refinery that processes crude oil. Sulfidation corrosion 
can cause thinning to the point of pipe failure when not properly monitored and controlled. 
 
The Interim Report noted a number of causal safety system deficiencies that highlight regulatory gaps 
relating to major accident prevention at California petroleum refineries. For example, in conducting its 
process hazard analysis6 (PHA) of the crude unit, which was required under California’s Process Safety 
1 With respect to the sulfidation corrosion damage mechanism that caused the Chevron incident, carbon steel piping 
corrodes at a rate that is significantly faster than other materials of construction, such as high chromium steels, 
including stainless steel. 
2 For an electronic copy of the CSB Chevron Interim Report see 
http://www.csb.gov/assets/1/19/Chevron_Interim_Report_Final_2013-04-17.pdf (accessed October 24. 2013). 
3 Piping damage mechanisms are any type of deterioration encountered in the refining and chemical process industry 
that can result in flaws/defects that can affect the integrity of piping (e.g. corrosion, cracking, erosion, dents, and 
other mechanical, physical or chemical impacts). See API 570. "Piping Inspection Code: In-Service Inspection, 
Rating, Repair, and Alteration of Piping Systems." 3rd ed., Section 3.1.1.5, November 2009. 
4 Distillation separates mixtures into broad categories of its components by heating the mixture in a distillation 
column where different products boil off and are recovered at different temperatures. See 
http://www.eia.gov/todayinenergy/detail.cfm?id=6970 (accessed April 4, 2013). 
5 Hydrogen sulfide is the most aggressive sulfur compound that causes sulfidation corrosion. 
6 A process hazard analysis (PHA) is a hazard evaluation to identify, evaluate, and control the hazards of a process. 
Facilities that process a threshold quantity of hazardous materials, such as the Chevron Richmond refinery, are 
required to conduct a process hazard analysis per the California Code of Regulations Title 8 Section 5189, Process 
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Management (PSM) standard,7 Chevron did not conduct a rigorous review of corrosion and damage 
mechanisms present in the crude unit, and did not identify sulfidation corrosion as a hazard. As such, 
Chevron did not effectively address inherent safety8 or implement effective controls to prevent sulfidation 
corrosion, including those controls proposed by Chevron’s technical group. Although both the California 
and federal PSM standards require that hazards be identified, evaluated, and controlled, there is no further 
discussion of how far to reduce risks, and there is no requirement to address the effectiveness of controls 
or to use the hierarchy of controls.9 Therefore, this type of analysis was not required to be conducted, and 
Chevron was never cited post-incident for failing to evaluate the effectiveness of safeguards. 
 
In another example, despite internal recommendations to replace the entire #4 sidecut piping with an 
inherently safer, more corrosion-resistant material of construction through the Management of Change 
(MOC) process, incident investigations, technical reports, and employee recommendations, Chevron 
repeatedly failed to implement those proposed recommendations. Chevron’s 2006 MOC analysis limited 
application of those recommendations to only a small section of the pipe. As a result, the portion of the 
pipe that failed on the August 6th incident remained in service until the incident. As there is no 
requirement to implement effective recommendations or control hazards under the MOC element, it is 
essentially an activity-based requirement. Chevron was not cited for narrowing the scope of the MOC, 
despite its disregard of internal recommendations. The CSB concluded in its Interim Report that Chevron 
did not regularly or rigorously apply inherently safer technology, which provides an opportunity for 
preventing major accidents, in its PHAs, MOCs, incident investigation recommendations, or during 
turnarounds. 
 
The CSB made safety recommendations in the Interim Report to a number of entities, including the 
California State Legislature, the U.S. Environmental Protection Agency, and Contra Costa County. The 
Board recommended that the California State Legislature require California petroleum refineries to 
perform damage mechanism hazard reviews, to identify and report leading and lagging process safety 
indicators, to document recognized methodologies, rationale, and conclusions used to claim that 
safeguards intended to control hazards will be effective, and to document their inherently safer systems 
analysis and the hierarchy of controls in establishing safeguards for process hazards, with the goal of 
driving risk of major accidents to as low as reasonably practicable, or ALARP. These concepts, 
introduced in the Interim Report and highlighted in the recommendations, are the basic building blocks 
for the implementation of the safety case regime, a regulatory scheme that will be discussed in great detail 
in the following report. 
 
The CSB concluded its Interim Report by highlighting additional issues that were still under 
investigation, including emergency planning and reporting, emergency response, safety culture, and 
regulatory oversight of petroleum refineries in California. The following report fulfills the CSB’s 
Safety Management of Acutely Hazardous Materials (1992). PHAs are also required by the California Accidental 
Release Prevention Program and the federal EPA Risk Management Program. 
7 Under 8 CCR §5189 (e). https://www.dir.ca.gov/title8/5189.html (accessed September 25, 2013). 
8 According to the Center for Chemical Process Safety (CCPS), “inherently safer design solutions eliminate or 
mitigate the hazard by using materials and process conditions that are less hazardous.” Center for Chemical Process 
Safety (CCPS). Inherently Safer Chemical Processes – A Life Cycle Approach. 2nd ed., Section 5.1.1, 2009. 
9 An effectiveness ranking of techniques used to control hazards and the risk they represent can be described as a 
hierarchy of controls. The further up the hierarchy, the more effective the risk reduction achieved. 
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commitment to examine whether the implementation of the safety case regulatory regime could be a more 
effective regulatory tool to achieve major accident prevention for California petroleum refineries. The 
reader will find additional issues, arguments, and counterarguments regarding the safety case regulatory 
regime addressed in Appendix C of this report. 
1.3 
Background 
Although both the federal and California PSM standards, respectively, were intended to be goal-setting or 
performance-based,10,11 in practice they appear to function primarily as reactive and activity-based12 
regulatory schemes that require extensive rulemaking to modify. As a result, the federal and California 
PSM standards have become static in the face of advancing best practices and technology, with the 
emphasis placed on the completion of a task or activity rather than achievement of continuous risk 
reduction.13 Many regions around the world such as the United Kingdom (UK), Australia, and Norway 
have acknowledged similar deficiencies and have implemented regulatory regimes consisting of both 
prescriptive14 and goal-setting elements that require duty holders15 to demonstrate to the regulator through 
rigorous reviews and audits that they have reduced risks to as low as reasonably practicable, or ALARP. 
This is referred to as the safety case regulatory regime.16 The safety case regulatory regime is a rigorous 
prescriptive and goal-setting regulatory approach applied globally both onshore and offshore. It is 
highlighted by its adaptability and requirements for continuous improvement in risk reduction for high 
hazard industrial facilities. A written case for safety, known as the safety case report, is generated by the 
duty holder and is generally rigorously reviewed, audited, and enforced by highly technically competent 
inspectors with skill sets familiar to those employed by the industries they oversee. Despite this global 
shift, the US has persisted in the use of a more activity-based regulatory scheme that lacks the ability to 
adapt to advancing technology and recently developed industry standards, and which has failed to 
adequately engage companies and their employees in continuous improvement and risk reduction with 
similarly-skilled inspectors. 
10 Also referred to as performance-based regulations, goal-setting regulatory requirements and acceptance criteria 
are specified and industry must document that their specific solutions meet such requirements, e.g. in terms of 
acceptable risk levels. 
11 See Preamble to Process Safety Management of Highly Hazardous Chemicals; Explosives and Blasting Agents. 
Section III. Summary and Explanation of the Final Rule (March 4, 1992). 
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=PREAMBLES&p_id=1041 (accessed August 
13, 2013). 
12 Activity-based standards and regulations require the mere completion of an activity and do not focus on the 
effectiveness of major accident prevention or risk reduction. 
13 As will be discussed below, certain sections of the PSM standard have elements of a performance-based 
regulatory approach. 
14 A prescriptive regulation or standard describes the specific means or activity-based actions to be taken for hazard 
abatement and compliance. Performance or goal-based regulations, on the other hand, state the objective to be 
obtained (such as risk reduction or hazard abatement) without describing the specific means of obtaining that 
objective. 
15 Duty holders are considered to be “those who create and/or have the greatest control of the risks associated with a 
particular activity. Those who create the risks at the workplace are responsible for controlling them.” HSE. 
Planning to do business in the UK offshore oil and gas industry? What you should know about health and safety; 
October 2011; p 2. These entities may include operators, contractors, and subcontractors. 
http://www.hse.gov.uk/offshore/guidance/entrants.pdf (accessed June 5, 2013). 
16 Norway’s offshore regulatory regime is not referred to as the safety case regime, but it does contain many of the 
same elements as the safety case regime, with some differences in style, substances, and implementation. 
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1.4 
Key Findings 
Technical 
 
1. In the ten years prior to the incident, highly knowledgeable and experienced Chevron technical staff 
repeatedly recommended that inspectors perform 100 percent component inspections on high temperature 
carbon steel piping susceptible to sulfidation corrosion. These recommendations were not implemented 
by Chevron management.17 
 
2. Chevron technical staff recommended implementing inherently safer designs through the MOC 
process, incident investigations, technical reports, and past recommendations from employees. However, 
Chevron failed to implement proposed inherently safer recommendations prior to the incident. For 
example, an inspection recommendation to upgrade piping to 9-Chrome was made, but the MOC to 
implement the recommendation narrowed the scope, allowing the 52-inch component that failed to remain 
in service. 
 
3. In January 2007, a failure due to sulfidation corrosion caused a fire in the Chevron Richmond 
Refinery crude unit, initiating a shelter-in-place for the surrounding community. A carbon steel piping 
spool18 failed catastrophically during operation. Chevron informed Contra Costa Health Services’ 
Hazardous Materials Program19 in a letter that the crude unit piping metallurgy had been upgraded 
following this incident as an inherently safer solution. However, this upgrade was limited to only the 
immediate piping spool that had failed. The inherently safer, more corrosion resistant metallurgy was not 
implemented more broadly in the crude unit as a result of this incident. 
 
4. Chevron and Chevron Energy Technology Company metallurgists, materials engineers, and piping 
inspectors had expertise regarding sulfidation corrosion. However, they had limited practical influence to 
implement their recommendations. They did not participate in the most recent crude unit PHA, and they 
did not affect decisions concerning control of sulfidation corrosion during the crude unit turnaround 
process.20 
 
5. The 2009 crude unit PHA did not identify corrosion as a potential cause of a leak or rupture in piping. 
The PHA cited non-specific, judgment-based qualitative safeguards to reduce risk, such as: utilizing 
metallurgy to minimize corrosion, having effective maintenance and inspection programs, and providing 
pipe wall corrosion allowances.21 The effectiveness of these safeguards was neither evaluated nor 
17 These recommendations are discussed in detail in paragraphs 44 through 51 of the Chevron Interim Report. 
18 A piping spool is a small, removable section of piping. In some cases, a piping spool is installed or removed in 
order to provide a temporary connection or complete disconnection between two piping circuits. 
19 Contra Costa Health Services’ Hazardous Materials program is designed to respond to emergencies and monitor 
hazardous materials within Contra Costa County. See http://cchealth.org/hazmat/ (accessed April 17, 2013). 
20 The turnaround process includes both the planning stage prior to the shutdown and the activities staged during the 
shutdown. 
21 Corrosion allowance refers to extra wall thickness added as a safety factor to the design of a piece of equipment 
beyond that needed solely for mechanical considerations such as design temperature and pressure. This extra 
thickness is provided to accommodate for expected loss of wall thickness due to corrosion over the life of the 
equipment. 
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documented; instead the safeguards were merely listed in the PHA. Had the adequacy of these safeguards 
been verified, improved safeguards intended to protect against sulfidation-induced failure of carbon steel 
piping could have been recommended. 
 
Regulatory 
 
6. Following the August 6th incident, California’s Division of Occupational Safety and Health 
(Cal/OSHA) inspected the Chevron facility and issued citations. Only one citation was related to PHAs; 
and it was not associated with evaluating the effectiveness of safeguards. Rather, the emphasis was that 
Chevron’s PHA did not adequately account for hazards caused by other units associated with the crude 
unit. Had the California PSM standard required documentation of the effectiveness of safeguards, 
Chevron would have been obligated to conduct this analysis. 
 
7. There is a significant discrepancy in the compensation between the California regulators and the 
Chevron Richmond Refinery personnel they interact with. The California regulators also lack the 
technical staff with the necessary skills, knowledge, and experience to provide sufficient direct oversight 
of petroleum refineries in California. 
 
8. The CSB has examined records that demonstrate a considerable problem with significant and deadly 
incidents at petroleum refineries over the last decade. The EPA has noted 234 recordable accidents at 
petroleum refineries between 2000 and 2010. This is more than any other industry despite the fact that 
the nation’s petroleum refineries make up only roughly one percent of the some 13,000 facilities covered 
by the EPA’s Risk Management Program. In 2007, OSHA stated that according to its IMIS (Integrated 
Management Information System) database, since May 1992, 36 fatality/catastrophe (FAT/CAT) 
incidents related to HHC releases in the refining industry occurred. These incidents included 52 
employee deaths and 250 employee injuries, 98 of these injuries required hospitalization. This number 
surpassed the combined total of the next three highest industries over the same period. In 2010, an OSHA 
official testified to a Congressional Subcommittee that over 20 major incidents resulting in injuries or 
fatalities across the country occurred between 2005 and 2010, including the Tesoro Anacortes explosion 
and fire in Washington. These incidents all repeated a lesson that should have already been learned by 
the industry. Finally, in 2012 alone, the CSB tracked 125 significant process safety incidents at US 
petroleum refineries. Seventeen of these took place in California. 
 
9. Under the existing regulatory regimes for onshore petroleum refineries in the US and California, such 
as the PSM and RMP programs, there is no requirement to reduce risks to ALARP. For example, under 
both PSM and RMP an employer must “control” hazards when conducting a process hazard analysis 
(PHA) of a covered process. However, there is no requirement to address the effectiveness of the controls 
or the hierarchy of controls. Thus, a PHA that meets the regulatory requirements may inadequately 
identify or mitigate major hazard risk. In addition, there is no requirement to submit PHAs to the 
regulator, and the regulator is not responsible for assessing the quality of the PHA or the proposed 
safeguards. 
 
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10. The PSM standard does not effectively establish goals to prevent accidents or reduce risk. Only two 
of the 14 elements (PHA and mechanical integrity) of the PSM standard contain some goal-setting 
component. 
 
11. In the last decade, the CSB has made a number of process-safety related recommendations to OSHA 
and EPA in its investigation reports and studies (e.g. Motiva, BP Texas City, and Reactive Hazards). 
However, none of the regulatory recommendations have been implemented, and there have been no 
substantive changes made to the PSM and RMP regulations to improve the prevention of major accidents. 
 
12. Available data from Norway and the United Kingdom (UK) shows a reduction in hydrocarbon 
releases offshore under the safety case regulatory regime.22 
 
13. Regulatory approaches similar to the safety case regulatory regime, which require risk reduction to 
ALARP or equivalent, have been implemented in the nuclear sector by the Nuclear Regulatory 
Commission (NRC) and the aerospace sector by NASA. 
 
14. Independent studies of the safety case regulatory regime in the UK have identified improvements to 
safety performance from the safety case and a variety of stakeholders, including major oil companies, 
have shown support of the safety case.23 
 
1.5 
Regulatory Conclusions 
The existing regulatory regimes for onshore petroleum refineries in the US and California: 
 
1. Rely on a safety and environmental management system framework that is primarily activity-based 
rather than requiring goal-based risk reduction to as low as reasonably practicable (ALARP) or 
equivalent. 
 
2. Are static, unable to adapt to innovation and advances in the management of major hazard risks. 
 
3. Do not require that companies effectively manage the risks they create; nor do they require regulator 
evaluation of the effectiveness of safeguards or regulator acceptance of companies’ plans for controlling 
those risks. 
 
4. Do not ensure continuous improvement by effectively incorporating lessons learned from major 
accidents; nor do they require companies to address newly-identified safety issues as a result of such 
incidents. 
 
5. Do not effectively collect or promote industry use of major accident performance indicators to drive 
industry to reduce risks to ALARP. 
 
22 Norway’s indicator data is discussed in Section 4.5. The UK data is discussed in Appendix C. 
23 See Sections 2.0, 3.2.1.2, and 3.2.2.3. Also see FAQ 4. 
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6. Do not require the use or implementation of inherently safer systems analysis or hierarchy of controls. 
 
7. Do not effectively involve the workforce in risk reduction and prevention of major accidents. 
 
8. Do not provide the regulator with the authority to accept or reject a company’s hazard analysis, risk 
assessment, or proposed safeguards; and 
 
9. Do not employ the requisite number of staff with the technical skills, knowledge, and experience to 
provide sufficient direct safety oversight of petroleum refineries. 
 
1.6 
Recommendations 
As a result of the findings and conclusions of this report, the CSB makes recommendations, summarized 
below, to the state of California: 
 
California State Legislature, 
Governor of California 
 
Enhance and restructure California’s process safety management (PSM) regulations for petroleum 
refineries by including the goal-setting attributes identified in this report for petroleum refineries in the 
state of California. 
________________________________________ 
 
Mayor and City Council, 
City of Richmond, California 
 
Establish or cause to be established a compensation system to ensure regulator capability in process safety 
oversight and policy development in Richmond, California. 
________________________________________ 
 
Board of Supervisors 
Contra Costa County, California 
 
Establish a compensation system to ensure regulator capability in process safety oversight and policy 
development in Contra Costa County, California. 
________________________________________ 
 
Section 8.0 details the recommendations. 
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2.0 Introduction 
 
Despite the fact that the nation’s roughly 150 petroleum refineries represent only a small fraction of the 
thousands of industrial and chemical facilities that exist in the US, the CSB has seen a great number of 
serious and deadly incidents at refineries over the last decade. 
 
In March 2005, the BP Texas City Refinery suffered one of the worst industrial accidents in recent US 
history, when overfill of a distillation column resulted in an explosion and fire that led to 15 fatalities, 
another 180 injuries, and the issuance of a shelter-in-place order that required 43,000 people to remain 
indoors. Houses were damaged as far as three-quarters of a mile away from the refinery. In a 2006 
statement, former CSB Chairwoman Carolyn Merritt said that while BP did make some safety 
improvements before the March 2005 explosion, “the focus of many of these initiatives was on improving 
procedural compliance and reducing occupational injury rates, while catastrophic safety risks 
remained….”24 
 
In November 2009, an explosion at the Silver Eagle Refinery damaged over 100 homes in a nearby 
subdivision in Woods Cross, Utah. At a public meeting to discuss the incident, former CSB Chairman 
John Bresland called on refineries to improve their safety performance, stating: 
 
The frequency of accidents in US refineries is very troubling. These 
accidents cost lives, inflict serious injuries and can harm communities. 
They also earn scrutiny from government regulators; in the past few 
weeks a refinery in Texas drew the largest OSHA fine in history, more 
than US $80 million, for alleged process safety violations. I call on all 
refineries to redouble their commitment to safer operations and safer 
communities. The current rate of accidents in refineries is not 
sustainable and it is not acceptable.25 
On the five-year anniversary of the BP Texas City explosion in March 2010, Chairman Bresland 
continued to relay his concern regarding refinery safety, noting that “refinery accidents…continue to 
occur with dismaying frequency…[and] will only stop when every refinery has made the financial and 
human commitment to sound process safety management.”26 Yet just ten days later, seven workers were 
fatally injured at the Tesoro refinery in Anacortes, Washington, following the catastrophic failure of a 
heat exchanger. Again, Chairman Bresland pointed out the alarming frequency of refinery incidents, 
stating that “if the aviation industry had the same number and types of incidents as the refining industry, I 
don’t think people would be flying too much.”27 
24 Scrutiny Finds BP Safety Troubles. http://usatoday30.usatoday.com/money/industries/energy/2006-10-30-bp-
blast-findings_x.htm (accessed September 5, 2013). 
25US Refineries Commitment to Safety Called Into Question. http://www.engineerlive.com/content/22354 (accessed 
September 5, 2013). 
26 http://www.csb.gov/statement-from-csb-chairman-john-bresland-on-5th-anniversary-of-fatal-bp-texas-city-2005-
explosion/?pg=18 (accessed September 5, 2013). 
27Refinery Tragedies All Too Common. See 
http://seattletimes.com/html/localnews/2011518449_safetysunday04m.html (accessed September 5, 2013) 
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On June 10, 2010, OSHA Deputy Assistant Secretary Jordan Barab testified before the Senate Committee 
on Health, Education, Labor and Pensions’ Subcommittee on Employment and Workplace Safety 
regarding worker safety in US energy production industries. Mr. Barab noted that OSHA had counted 
over 20 major incidents resulting in injuries or fatalities across the country that had occurred within the 
last five years, including the Tesoro Anacortes explosion and fire in Washington. These incidents all 
repeated a lesson that should have already been learned by the industry.28 According to Mr. Barab, “[t]his 
cycle of workers being hurt or killed because their employers failed to implement well-known safety 
measures points out major deficiencies in chemical process safety management in the nation’s refineries 
and, quite possibly, to systemic safety and health problems in the entire petrochemical industry.”29 
According to OSHA’s compliance instruction document CPL-03-00-00430 on the OSHA Petroleum 
Process Safety Management National Emphasis Program (NEP) issued in 2007, 
Since the PSM standard was promulgated by OSHA in 1992, no other 
industry sector has had as many fatal or catastrophic incidents related to 
the release of HHC [highly hazardous chemicals] as the petroleum 
refining industry []. According to OSHA's IMIS [Integrated Management 
Information System] database, since May 1992, 36 fatality/catastrophe 
(FAT/CAT) incidents related to HHC releases in the refining industry 
have occurred. These incidents included 52 employee deaths and 250 
employee injuries, 98 of these injuries required hospitalization. The 
number of refinery FAT/CAT incidents surpasses the combined total of 
the next three highest industries over the same period (SIC 2899 
Chemical Manufacturing, Not Elsewhere Classified (NEC) – 12 
FAT/CATs; SIC 2869 Industrial Organic Chemical Manufacturing, NEC 
– 12 FAT/CATs; and SIC 2892 Explosive Manufacturing – 11 
FAT/CATs).31 
In 2012 alone, the CSB tracked 125 significant32 process safety incidents at US petroleum refineries, 
which are listed in Appendix A. Seventeen of these took place in California, including a major release of 
8,614 pounds of highly toxic hydrogen sulfide at the Chevron Richmond Refinery on August 2, 2012, just 
four days prior to the incident. 
Of the 14 major accidents that the CSB is currently investigating, five occurred in petroleum refineries. 
These include two separate explosions at the Silver Eagle refinery in Woods Cross, Utah, which resulted 
in injuries and offsite consequences, and a series of equipment failures at CITGO’s refinery in Corpus 
Christi, Texas, involving highly toxic hydrogen fluoride. In May 2014, the CSB released its final 
28 Jordan Barab’s Congressional testimony is available at 
http://www.dol.gov/ocia/congressionaltestimony/20100610_JBarab.htm (accessed January 7, 2014). 
29 Ibid. 
30 OSHA Instruction CPL 03-00-004. Petroleum Refinery Process Safety Management National Emphasis Program. 
June 7, 2007. 
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=3589#VIII (accessed 
January 7, 2014). 
31 Ibid at Section VIII. 
32 These incidents were reported to the Department of Energy and/or the National Response Center and examined by 
the CSB’s Incident Screening Department. The CSB believes that incidents that result in disruptions to the national 
energy supply, serious injuries, or receive high media attention are all significant. 
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investigation report on the heat exchanger rupture at the Tesoro refinery in Anacortes, Washington, which 
resulted in seven fatalities. The U.S. Environmental Protection Agency (EPA) has also documented 234 
recordable accidents at petroleum refineries between 2000 and 2010. Despite the fact that the nation’s 
petroleum refineries make up only roughly one percent of the some 13,000 facilities covered by the 
EPA’s Risk Management Program, they accounted for more incidents in that time period than any other 
industry, including the much larger sector of chemical manufacturing, which EPA documented as having 
218 recordable accidents.33 
 
The CSB concludes that the continuing occurrence of refinery accidents demonstrates the pressing need to 
examine the current regulatory structure in place in the US and, in light of the Chevron incident, in the 
state of California for petroleum refineries. There have been a number of positive developments in the 
wake of the Chevron incident that demonstrate California’s prime opportunity to lead the nation in 
implementing changes to improve safety and health in the refining industry. In the Fall of 2012 following 
the Chevron incident, California Governor Jerry Brown created the California Interagency Working 
Group on Refinery Safety (“the working group”), charged with improving cooperation among agencies, 
including the EPA, Cal EPA, California’s Division of Occupational Safety and Health (Cal/OSHA), and 
Contra Costa County, with the goal of improving safety at California’s petroleum refineries and 
preventing major accidents. 
 
The working group began its initiative by commissioning the Labor Occupational Health Program34 
(LOHP) to conduct “listening panels” throughout California, enabling community members to meet with 
working group members to discuss their concerns surrounding refineries. LOHP convened a series of 
meetings and conference calls with labor unions, community-based organizations, fire agencies, and 
environmental health groups between November 6, 2012, and March 18, 2013. Dr. Michael P. Wilson, 
the former Director of LOHP,35 documented his findings and recommendations regarding refinery safety 
in a summary report entitled Refinery Safety in California: Labor, Community and Fire Agency Views, 
which was released on June 4, 2013.36 In the report, Dr. Wilson quoted Swiss Re’s finding that the US 
has experienced financial losses from refinery incidents that are three times that of industry counterparts 
in countries within the “EU cluster,”37 a gap which continues to grow due in part to the US refining 
industry’s “pushing…mode of operation”, its “compliance-driven focus on safety”, and “a ‘detached’ 
workforce….”38 
33 Matthiessen, Craig. EPA Risk Management Program: An Overview of the EPA Risk Management Program and 
Inherently Safer Processes. NAS-MIC Bayer Public Meeting Power Point Presentation; May 24, 2011; p 20. 
34 LOHP is a public service program for the Center for Occupational and Environmental Health at UC Berkeley’s 
School of Public Health. LOHP seeks “to reduce occupational injury, illness and death by protecting the health and 
safety of workers worldwide.” For more information, see http://www.lohp.org/ (accessed July 8, 2013). 
35 Dr. Wilson now serves as Chief Scientist in the Office of the Director, California Department of Industrial 
Relations (DIR). DIR oversees state programs dedicated to protecting the health, safety, and economic security of 
California’s workers. 
36 Dr. Wilson released an initial draft of the summary report on March 27, 2013. He then released a revised copy of 
the summary report on June 4, 2013. See http://www.lohp.org/projects/refinery_safety.html (accessed July 8, 2013). 
37 The countries in the EU cluster are all of Europe, Singapore, South Korea, Japan, Saudi Arabia, Gulf States and 
Egypt. 
38 Wilson, Michael P. Refinery Safety in California: Labor, Community and Fire Agency Views; Summary Report 
for Office of Governor Jerry Brown, Interagency Task Force on Refinery Safety; March 27, 2013, Revised June 4, 
2013; pp 5 and 6. Citing Zirngast, Ernst. (June 6, 2006). Selective U/W in Oil-Petro Segment: Loss Burden in 
Different Regions, USA vs. Rest of the World, History of Selective U/W, Cause of Losses. Technical report-DRAFT-
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Dr. Wilson reiterated a number of the findings contained in the CSB’s Interim Report on the Chevron 
incident, including the “striking lack of attention on the part of the Richmond Chevron refinery to 
maintenance and metallurgy upgrades…,” and the Chevron Richmond Refinery’s failure to implement a 
recommended 100% component inspection program for high-risk piping. He also stated that California’s 
refineries are able to operate without demonstrating competence in health, safety, and environmental 
performance to a regulatory agency or to the public, and as such recommended that California establish a 
regulatory approach similar to that of the safety case regulatory regime, a rigorous prescriptive39 and 
goal-setting40 regulatory regime used widely by other regions throughout the world such as the United 
Kingdom (UK) and Australia to regulate high hazard industrial facilities. It is highlighted by its 
adaptability and requirements for continuous improvements in risk reduction, places the duty on industry 
to demonstrate its competence in health and safety to the regulator. The regime is overseen by highly 
competent, well-funded regulators that rigorously audit facilities for compliance with the written safety 
case report and good industry practice. 
 
On July 11, 2013, the working group released a draft report entitled Improving Public and Worker Safety 
at Oil Refineries,41 which the CSB has recognized as an important step forward in improving petroleum 
refinery safety and environmental performance both in California and nationally. The report outlined the 
process of adopting several of the CSB‘s recommendations from its Interim Report on the Chevron 
incident, including requiring refineries to implement inherently safer systems and conduct damage 
mechanism hazard reviews. Furthermore, the report announced the creation of an Interagency Refinery 
Task Force within the California Environmental Protection Agency (Cal/EPA) by September 1, 2013, 
aimed at facilitating information sharing and improving coordination of oversight and enforcement 
activities among regulatory agencies. The CSB welcomed the report’s recommendation for California to 
study the safety case regulatory approach. 
 
In addition to the work being done by the working group, the California State Legislature approved a 
2013-2014 state budget bill (AP 110) that allows the California Department of Industrial Relations to 
charge state petroleum refineries a “fee” by March 31, 2014, to help pay for at least 15 new positions in 
Cal/OSHA’s Process Safety Unit, which enforces the California Process Safety Management (PSM) 
standard throughout the state.42 
 
The Chevron incident also spurred the formation of the City of Richmond’s Refinery Action 
Collaborative (“the collaborative”), which was launched on January 30, 2013. The collaborative, whose 
EXTRACT. Risk Engineering Services, Swiss Re. 
http://coeh.berkeley.edu/people/apers_educ/docs/LOHPRefinery%20Safety.pdf (accessed December 30, 2013). 
39 A prescriptive regulation or standard describes the specific means or activity-based actions to be taken for hazard 
abatement and compliance. Performance or goal-based regulations, on the other hand, state the objective to be 
obtained (such as risk reduction or hazard abatement) without describing the specific means of obtaining that 
objective. 
40 Also referred to as performance-based regulations, goal-setting regulatory requirements and acceptance criteria 
are specified and industry must document that their specific solutions meet such requirements, e.g. in terms of 
acceptable risk levels. 
41 See http://www.calepa.ca.gov/Publications/Reports/2013/Refineries.PDF (accessed September 25, 2013). 
42 See http://www.caltax.org/homepage/062113_Legislature_Approves.html (accessed July 9, 2013). 
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members include the United Steelworkers43 (USW) Local 5, the USW International, Communities for a 
Better Environment,44 and LOHP,45 was launched after a preliminary exploratory meeting held in October 
2012. The collaborative advocates for community and worker safety, better transparency, and 
environmental health, and has already made recommendations to the working group to improve emissions 
reporting and require more thorough assessments of pipe corrosion damage at oil refineries.46 
 
On October 10, 2013, the collaborative formally responded in a memo to the July 2013 draft report issued 
by the Interagency Working Group on Refinery Safety (Improving Public and Worker Safety at Oil 
Refineries). In the memo, the collaborative stated its support for the working group’s findings and 
recommendations. The collaborative also issued its own recommendations and highlighted 12 principles 
as being important to the development of effective regulatory policy in California. These principles 
include linking regulatory non-compliance to an operator’s license to operate and integrating meaningful 
participation in decision-making by workers and communities.47 The collaborative also noted in the 
memo that it supported “shifting the ‘burden of proof’ of safety from public agencies to the industry, as is 
required in the ‘Safety Case’ approach….”48 
 
The CSB noted in its Chevron Interim Report the important role of transparency between industry and the 
public in improving health and safety for the facility and the surrounding communities. Following the 
Chevron incident the collaborative, worker representatives, regulators, and governmental bodies played a 
key role in driving transparency, accountability, and improved risk reduction during the decision-making 
process related to crude unit piping repairs. The CSB recommended to the California State Legislature in 
the Interim Report to establish a multi-agency process safety regulatory program for all California 
petroleum refineries to further improve public accountability and transparency by establishing a system to 
report to the regulator methodologies, findings, conclusions, and corrective actions related to refinery 
mechanical integrity inspection and repair work arising from California petroleum refinery PHAs, 
turnarounds, and maintenance-related shutdowns.49 This system would require reporting of information 
such as damage mechanism hazard reviews, establish procedures for greater workforce and public 
participation, and provide mechanisms for federal, state, and local agency operational coordination, 
43 The USW is the largest industrial union in North America and has approximately 1.2 million active and retired 
members in the US, Canada, and the Caribbean. For more information see http://www.usw.org/ (accessed July 17, 
2013). 
44 Communities for a Better Environment is an “environmental justice organization[s]” in California which has the 
mission of “build[ing] people’s power in California’s communities of color and low income communities to achieve 
environmental health and justice by preventing and reducing pollution and building green, health and sustainable 
communities and environments.” See http://www.cbecal.org/about/mission-vision/ (accessed August 14, 2013). 
45 Other members of the collaborative include the BlueGreen Alliance (a coalition of labor unions and 
environmental groups that advocate for a green economy and safer workplaces), the National Resources Defense 
Council, and the Asian Pacific Environmental Network. 
46 See http://richmondconfidential.org/2013/02/20/labor-and-environmental-groups-join-forces-on-refinery-issues/ 
(accessed July 9, 2013). 
47 Refinery Action Collaborative. Initial Response of the Collaborative to the Findings & Recommendations of The 
July 2013 Draft Report of the Interagency Working Group on Refinery Safety, Governor Jerry Brown. October 10, 
2013; p 10. 
48 Ibid at 7. 
49 Under the existing federal and California state PSM standards, this information is not currently made publicly 
available. 
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sharing of data, and joint accident prevention activities. California is actively working to implement this 
recommendation through the creation of the Interagency Refinery Task Force mentioned above. 
 
It is also important to note that a growing dialogue has emerged throughout the US surrounding the need 
to improve the regulation of hazardous materials and processes, to which the CSB has been an important 
contributor. The CSB first examined the safety case in its 2002 investigation report entitled Improving 
Reactive Hazard Management50 as a potentially effective alternative framework for the regulation of 
reactive hazards. The CSB noted that successful implementation of this “comprehensive” regulatory 
approach required a competent and experienced regulator. In December 2010, the CSB held a public 
hearing in Washington, DC on the Regulatory Approaches to Offshore Oil and Gas Safety, where 
internationally recognized experts in industrial safety and accident analysis provided important testimony 
on managing risks offshore.51 Much of this testimony supported the implementation of the safety case as 
a model for regulating major hazards, both onshore and off. For example, a Shell Oil Company 
representative testified that the company had been using the safety case globally since 2002, and noted 
that the most valuable aspect of that type of regulatory regime was the need to demonstrate that major 
hazards have been managed using effective barriers52 and controls. In July 2012, the CSB held an 
additional public hearing on Safety Performance Indicators.53 A number of international regulators 
testified on the regulator’s ability under the safety case to drive continuous improvement in the oil and 
gas industry. Finally, on July 25, 2013, the CSB held a public meeting to discuss the U.S. Occupational 
Safety and Health Administration’s (OSHA’s) failure to implement a number of key CSB safety 
recommendations made to OSHA in the last decade to revise and improve its Process Safety Management 
(PSM) standard and to issue a new combustible dust standard. 
 
On January 18, 2011, President Obama issued Executive Order 13563,54 which called for improvements 
in the nation’s regulatory system to promote predictability and reduce uncertainty and to use the best, 
most innovative, and least burdensome tools for achieving regulatory ends. Specifically, it directed that 
agencies review existing and proposed standards and regulations to ensure they effectively protect “public 
health, welfare, safety, and our environment while promoting economic growth, innovation, 
competitiveness, and job creation.”55 Finally, the order emphasized that to the extent feasible, regulations 
and standards should specify performance objectives rather than the behavior or manner of compliance 
that regulated entities must adopt, and be adopted through a process that involves public participation. As 
a result of this Executive Order, OSHA, the Bureau of Safety and Environmental Enforcement (BSEE), 
the EPA, the Department of Transportation’s Pipeline and Hazardous Materials Safety Administration 
50 A full copy of the report is available at http://www.csb.gov/improving-reactive-hazard-management/ (accessed 
July 10, 2013). 
51 For a copy of the transcript from the CSB Public Hearing on the Regulatory Approaches to Offshore Oil and Gas 
Safety, see http://www.csb.gov/assets/1/19/Transcript_of_Public_Meeting_12_15_2010.pdf (accessed August 14, 
2013). 
52 A barrier is a “technical, operational and/or organizational element[] which individually or collectively reduce[s] 
opportunities for specific error, hazard or accident to occur, or which limits its harm/drawbacks.” Petroleum Safety 
Authority. Safety Status & Signals, 2012-2012; 2013; p 31. 
53 For the proceedings of the CSB Public Hearing on Safety Performance Indicators see 
http://www.csb.gov/events/csb-public-hearing-safety-performance-indicators/ (accessed August 14, 2013). 
54 Improving Regulation and Regulatory Review. Exec. Order No. 13563, 76 Fed. Reg. 14 (January 21, 2011). 
http://www.archives.gov/federal-register/executive-orders/2011.html (accessed July 10, 2013). 
55 Ibid. 
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(PHMSA), and the U.S. Coast Guard (USCG) solicited views from the public and stakeholders regarding 
opportunities to address improving efficiency and effectiveness of safety and environmental regulations 
and standards in the oil and gas industry.56 These five agencies then convened an expert forum57 in 
September 2012 in Texas City, Texas, to explore the benefits of implementing goal or performance-based 
regulatory models such as the safety case in the oil and gas industry, and ways to advance the use of such 
models in the US. The forum included a discussion of the safety case regulatory regime as a 
performance-based regulatory model, and industrial safety and accident analysis expert Dr. Andrew 
Hopkins spoke in support of that model. 
 
In the wake of the April 2013 explosion and fire that occurred at a fertilizer storage and distribution 
facility in West, Texas, and resulted in fifteen fatalities and hundreds of injuries, President Obama issued 
Executive Order 1365058 on August 1, 2013. The Executive Order established the Chemical Facility 
Safety and Security Working Group, a working group of federal agencies59 tasked with, among other 
things, developing options for enhancing and modernizing policies, regulations, and standards to improve 
the safety and security of chemical facilities.60 As will be discussed in Section 4.3, the group has 
included the safety case regulatory model in a list of potential actions it may consider taking to improve 
chemical safety regulation.61 
 
The CSB has utilized a broad range of expert testimony and research to gain a comprehensive 
understanding of regulatory models for onshore and offshore oil and gas facilities in countries around the 
world, and, in light of this investigation, the state of California. This report highlights the significant 
attributes of the safety case regime that together result in a more effective regulatory approach to process 
safety and risk reduction. It also provides a detailed contrast of the safety case regulatory model to the 
existing regulatory structures in the US and California, and makes recommendations to improve 
California’s regulatory oversight of its petroleum refineries and to promote a broader national dialogue on 
the safety case regulatory approach. 
 
 
56 For more information see 
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=23267 
(accessed July 10, 2013). 
57 See https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=23267 
(accessed August 13, 2013). 
58 Improving Chemical Facility Safety and Security. Exec. Order No. 13650, 78 Fed. Reg. 48029 (August 1, 2013). 
https://www.federalregister.gov/articles/2013/08/07/2013-19220/improving-chemical-facility-safety-and-security 
(accessed January 7, 2014). 
59 The working group includes the EPA, the Department of Justice, the Department of Agriculture, the Department 
of Transportation, and the Department of Labor. 
60 See Section 6 of the Executive Order. 
61 See Working Group response to Executive Order 13650, Section 6(a) – Solicitation of Public Input on Options for 
Policy, Regulation, and Standards Modernization. 
https://www.osha.gov/chemicalexecutiveorder/Section_6ai_Options_List.html (accessed January 7, 2014). 
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3.0 The Safety Case Regulatory Regime 
3.1 
Introduction 
Throughout modern history, major industrial accidents have been catalysts for significant regulatory 
reform, as countries around the world strive to mitigate risk and improve the safety of their facilities and 
processes in order to protect human health and the environment. According to industrial safety and 
accident analysis expert Dr. Andrew Hopkins, “[d]isasters…offer an unparalleled opportunity to study the 
workings of an organisation and to identify where things are going wrong.”62 Around the world, many of 
these large-scale incidents have resulted in sweeping changes to legislation surrounding industrial safety 
and health. These changes replace prescriptive, compliance-based regulations with goal-setting 
regulations supplemented by prescriptive requirements that support adaptability, require duty holders63 to 
demonstrate to the regulator that they have driven risks to as low as reasonably practicable (ALARP) or 
equivalent, and provide the regulator with the tools to drive continuous improvement among major hazard 
facilities.64 A majority of these regulatory regimes are referred to as the safety case, which Dr. Hopkins 
defines as: 
a case which the operator of a hazardous facility makes to the regulator, 
setting out how safety is to be managed. It must include details of the 
hazard identification process, the hazards which have been identified and 
the procedures which have been set in place to control them. The system 
remains self-regulatory in principle but rather than the facility being left 
to its own devices by the regulator it must convince the regulator that its 
strategy for managing safety is satisfactory [emphasis added]. Under 
any safety case regime, facility operators are expected to adopt best 
practice risk management.65 
The safety case regulatory regime is much more than a written report; it shifts risk management 
responsibility to the company and its employees and provides for rigorous review and oversight by a 
technically competent regulator to ensure effective implementation.66 
62 Hopkins, Andrew. Managing Major Hazards: The Lessons of the Moura Mine Disaster; National Library of 
Australia, 1999; p 1. 
63 Duty holders are considered to be “those who create and/or have the greatest control of the risks associated with a 
particular activity. Those who create the risks at the workplace are responsible for controlling them.” HSE. 
Planning to do business in the UK offshore oil and gas industry? What you should know about health and safety; 
October 2011; p 2. These entities may include operators, contractors, and subcontractors. 
http://www.hse.gov.uk/offshore/guidance/entrants.pdf (accessed June 5, 2013). 
64 Major hazard facilities are workplaces that store, handle or process large quantities of hazardous material. 
Incidents at such facilities have the potential to cause serious damage to employees, people in surrounding areas, and 
the environment. See http://www.pc.gov.au/__data/assets/pdf_file/0018/82350/21-appendixd.pdf (accessed May 9, 
2013). 
65 Hopkins, Andrew. Lessons from Esso’s Gas Plant Explosion at Longford; Australian National University 
[Online]; p 7. 
http://www.sirfrt.com.au/Meetings/IMRt/Southeast/IMRt%20East%2000Nov30/Andrew%20Hopkins%20presentati
on/Lonford%20talk.PDF (accessed May 8, 2013). 
66 The CSB notes that that the burden is currently on the PSM regulator to verify compliance with existing 
regulations, which is primarily done following an incident or complaint. Rarely is this done proactively under the 
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The remaining portions of Section 3 will introduce major accidents that have occurred around the world 
and discuss the history behind the global development and implementation of the safety case regulatory 
approach on and offshore. Section 4.0 will then highlight major attributes of the safety case regulatory 
approach. The US regulatory model will also be introduced and discussed throughout these sections to 
allow for comparisons between the different approaches. Finally, Section 5.0 will discuss the regulation 
of petroleum refineries in California specifically, including Chevron. The report concludes with 
important recommendations focused on improving the regulatory oversight of California’s 14 refineries, 
and encouraging OSHA, industry, labor, and others to work together to improve the regulation of 
petroleum refineries throughout the US. 
3.2 
Initial Safety Case Implementation 
3.2.1 
United Kingdom 
3.2.1.1 
Onshore 
Two major onshore incidents in the 1970s helped spark legislative reform focused on major accident 
prevention and risk reduction for onshore major hazard facilities. A large dioxin67 release in Seveso, 
Italy, in 1976, which injured hundreds of individuals, led the European Commission68 to adopt legislation 
in 1982 known as the Seveso Directive, aimed at the prevention and control of major industrial 
accidents.69 Following the 1984 toxic release in Bhopal, India, which resulted in several thousand known 
fatalities, and the Sandoz chemical plant fire near Basel, Switzerland, which injured 14 individuals and 
released nearly 30 tons of pesticides into the Rhine River, turning it red, the Seveso Directive was 
amended and replaced in 1996 with the Seveso II Directive.70 The regulation requires owners or 
operators of facilities that contain threshold quantities of listed substances to submit safety reports to a 
competent authority (CA) within a Member State of the European Commission for its review and 
acceptance.71 These reports must demonstrate to the CA that major-accident prevention policies, safety 
management systems, and internal emergency plans have been created and implemented.72 The 
current system. The Refinery NEP is a primary example of proactive inspections to verify compliance. It was 
discontinued in 2011. 
67 The term Dioxin refers to a family of toxic chemicals. They have been characterized by EPA as likely to be 
human carcinogens and are anticipated to increase the risk of cancer at background levels of exposure. See 
http://www.epa.gov/pbt/pubs/dioxins.htm (accessed June 17, 2013). 
68 The European Commission consists of 27 Commissioners and “represents the interests of the EU [European 
Union] as a whole. It proposes new legislation to the European Parliament and the Council of the European Union, 
and it ensures that EU law is correctly applied by member countries.” http://ec.europa.eu/atwork/index_en.htm 
(accessed May 6, 2013). 
69 See http://ec.europa.eu/environment/seveso/ (accessed May 6, 2013). 
70 The Seveso Directive was adopted in 1982 and was amended twice, in 1987 and 1988. On December 9, 1996, the 
Seveso II Directive was adopted and replaced the original Seveso Directive. The Seveso III Directive was then 
adopted on July 4, 2012, and became effective on August 13, 2012. Member States must implement Seveso III by 
June 1, 2015. http://ec.europa.eu/environment/seveso/ (accessed May 6, 2013). 
71See http://ec.europa.eu/environment/seveso/legislation.htm (accessed May 6, 2013). 
72 Seveso II Directive, Article 9 (1996). Available at http://eur-
lex.europa.eu/LexUriServ/LexUriServ.do?uri=CONSLEG:1996L0082:20031231:EN:PDF (accessed July 15, 2013). 
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regulation also requires owners or operators to “prove to the competent authority…that he has taken all 
measures necessary as specified in this Directive.”73 
On June 1, 1974, the Flixborough Works of Nypro (UK) 
Limited experienced a massive cyclohexane vapor cloud 
explosion, killing 28 workers and injuring 36 workers 
and hundreds of members of the public offsite. This 
incident along with the Seveso incident led to the 
Seveso Directive in 1982, and this was converted into 
legislation in the United Kingdom (UK) via the Control 
of Industrial Major Accident Hazards (CIMAH) 1984 
Regulations. The Control of Major Accidents74 Hazards 
Regulations (COMAH) replaced CIMAH in April 1999 
to conform to the updated Seveso II Directive. The 
Health and Safety Executive75 (HSE), the Environment 
Agency76 (EA), and the Scottish Environmental 
Protection Agency77 (SEPA) are considered to be the 
UK’s CA responsible for the enforcement of these 
regulations. A key feature differentiating these two 
regulations is the increasing emphasis from the operator 
having to “describe” the safety systems in CIMAH to 
being required to “demonstrate” their adequacy in 
COMAH.78 
73 Seveso II Directive, Article 5, Paragraph 2 (1996). Available at 
http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=CONSLEG:1996L0082:20031231:EN:PDF (accessed July 
15, 2013). 
74 The COMAH regulations define “major accident” as “an occurrence (including in particular, a major emission, 
fire or explosion) resulting from uncontrolled developments in the course of the operation of any establishment and 
leading to serious danger to human health or the environment, immediate or delayed, inside or outside the 
establishment, and involving one or more dangerous substances…” COMAH Regulations, Part 1, Regulation 2 
(2005). 
75 HSE is an independent regulator, and “act[s] in the public interest to reduce work-related death and serious injury 
across Great Britain’s workplaces.” See http://www.hse.gov.uk/aboutus/ (accessed May 7, 2013). According to the 
HSE’s Enforcement Policy Statement, the HSE’s purpose is “to protect the health, safety and welfare of people at 
work, and to safeguard others, mainly members of the public, who may be exposed to risks from the way work is 
carried out.” http://www.hse.gov.uk/pubns/hse41.pdf (accessed May 7, 2013). 
76 EA is an Executive Non-departmental Public Body responsible for protecting the environment and promoting 
sustainable development. For more information see http://www.environment-agency.gov.uk/default.aspx (accessed 
July 17, 2013). 
77 SEPA is Scotland’s environmental regulator, aimed at protecting and improving the environment. For more 
information see http://www.sepa.org.uk/ (accessed July 17, 2013). 
78 COMAH Regulations. Schedule 4, Part 1. Purpose of safety reports is to “1. demonstrate[e] that a major accident 
prevention policy and a safety management system for implementing it have been put into effect in accordance with 
the information set out in Schedule 2; 2. Demonstrate[e] that major accident hazards have been identified and that 
the necessary measures have been taken to prevent such accidents and to limit their consequences for persons and 
the environment; 3. Demonstrate[e] that adequate safety and reliability have been incorporated into the – (a) design 
and construction, and (b) operation and maintenance, of any installation and equipment and infrastructure connected 
with its operation which are linked to major accident hazards within the establishment.…” (2005). 
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The COMAH regulations apply to all onshore facilities that have sufficient quantities of dangerous 
substances as listed in Schedule 179 of the regulations.80 The general duty for all duty holders of facilities 
covered under the COMAH regulations is to “take all measures necessary to prevent major accidents and 
limit their consequences to people and the environment.”81 The HSE interprets this duty as the equivalent 
of reducing risks82 to “as low as reasonably practicable,” or ALARP.83,84,85 Duty holders are required to 
prepare a safety report that “demonstrate[s] to the CA that all measures necessary for the prevention and 
mitigation of major accidents have been taken.”86 These reports must contain information for the CA to 
review and analyze, including a policy on preventing and mitigating major accidents; a management 
system for implementing that policy that complies with good practice;87 an effective method for 
identifying any major accidents that might occur; and measures to prevent and mitigate major accidents.88 
To assist operators with reducing risks to ALARP, the HSE publishes guidance documents that contain 
good practice guidelines and standards and that discuss what constitutes good practice.89 
79 Available at http://www.legislation.gov.uk/uksi/1999/743/schedule/1/made (accessed June 17, 2013). 
80 COMAH Regulations, Part 1, Regulation 3 (2005). 
81 COMAH Regulations, Part 2, Section 4 (2005). 
82 HSE describes “risk” as “the likelihood that a hazard will actually cause its adverse effects, together with a 
measure of the effect.” See http://www.hse.gov.uk/risk/theory/alarpglance.htm (accessed May 7, 2013). 
83 See http://www.hse.gov.uk/foi/internalops/hid_circs/permissioning/spc_perm_37/ (accessed May 15, 2013). 
84 The principal health and safety legislation in the UK is the Health and Safety at Work etc. Act 1974. It requires 
employers to ensure that risks to employees and others are reduced “so far as is reasonably practicable,” or SFAIRP. 
Health and Safety at Work etc. Act, Part I, Section 2 (1) and (2) (1974). HSE has interpreted that SFAIRP duties 
call for the same set of tests to be applied as duties to reduce risks “as low as reasonably practicable,” or ALARP. 
According to HSE, “”the two terms mean essentially the same thing and at their core is the concept of ‘reasonably 
practicable’;…” See http://www.hse.gov.uk/risk/theory/alarpglance.htm (accessed May 7, 2013). 
85 According to HSE, the concept of “reasonably practicable” “involves weighing a risk against the trouble, time and 
money needed to control it. Thus, ALARP describes the level to which [they] expect to see workplace risks 
controlled.” This allows HSE to “set goals for duty-holders, rather than being prescriptive; HSE’s policy is that any 
proposed regulatory action should be based on what is reasonably practicable.” According to HSE, in most 
situations, deciding whether the risks are ALARP involves a “comparison between the control measures a duty-
holder has in place or is proposing and the measures [they] would normally expect to see in such circumstances i.e. 
relevant good practice. ‘Good practice’ is defined as ‘those standards for controlling risk that HSE has judged and 
recognized as satisfying the law, when applied to a particular relevant case, in an appropriate manner.’… Once what 
is good practice has been determined, much of the discussion with duty-holders about whether a risk is or will be 
ALARP is likely to be concerned with the relevance of the good practice, and how appropriately it has been (or will 
be) implemented.” See http://www.hse.gov.uk/risk/theory/alarpglance.htm (accessed May 7, 2013). 
86COMAH Regulations, Schedule 4, Part 1 (2005). See http://www.hse.gov.uk/comah/background/comah99.htm 
(accessed May 7, 2013). 
87 HSE defines “good practice” as “those standards for controlling risk that HSE has judged and recognized as 
satisfying the law, when applied to a particular relevant case, in an appropriate manner.” HSE, “Assessing 
compliance with the law in individual cases and the use of good practice,” May 2003. Available at 
http://www.hse.gov.uk/risk/theory/alarp2.htm (accessed June 11, 2013). 
88 COMAH Regulations, Schedule 4, Part 2 (2005). See http://www.hse.gov.uk/comah/background/comah99.htm 
(accessed May 7, 2013). 
89 Such as HSE’s “Guidance for the topic assessment of the major accident hazard aspects of safety cases,” 
published in April 2006, and HSE’s “Assessing compliance with the law in individual cases and the use of good 
practice,” May 2003, available at http://www.hse.gov.uk/risk/theory/alarp2.htm (accessed June 11, 2013). 
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3.2.1.2 
Offshore 
The international offshore energy sector experienced several catastrophic incidents in the 1980s, 
including the Alexander Kielland 90 incident in Norway in 1980 which resulted in 123 fatalities, and the 
Piper Alpha91 incident in the UK in 1988, which fatally injured 167 workers. These incidents initiated 
offshore regulatory changes focused on risk reduction and control that were modeled after the CIMAH 
regulations. 
Following the Piper Alpha incident, the UK Secretary of State for the Department of Energy ordered that 
a public inquiry be held to determine the circumstances surrounding the incident.92 The Secretary 
directed Lord Cullen, a Senator of the College of Justice in Scotland, to hold the inquiry and report to the 
Secretary “the circumstances of the accident and its cause together with any observations and 
recommendations which he thinks fit to make with a view to the preservation of life and the avoidance of 
similar accidents in the future.”93 
The result was The Public Inquiry into the Piper Alpha Disaster (“the Cullen Report”), an extensive 
report released in October 1990. The report called into question the adequacy of the detailed prescriptive 
regulatory regime that existed at the time of the incident94 for offshore oil and gas operations, and listed 
106 recommendations to revamp offshore safety regulation in the UK, 57 of which the HSE was 
responsible for overseeing.95 
The Cullen Report found that the operating company (Occidental Petroleum, a US company), “did not 
possess any system which ensured that such remote, but potentially disastrous, events were subjected to 
systematic scrutiny…[and] there was for major projects no comprehensive system of safety assessment 
and management did not appear to appreciate fully the contribution which it could make.”96 The report 
noted that there was a need for a formal safety assessment (FSA), “an assessment essentially equivalent to 
the Safety Case,”97 which “involves the identification and assessment of hazards over the whole life cycle 
of a project…[because]…the combinations of potential hardware and human failures are so numerous that 
a major accident hardly ever repeats itself…[and] [a] strategy for risk management must [] address the 
entire spectrum of possibilities.”98 
90 The Alexander Kielland was a flotel for housing workers. A total of 212 people were on board when it capsized 
near the Edda platform in the Ekofisk area of the North Sea on March 27, 1980. As a result of this incident, 123 
individuals lost their lives and only 89 survived. 
91 On July 6, 1988, an explosion occurred aboard the Piper Alpha oil production platform 120 miles off the coast of 
Scotland in the North Sea. A series of explosions and fire killed 167 workers and almost completed destroyed the 
platform. This incident became the deadliest accident in the history of the offshore industry. 
92 Department of Energy. The Public Inquiry into the Piper Alpha Disaster; Presented to Parliament by the 
Secretary of State for Energy by Command of her Majesty; November 1990; p iii. 
93 Department of Energy. The Public Inquiry into the Piper Alpha Disaster; Presented to Parliament by the 
Secretary of State for Energy by Command of her Majesty; November 1990; p iv. 
94Department of Energy. The Public Inquiry into the Piper Alpha Disaster; Presented to Parliament by the Secretary 
of State for Energy by Command of her Majesty; November 1990; p 27. 
95 Oil &Gas UK. Piper Alpha: Lessons Learnt; 2008; p 2. 
96 Department of Energy. The Public Inquiry into the Piper Alpha Disaster; Presented to Parliament by the 
Secretary of State for Energy by Command of her Majesty; November 1990; p 275. 
97 Lord Cullen describes the Safety Case as “a means by which an operator demonstrates to itself the safety of its 
activities…[and] as the basis for the regulation of major hazard activities…” Ibid at 276-277. 
98 Ibid. 
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In his analysis, Lord Cullen noted that the current offshore regulations were prescriptive in nature rather 
than goal-setting, and that this had the effect of hampering operators’ flexibility and stifling innovation.99 
He stated that “one of the reasons for adopting the goal-setting approach was to make regulations that 
were more flexible, so that changing technology could be accommodated without the need for new 
legislation.”100 Lord Cullen pointed to the CIMAH Regulations, discussed above, as a forward-looking 
regulatory model, which required onshore major hazard installation operators to “provide HSE with a 
written report on the safety of the installation…commonly called the Safety Case.”101 Lord Cullen noted 
that the safety case “is a means by which an operator demonstrates to itself the safety of its 
activities…[and] also serves as the basis for the regulation of major hazard activities.”102 
Lord Cullen concluded that an FSA “is an essential element in a modern safety regime for major hazard 
installations…that this FSA should take the form of a Safety Case…[and that] [t]he regime should have 
as its central feature demonstration of safe operation by the operator.”103 He recommended that a safety 
case regulatory regime be implemented offshore for both fixed and mobile installations as it already was 
for onshore major hazard installations, that it be complemented by other regulations dealing with specific 
features, that the safety case contain goal-setting regulations, and that it be part of a continuing dialogue 
between the operator and the regulatory body.104 
Lord Cullen recommended the implementation of safety regulations requiring the owner or operator of 
every fixed and mobile installation operating in UK waters to submit a safety case to HSE. In response, 
the UK established the Offshore Installations (Safety Case) Regulations in 1992.105 The primary goal of 
these Regulations was “to reduce the risks from major accident hazards to the health and safety of the 
workforce employed on offshore installations or in connected activities.”106 
Oil & Gas UK, 107 the main UK offshore oil industry trade association whose members include the major 
oil companies that operate in the Gulf of Mexico (such Shell and Exxon), has expressed strong support for 
the safety case regime. In its response to the European Commission’s published draft legislative 
proposals to modify offshore safety case regulations, Oil & Gas UK noted that those proposals would 
undermine the “proactive, flexible and responsive approach to managing risks, borne out of the lessons 
learnt from Piper Alpha as well as the evolving nature of the offshore oil and gas business itself.”108 In 
the wake of the Macondo incident in the Gulf of Mexico, the UK government directed Professor Geoffrey 
99 Department of Energy. The Public Inquiry into the Piper Alpha Disaster; Presented to Parliament by the 
Secretary of State for Energy by Command of her Majesty; November 1990; p 339. 
100 Department of Energy. The Public Inquiry into the Piper Alpha Disaster; Presented to Parliament by the 
Secretary of State for Energy by Command of her Majesty; November 1990; p 364. 
101 Ibid at 276. 
102 Ibid at 276 and 277. 
103 Ibid at 282. 
104 Ibid at 283 and 284. 
105 The 1992 Regulations have since been replaced by the Offshore Installations (Safety Case) Regulations 2005, 
which were effective as of April 6, 2006. The objective of the revisions in 2005 was “to improve the effectiveness 
of the regulations whilst at the same time reducing the burden of three yearly resubmissions.” Oil & Gas UK. Piper 
Alpha: Lessons Learnt; 2008. 
106 HSE. A Guide to the Offshore Installations (Safety Case) Regulations 2005: Guidance on Regulations; 2006; p 
5. http://www.hse.gov.uk/pubns/priced/l30.pdf (accessed May 7, 2013). 
107 See http://www.oilandgasuk.co.uk/aboutus/aboutus.cfm (accessed December 10, 2013). 
108 Oil & Gas UK. European Commission Proposed Regulation on Offshore Safety and Related Issues: Oil & Gas 
UK Position Paper. November 2011; p 1. http://www.oilandgasuk.co.uk/ProposedEURegulation.cfm (accessed 
December 10, 2013). 
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Maitland of Imperial College London to lead an independent review of the offshore safety case regime in 
the UK.109 In the report stemming from the review, which highlighted strengths of the safety case regime 
as well as recommendations for improvement, Professor Maitland commended the UK’s “‘goal-setting’ 
safety regime and its ability to foster innovation and continuous improvement in process integrity…”110 
and noted that the UK authorities, including the HSE, are held in high regard by both the UK operators 
and international observers.111 
3.2.2 
Global Analysis of Safety Case Implementation 
3.2.2.1 
Australia 
3.2.2.1.1 Offshore 
Following the Piper Alpha disaster in 1988, the then Australian Commonwealth Minister for Resources at 
the time, Senator Peter Cook, formed a Consultative Committee on Safety in the Offshore Petroleum 
Industry to advise him on safety issues surrounding offshore operations in Australia. In 1991, the 
Committee released its Report of the Consultative Committee on Safety in the Offshore Petroleum 
Industry.112 In the report, the Committee examined the circumstances, causes, and recommendations 
described in both the Cullen Report and Esso Australia’s113 investigation report on a fire that occurred on 
the Tuna platform in April 1989 in Bass Strait that injured four individuals. The Committee noted that 
while there were many differences between the two incidents, they “both demonstrated the need for 
greater attention to the management of safety in a number of areas of offshore operations.”114 They 
pointed to the safety case as an important regulatory concept that should be applied to oil and gas 
operations in Australian waters, and concluded by recommending that the safety case concept described 
by Lord Cullen and carried out onshore by the Seveso Directive and CIMAH regulations be adopted for 
Australian offshore petroleum operations.115 It would “require the operator of a facility to formally 
document how safety is to be managed within the facility, [and] [] demonstrate that the major hazards of 
the installation have been identified and appropriate controls provided…”116 The Committee also 
recommended the implementation of both prescriptive and “objective” regulations.117 At that time, 
offshore petroleum safety was the joint responsibility of the Commonwealth and the States/Northern 
Territory. Following this inquiry, new Commonwealth regulations were created: for example, Schedule 
109 Maitland, Geoffrey. Offshore Oil and Gas in the UK: an independent review of the regulatory regime. 
December 2011. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/48252/3875-
offshore-oil-gas-uk-ind-rev.pdf (accessed December 10, 2013). 
110 Ibid at 3. 
111 Ibid at 3. 
112 See http://www.mrt.tas.gov.au/mrtdoc/petxplor/download/OR_0935/OR_0935.pdf (accessed May 8, 2013). 
113 Esso was an oil and gas company in Australia that was sold to Mobil Oil Corporation in 1990. It is now part of 
Exxon Mobil. See http://www.exxonmobil.com/Australia-English/PA/about_who_history_esso.aspx (accessed May 
8, 2013). 
114 Report of the Consultative Committee on Safety in the Offshore Petroleum Industry, 1991; p 2. See 
http://www.mrt.tas.gov.au/mrtdoc/petxplor/download/OR_0935/OR_0935.pdf (accessed May 8, 2013). 
115 Ibid at 25. 
116 Report of the Consultative Committee on Safety in the Offshore Petroleum Industry, 1991; p 3. See 
http://www.mrt.tas.gov.au/mrtdoc/petxplor/download/OR_0935/OR_0935.pdf (accessed May 8, 2013). 
117 Ibid. 
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8 on “Occupational Health and Safety” was added to the Petroleum Submerged Lands Act (PSLA) in 
1992 to require safety cases to be developed for all offshore petroleum facilities. 
The Offshore Petroleum and Greenhouse Gas Storage (Safety) Regulations 2009 set out the requirements 
for the contents of offshore safety cases. The operator of an offshore petroleum facility must submit a 
safety case for review and acceptance to the Australian National Offshore Petroleum Safety and 
Environmental Management Authority (NOPSEMA), the Australian Commonwealth Statutory Agency 
charged with regulating the health and safety, structural integrity, and environmental management of all 
offshore petroleum facilities in Australian Commonwealth waters, and in coastal waters where State 
powers have been reduced. NOPSEMA accepts a safety case “if it is satisfied that the arrangements set 
out in the document demonstrate that the risks will be reduced to…ALARP.”118 
3.2.2.1.2 Onshore 
In 1998, Esso Australia’s gas plant at Longford in Victoria suffered a major release and fire caused by 
cold temperature embrittlement due to a process upset and lack of engineering support for diagnosis, 
which resulted in two fatalities, eight additional injuries, and cut the State of Victoria’s gas supply for two 
weeks causing major industrial disruption and workforce stand downs. While the safety case at this time 
was required for offshore operations in Australia, onshore facilities like the Longford plant were subject 
only to prescriptive provisions contained within the Victoria Occupational Health and Safety Act 1985. 
In its report on the incident, the Royal Commission concluded that all major hazard facilities in Victoria 
should be required to develop and submit a safety case to the appropriate regulatory authority. In 1996, 
Australia’s National Occupational Health and Safety Commission119 (NOHSC) recommended the safety 
case be adopted for all major onshore hazard facilities in Australia, and in 2002 NOHSC established a 
National Standard for the Control of Major Hazard Facilities and a National Code of Practice for the 
Control of Major Hazard Facilities.120 The Standard states that operators of major hazard facilities “shall 
provide the relevant public authority with a safety report…” that, among other things, identifies the type, 
relative likelihood and consequences of major accidents that might occur, and provides details of the 
safety management system (SMS) for that facility.121 In addition, operators of major hazard facilities 
must identify all major hazards and the risks associated with those hazards, and minimize each risk “so far 
as practicable.”122 
118 See http://www.nopsema.gov.au/safety/safety-case/what-is-a-safety-case/ (accessed July 15, 2013). 
119 In 1985 The National Occupational Health and Safety Commission (NOHSC) was established as a tripartite body 
to develop, facilitate and implement a unified national approach to occupational health and safety in Australia. On 
January 1, 2006, NOHSC was replaced by the Australian Safety and Compensation Council (ASCC). On March 31, 
2009, the ASCC was abolished and replaced with Safe Work Australia. Safe Work Australia was established by the 
Safe Work Australia Act 2008 with the authority to help develop policy to improve worker health, safety, and 
compensation across Australia. It does not regulate work health and safety laws; rather it develops national policy. 
See http://www.safeworkaustralia.gov.au/sites/swa/about/pages/about (accessed May 8, 2013). 
120 National standards are documents which prescribe preventative action to avert occupational deaths, injuries and 
diseases; national codes of practice are documents prepared for the purpose of advising employers and workers of 
acceptable ways of achieving national standards. National Standard for the Control of Major Hazard Facilities 
[NOHSC: 1014(2002)], p 2. 
http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/271/NationalStandard_ControlMajo
rHazardFacilities_NOHSC_1014-2002_PDF.pdf (accessed May 8, 2013). 
121 Ibid at 13. 
122 Ibid at 12. 
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According to the Australian Safety and Compensation Council’s 2004 Annual Situation Report for the 
National Standard for the Control of Major Hazard Facilities, all Australian jurisdictions were expected 
to have the standard in place before the end of 2005, roughly three years after its inception.123 
3.2.2.2 
Norway 
Following the capsizing of the Alexander Kielland in 1980, Norway moved in a direction similar to the 
European Commission and developed performance-based regulations focused on major accident 
prevention. Although the country did not adopt the safety case regulatory regime per se, the current 
regulatory approach implements many similar elements. 
Currently in Norway, the Petroleum Safety Authority124 (PSA) regulates safety for activities at onshore 
and offshore major hazard facilities, and requires the responsible party125 to reduce risk “to the extent 
possible,” and “select technical, operational and organisational solutions that reduce the probability that 
harm, errors and hazard and accident situations occur.”126 This concept is akin to ALARP whereby 
companies choose the solutions and barriers that have the greatest risk-reducing effect, provided the costs 
are not significantly disproportionate to the risk reduction achieved.127 However, unlike the UK and 
Australia, PSA regulations do not require the submission of a safety case report by the operator of a 
facility, although facilities are still expected to develop them and make them available to the regulator 
upon request for auditing purposes. Rather, PSA “supervises” industry, as explained in the following: 
Supervision involves much more than audits offshore or on land. It 
embraces the total contact between the regulator and the regulated. It 
covers everything which gives the PSA the necessary basis to determine 
whether the companies are accepting their responsibility to operate 
acceptably in all phases. Supervisory activities include investigations, 
considering consent applications and meetings with the industry.128 
As will be discussed below, because the safety case regulatory approach requires the regulator to conduct 
detailed assessments of safety case reports and auditing of facilities against the safety case, its 
implementation requires substantial funding to support and maintain a sufficient number of highly 
experienced and competent staff. 
123Australian Safety and Compensation Council. Major Hazard Facilities Annual Situation Report; 2004; p1. 
http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/475/MHFAnSituationReport_2004.
pdf (accessed May 8, 2013). 
124 The Petroleum Safety Authority (PSA) is “the regulatory authority for technical and operational safety and for 
the working environment.” PSA was created in 2004 as a result of a government decision to split the Norwegian 
Petroleum Directorate (NPD) into two parts. See http://www.ptil.no/main-page/category9.html (accessed May 8, 
2013). 
125 PSA defines a “responsible party” as “[t]he operator and others participating in activities covered by these 
regulations, without being a licensee or owner of an onshore facility.” Regulations Relating to Health, Safety and 
the Environment in the Petroleum Activities and at Certain Onshore Facilities (The Framework Regulations); 
Section 6(a). Definitions. http://www.ptil.no/framework-hse/category403.html (accessed November 26, 2013). 
126 PSA. Regulations Relating to Health, Safety and the Environment in the Petroleum Activities and at Certain 
Onshore Facilities (The Framework Regulations); Section 11, Risk Reduction Principles. 
http://www.ptil.no/framework-hse/category403.html (accessed November 26, 2013). 
127 Ibid. 
128 http://www.ptil.no/supervision/what-is-supervision-article8519-88.html (accessed June 3, 2013). 
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3.2.2.3 
The United States 
Despite the international shift to the safety case regime and even though major oil companies that operate 
both onshore and offshore in the US also operate globally under safety case regimes and have shown 
support for the safety case,129 the US has persisted in the use of a more activity-based regulatory scheme 
that does not contain a specific risk reduction target and that lacks the ability to adapt to advancing 
technology and recently developed industry standards. Due to the major potential hazards present in 
onshore and offshore oil and gas operations, these sectors should have in place adaptable safety regimes 
that adequately engage companies and their employees in continuous improvement and risk reduction. 
As the CSB has devoted extensive time and resources to studying and analyzing the regulation of offshore 
oil and gas facilities in the US as a result of its Macondo incident investigation, this report will focus on 
the regulation of onshore oil and gas operations in the US and California. 
On October 23, 1989, a massive explosion and fire occurred at the Phillips 66 Company’s Houston 
Chemical Complex in Pasadena, Texas, resulting in 23 fatalities and injuring more than 130. In response, 
the U.S. Department of Labor issued a report to the President and declared, among other things, that the 
U.S. Occupational Safety and Health Administration (OSHA) would “expedite completion of its 
rulemaking requiring employers to implement comprehensive chemical process safety management plans 
for hazardous chemical processes.”130 Sparked by a number of serious accidents, including the Phillips 
66 incident and the 1984 toxic release in Bhopal, India, which resulted in several thousand known 
fatalities, OSHA published in the Federal Register (55 FR 29150) on July 17, 1990, a proposed standard 
containing requirements for the management of hazards associated with processes using highly hazardous 
chemicals.131 Soon after, Congress adopted the Clean Air Act (CAA) Amendments (CAAA) of 1990, 
129A Shell Oil Company representative testified at the CSB December 2010 public meeting on the safety case that 
the company had been using the safety case globally since 2002, and noted that the most valuable aspect of that type 
of regulatory regime was the need to demonstrate that major hazards have been managed using effective barriers and 
controls. Shell Geelong Refinery Plant Manager Huck Poh has stated, “As a Major Hazard Facility, Shell Geelong 
Refinery and Lara Terminal is required to submit a Safety Case for assessment by Safe Work Victoria. This 
document is a summary of that Safety Case and explains the potential impact of the facility on our neighbours and 
the community. We take a systematic approach to managing safety and preventing incidents that place our people, 
our neighbours, the Geelong community, the environment and our facilities at risk. This is reflected in our Safety 
Management System and the approach that has been undertaken for the development and review of the Safety Case. 
Shell is committed to achieving continuous Health, Safety, Security and Environment (HSSE) performance 
improvement. There are ongoing review and revision activities to ensure our analyses remain relevant and reflect 
the current status of operations and our risk reduction measures are consistent with latest industry practice. This 
commitment to continuous improvement is reflected in the Shell HSSE Policy and supported by our HSSE results.” 
See http://s04.static-shell.com/content/dam/shell-new/local/country/aus/downloads/geelong/safety-case-
summary.pdf p3. (accessed December 10, 2013). Esso Longford Plant Manager Monte Olson has stated that “[t]he 
Safety Case is a systematic and comprehensive review of our operations and processes which includes the 
identification of potential major incidents that could occur, assesses the risks associated with these major incidents 
and demonstrates the controls we have in place to manage these risks to as low as reasonably practicable.” See 
http://www.exxonmobil.com/Australia-English/PA/Files/publication_Longford_Safety_Case_2013.pdf p5. 
(accessed December 10, 2013). 
130 Dole, Elizabeth. Phillips 66 Company Houston Chemical Complex Explosion and Fire: Implications for Safety 
and Health in the Petrochemical Industry, A Report to the President; April 1990; p ix. 
http://ncsp.tamu.edu/reports/phillips/first%20part.pdf (accessed August 6, 2013). 
131 Preamble to Process Safety Management of Highly Hazardous Chemicals; Explosives and Blasting Agents. 
Section 1 – I. Background (March 4, 1992). See 
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=PREAMBLES&p_id=1039 (accessed May 10, 
2013). 
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which resulted in the creation of the CSB and authorized the first federal regulations specifically designed 
to prevent major chemical accidents that threaten workers, the public, and the environment: OSHA’s 
Process Safety Management (PSM) standard and the U.S. Environmental Protection Agency’s (EPA’s) 
Risk Management Program. 
3.2.2.3.1 OSHA PSM Standard 
Section 304 of the CAAA mandated that OSHA develop “a chemical process safety standard designed to 
protect employees from hazards associated with accidental release of highly hazardous chemicals in the 
workplace.”132 OSHA responded by adopting 29 CFR §1910.119 Process Safety Management of Highly 
Hazardous Chemicals (“the PSM standard”) in 1992. The PSM standard applies to a process133 involving 
a chemical at or above the listed threshold quantity (also known as a highly hazardous chemical), or 
flammables in a quantity of 10,000 pounds or more.134 It contains 14 elements with broad requirements 
to implement management systems, identify and control hazards, and prevent “catastrophic releases of 
highly hazardous chemicals.” While the PSM standard was intended to be performance-based and does 
contain some goal-setting elements, a majority of the standard is activity-based, and there is no general 
duty requirement under the PSM standard to reduce risks to a certain extent or prevent catastrophic 
accidents. As will be discussed at length in Section 4.3, the PSM standard has essentially remained 
stagnant since its inception in 1992. According to the Center for Chemical Process Safety (CCPS), the 
PSM standard has resulted “in a minimum cost, compliance-based approach to managing process safety… 
‘If [it] isn’t a regulatory requirement, I’m not going to do it!’”135 
 A key provision of the PSM standard is the process hazard analysis (PHA) of covered processes. 136 
PHA requirements include a review of the process to identify, evaluate, and control the hazards, and an 
evaluation of the consequences of failure of those controls.137,138 The PHA required by the OSHA PSM 
standard is an example of a goal-setting requirement in that it allows for a variety of hazard analysis 
methodologies to be performed to satisfy the requirement. However, the element is activity-based in that 
completing a PHA for each covered process and updating it at least every five years is satisfactory. The 
regulator is not responsible for evaluating the effectiveness of controls or safeguards, and there is no 
requirement to reduce risks to a certain extent such as ALARP. Thus, the resulting PHA that meets the 
132 Clean Air Act Amendments of 1990. Section 304(a). November 5, 1990. See 
http://www.epa.gov/air/caa/caaa.txt (accessed May 10, 2013). 
133 The PSM standard defines “process” as “any activity involving a highly hazardous chemical including any use, 
storage, manufacturing, handling, or the on-site movement of such chemicals, or combination of these activities.” 
29 CFR §1910.119(b) (1992). 
134 29 CFR §1910.119(a)(1) (1992). This standard also applies to the manufacture of explosives and pyrotechnics in 
any quantity [29 CFR §1910.109(k)(2) & (3)]. 
135 CCPS. Guidelines for Risk Based Process Safety. 2007; p 2. 
136 A Process hazard analysis is a thorough, orderly, systematic approach for identifying, evaluating, and controlling 
hazards of processes involving highly hazardous chemicals. The employer must perform an initial process hazard 
analysis on all processes covered by the PSM standard and all process hazard analyses must be updated and 
revalidated, based on their completion date, every five years. See 
http://www.osha.gov/doc/outreachtraining/htmlfiles/psm.html (accessed May 10, 2013). 
137 29 CFR §1910.119(e) (1992). 
138 The other elements of the PSM standard are process safety information, operating procedures, employee 
participation, training, contractor safety, pre-startup safety review, mechanical integrity, hot work permits, 
management of change, incident investigation, emergency planning and response, and compliance audits. The 14th 
“element” is mainly a requirement that maintaining trade secrecy not interfere with an employer’s compliance with 
the other 13 elements. 
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regulatory requirements of “controlling” hazards may actually inadequately identify or mitigate the 
hazards. In addition, there is no requirement for employers to submit their PHAs to the regulator for 
review. In most cases, this means the regulator will not review these PHAs until there is a significant 
process accident, a complaint, or a (rare) planned inspection. 
 
Another key element of the PSM standard, the Management of Change (MOC) provision, requires the 
development of written procedures “to manage changes to process chemicals, technology, equipment, and 
procedures…”139 The procedures must consider, among other things, the technical basis for a proposed 
change and its potential impact on safety and health.140 Historically, the MOC requirement has been 
treated and enforced as an activity-based requirement as well. For example, when the BP Texas City 
refinery explosion and fire occurred on March 23, 2005, all 15 fatalities and many of the 180 injuries 
occurred in or around nine contractor trailers that were sited near process areas and as close as 121 feet to 
the isomerization (ISOM) unit where the incident occurred. The refinery had been using trailers as 
temporary office spaces for several years. The refinery addressed facility siting for trailers during its 
2004 MOC for an upcoming 2005 turnaround. The MOC form indicated that a double-wide mobile office 
trailer would be temporarily sited in the open area between the ISOM and naphtha desulfurization units 
(NDU) for use during the upcoming turnaround, to be removed at the end of April 2005. However, the 
MOC did not analyze siting hazards; rather the MOC team attached a drawing showing the proposed 
interior configuration of the trailer and measured its location from the catalyst warehouse.141 In early 
2005, eight other trailers were sited between the ISOM and NDU without even conducting an MOC. The 
CSB pointed out in its Urgent Recommendations stemming from the Texas City incident that these 
trailers could have been easily relocated to less hazardous sites, and BP did so following the incident.142 
Despite this fact, BP’s siting policy considered that utilizing trailers in this way posed little or no danger 
to occupants, which conformed with the American Petroleum Institute’s (API) Recommended Practice 
(RP) 752, Management of Hazards Associated with Location of Process Plant Buildings. 
 
Although the MOC failed to identify or analyze hazards stemming from siting trailers so close to process 
areas, OSHA did not cite BP for conducting a poor MOC following the incident, as merely completing 
the MOC satisfied the requirements of the PSM standard. As it would have been very practical to move 
the trailers to a safer location, a regulator under the safety case regulatory regime would have the ability 
to require BP to do just that to reduce risks to ALARP. 
 
The OSHA PSM standard includes requirements for two of its 14 elements – mechanical integrity and 
process safety information (PSI) – to comply with recognized and generally accepted good engineering 
practices, or RAGAGEP.143 RAGAGEPs are technologically focused, with no emphasis on 
139 29 CFR §1910.119(l)(1) (1992). 
140 Id at (l)(2)(i) and (ii) (1992). 
141 To learn more about the PHA and MOC processes relating to the BP Texas City Refinery, see the CSB BP Texas 
City Final Investigation Report at http://www.csb.gov/assets/1/19/CSBFinalReportBP.pdf (accessed October 24. 
2013). 
142 See CSB Urgent Trailer Siting Recommendations at http://www.csb.gov/assets/1/19/BP_Recs_2.pdf (accessed 
October 24. 2013). 
143 RAGAGEPs “are engineering, operation, or maintenance activities based on established codes, standards, 
published technical reports or recommended practices (RP) or a similar document. RAGAGEPs detail generally 
approved ways to perform specific engineering, inspection or mechanical integrity activities, such as fabricating a 
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organizational, human factors, or culture-based measures. OSHA developed the mechanical integrity 
RAGAGEP requirement to “make sure that process equipment is inspected and tested properly, and that 
the inspections and tests are performed in accordance with appropriate codes and standards.”144 OSHA 
has recognized a number of practices, guidelines, and standards as RAGAGEPs, including the American 
Society of Civil Engineers, Design of Blast Resistant Buildings in Petrochemical Facilities, the 
Department of Defense, TMS-1300 Structures to Resist the Effects of Accidental Explosions, and the 
American Petroleum Institute (API) Recommended Practice (RP) 520: Sizing, Selection, and Installation 
of Pressure-Relieving Devices in Refineries.145 Unlike other regulators such as the HSE, OSHA has not 
compiled a comprehensive list of good practices, or RAGAGEPs, for companies to utilize during 
operations, and the CSB has only identified two OSHA Letters of Interpretation regarding 
implementation of RAGAGEP in PSM. According to CCPS, “[o]rganizations lack a thorough 
understanding of recognized and generally accepted good engineering practices and are inconsistent in 
interpreting and applying them.”146 In addition, key PSM elements such as PHA, incident investigation, 
and MOC do not reference RAGAGEP, and have not kept up to date with good practice guidelines, 
including CCPS’ Guidelines for Risk Based Process Safety, which addresses 20 PSM elements for 
process safety, including human factors, workforce involvement, and safety culture. 
 
Historically, OSHA has primarily enforced147 RAGAGEP reactively, and may cite companies for 
violations of RAGAGEPs following an incident. For example, following the BP Texas City Refinery 
incident, OSHA issued BP hundreds of citations, some of which covered BP’s willful violations of API 
520 and the American Society of Mechanical Engineers (ASME) Boiler and Pressure Vessel Code, both 
considered by OSHA to be RAGAGEPs. Following the Chevron incident, California’s Division of 
Occupational Safety and Health (Cal/OSHA) issued Chevron two willful citations for allegedly not 
complying with API RP 939-C, Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil 
Refineries and Chevron’s own internal corrosion mitigation plan as RAGAGEPs (this will be discussed in 
greater detail in Section 5.1.2.2). 
 
3.2.2.3.2 U.S. Environmental Protection Agency Risk Management Program 
 
Section 301(r) of the CAAA called for EPA to develop regulations related to the prevention and detection 
of accidental releases for regulated substances, including requiring owners or operators of stationary 
sources that have regulated substances present to prepare and implement a “risk management plan to 
vessel, inspecting a storage tank, or servicing a relief valve.” OSHA Instruction CPL 03-00-004. June 7, 2007. 
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=3589&p_table=DIRECTIVES (accessed August 
13, 2013). 
144 OSHA. Preamble to 29 CFR Part 1910, Process Safety Management of Highly Hazardous Chemicals, Section 3, 
Title III. Summary and Explanation of the Final Rule, 1992. Available at 
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=PREAMBLES&p_id=1041 (accessed June 6, 
2013). 
145 All three are cited in OSHA Letter of Interpretation. Applicability of the PSM standard’s mechanical integrity 
requirements to refinery structures, February 1, 2010. 
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=27443 (accessed 
June 6, 2013). 
146 CCPS. Guidelines for Risk Based Process Safety. 2007; p 2. 
147 An exception to this would be OSHA’s NEP that was implemented from 2007 to 2011, where OSHA inspectors 
cited to RAGAGEP following NEP audits. 
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detect and prevent or minimize accidental releases of such substances from the stationary source.…”148 
The risk management plan would require a “hazard assessment to assess the potential effects of an 
accidental release of any regulated substance.”149 In 1996, EPA promulgated the Risk Management 
Program regulations at 40 CFR Part 68, which went into effect in 1999. 
 
The EPA’s Risk Management Program requires facilities that contain more than the threshold quantity of 
any of the 77 listed toxic chemicals or 63 flammable substances150 to prepare and submit to the regulating 
agency emergency contact information, descriptions of processes and hazardous chemicals onsite, an 
accident history, and worst-case release scenarios.151 The regulation defines three different Program 
levels (Program 1, 2, or 3) based on a process unit’s potential for impact to the public and the 
requirements to prevent accidents.152 Program 3 processes are subject to additional, more stringent 
requirements to prevent accidents similar to those of the OSHA PSM standard. Program 3 facilities must 
implement elements of a prevention program, including: process safety information (PSI), PHA, standard 
operating procedures (SOPs), training, mechanical integrity, compliance audits, incident investigations, 
MOC, pre-startup reviews, employee participation, and hot work permits. These prevention program 
elements are based primarily on the OSHA PSM standard, and much of the language contained in each 
element is identical to the PSM standard. As such, the Risk Management Program regulations contain the 
same RAGAGEP requirements for mechanical integrity and PSI as the OSHA PSM standard for covered 
facilities. For example, 40 CFR §68.48 requires an owner or operator to “ensure that the process is 
designed in compliance with recognized and generally accepted good engineering practices 
[RAGAGEP].”153 Like OSHA, the EPA is able to cite facilities for failure to comply with RAGAGEP 
following an incident, but does not maintain a list of RAGAGEPs for reference. 
 
Finally, each covered facility must submit a risk management plan (RMP) to EPA for all covered 
processes154 and update and resubmit these plans at least once every five years, or whenever a major 
accident occurs or the emergency contact information changes. Completing and submitting the RMP 
satisfies the regulatory requirement; again, the effectiveness of the RMP in risk reduction is not assessed 
by the EPA, rendering this another activity-based requirement for a covered facility. There is no approval 
of the RMP by the EPA, and there is no additional duty on the facility to implement what it says it is 
doing in the RMP, unlike the safety case regulatory regime. 
 
Any facility with one or more covered processes must include in its RMP an executive summary; the 
registration for the facility; the certification statement; a worst-case scenario for each process involving 
flammables or toxics; the five-year accident history for each process; information concerning emergency 
148 Clean Air Act Amendments of 1990. Section 301(r)(7)(B)(ii). November 5, 1990. See 
http://www.epa.gov/air/caa/caaa.txt (accessed May 10, 2013). 
149 Clean Air Act Amendments of 1990. Section 301(r)(7)(B)(ii)(I). November 5, 1990. See 
http://www.epa.gov/air/caa/caaa.txt (accessed May 10, 2013). 
150According to 40 CFR §68.10(a), “[a]n owner or operator of a stationary source that has more than a threshold 
quantity of a regulated substance in a process, as determined under §68.115, shall comply with the requirements of 
this part no later than the latest of the following dates.…” 
151 See 40 CFR §68.12. General Requirements. 
152 See 40 CFR §68.10. Applicability. 
153 40 CFR §68.48(b) (1999). Additionally see 40 CFR §68.56 (d) which requires the owner or operator‘s inspection 
and testing procedures to “follow recognized and generally accepted good engineering practices.” 
154 40 CFR §68.150 (1999). 
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response at the facility; at least one alternative release scenario analysis for each regulated toxic substance 
or flammable; a summary of the prevention program for each Program 2 process; and a summary of the 
prevention program for each Program 3 process.155 
 
The CSB found in its BP Texas City Investigation Report that as of March 2007, the RMP regulation had 
focused primarily on reviewing the submitted RMPs and required updates by covered facilities. The EPA 
Office of Inspector General (OIG) concluded in 2009 that over half of the RMP-covered facilities 
identified in the US as high-risk156 had never received an on-site inspection or audit, and over 65 percent 
of all active RMP facilities had not received an on-site inspection or audit since inception of the RMP 
program in 1999.157 The EPA OIG also noted that of the 296 uninspected high-risk facilities regulated by 
the EPA, 151 of these could each impact 100,000 people or more in a worst-case accident scenario.158 
 
3.2.2.3.3 Safety Case in the United States 
 
In contrast to its mainly activity-based regulation of hazardous 
chemicals, including oil and gas operations, the US has adopted a 
more goal-based regulatory approach for its nuclear and 
aeronautics and space science sectors. The U.S. Nuclear 
Regulatory Commission (NRC) was an early adopter of goal or 
performance-based regulation, which it defines as “[a] regulatory 
approach that focuses on desired, measureable outcomes, rather 
than prescriptive processes, techniques, or procedures…[and] leads 
to defined results without specific direction regarding how those 
results are to be obtained.”159 According to the NRC, 
performance-based regulations permit licensees to “have flexibility 
to determine how to meet the established performance criteria in ways that encourage and reward 
improved outcomes.”160 The NRC’s Reactor Oversight Process, the means by which it achieves its 
mission of public health and safety in commercial nuclear power plant operations, is its primary 
155 EPA Office of Solid Waste and Emergency Response. General Guidance on Risk Management Programs for 
Chemical Accident Prevention (40 CFR Part 68); March 2009; pp 9-1 and 9-2. See 
http://www.epa.gov/osweroe1/docs/chem/Toc_final.pdf (accessed May 14, 2013). 
156 A high-risk facility is one that meets one of more of the following characteristics established by the EPA Office 
of Emergency Management: 1) Facilities whose reported RMP worst-case scenario population exceeds 100,000 
people; 2) Any RMP Program facility with a hazard index greater than or equal to 25; and/or 3) Facilities that have 
had one or more significant accidental releases within the previous five years. See “EPA Office of Inspector 
General, “Improvements Needed in EPA Training and Oversight for Risk Management Program Inspections.” 
March 21, 2013; Page 5. Available at http://www.epa.gov/oig/reports/2013/20130321-13-P-0178.pdf (accessed 
June 11, 2013). 
157 EPA OIG. Evaluation Report: EPA Can Improve Implementation of the Risk Management Program for 
Airborne Chemical Releases; February 10, 2009; p 15. 
158 Ibid. 
159 See NRC Glossary, available at http://www.nrc.gov/reading-rm/basic-ref/glossary/performance-based-
regulation.html (accessed June 10, 2013). 
160 US NRC NUREG/BR-0303. Guidance for Performance-Based Regulation (2002). http://www.nrc.gov/reading-
rm/doc-collections/nuregs/brochures/br0303/br0303.pdf (accessed June 13, 2013). 
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performance-based regulation.161 It uses seven “cornerstones,” such as mitigating systems and barrier 
integrity, to monitor three performance areas (reactor safety, radiation safety, and security safeguards).162 
Licensee performance data, inspection plans, quarterly assessments, and assessment and inspection 
responses are tied to each performance area and several cross-cutting objectives, such as worker 
involvement and human performance.163 Licensees are permitted to choose the precise methods they use 
to meet overarching performance goals, which are guided by their duty to reduce risks to as low as 
reasonably achievable, or ALARA.164,165 The NRC has stated that this flexibility is one of the main 
reasons that its regulatory philosophy encourages continuous improvement.166 
 
The National Aeronautics and Space Administration (NASA) has the goal of implementing a safety 
system that is “as safe as reasonably practicable,” or ASARP,167 which it considers to be closely related to 
ALARP. NASA relies on a risk-informed safety case, or RISC,168 to ensure that the system’s safety 
objectives, goals, and thresholds have been achieved, and that safety risk is as low as possible within 
reasonable impacts on cost, schedule, and performance.169 
 
 
 
 
 
 
161 http://www.nrc.gov/about-nrc/regulatory/risk-informed/concept/performance.html#example (accessed June 13, 
2013). 
162 NRC Reactor Oversight Process publication (2006), available at 
http://pbadupws.nrc.gov/docs/ML0708/ML070890365.pdf (accessed June 13, 2013). 
163 NRC Reactor Oversight Process publication (2006), available at 
http://pbadupws.nrc.gov/docs/ML0708/ML070890365.pdf (accessed June 13, 2013). 
164 US NRC NUREG/BR-0303, Guidance for Performance-Based Regulation (2002). http://www.nrc.gov/reading-
rm/doc-collections/nuregs/brochures/br0303/br0303.pdf (accessed June 13, 2013). 
165 ALARA “means making every reasonable effort to maintain exposures to radiation as far below the dose limits 
in this part as is practical consistent with the purpose for which the licensed activity is undertaken, taking into 
account the state of technology, the economics of improvements in relation to state of technology, the economics of 
improvements in relation to benefits to the public health and safety, and other societal and socioeconomic 
considerations, and in relation to utilization of nuclear energy and licensed materials in the public interest.” 10 CFR 
§20.1003 (2007). 
166 US NRC NUREG/BR-0303, Guidance for Performance-Based Regulation (2002). http://www.nrc.gov/reading-
rm/doc-collections/nuregs/brochures/br0303/br0303.pdf 
167 NASA defines ASARP as “a fundamental principle of adequate safety. A determination that a system is ASARP 
entails weighing its safety performance against the sacrifice needed to further improve it. The system is ASARP if 
an incremental improvement in safety would require a disproportionate deterioration of system performance in other 
areas.” NASA/SP-2010-580, NASA System Safety Handbook, Volume 1, System Safety Framework and Concepts 
for Implementation; November 2011; p 5. 
http://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20120003291_2012003429.pdf (accessed June 10, 2013). 
168 NASA defines RISC as “a structured argument, supported by a body of evidence that provides a compelling, 
comprehensive and valid case that a system is or will be adequately safe for a given application in a given 
environment. This is accomplished by addressing each of the operational safety objectives that have been negotiated 
for the system, including articulation of a roadmap for the achievement of safety objectives that are applicable to 
later phases of the system life cycle. The term ‘risk-informed’ is used to emphasize that a determination of adequate 
safety is the result of a deliberative decision making process that necessarily entails an assessment of risks and tries 
to achieve a balance between the system’s safety performance and its performance in other areas.” Ibid at 13. 
169 Ibid at xiii. 
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4.0 Key Features of an Effective Safety Case Regulatory Regime 
 
Following the Macondo disaster, the National Commission on the Macondo Oil Spill and Offshore 
Drilling170 made a recommendation in its Report to the President171 for the US to “develop a proactive, 
risk-based performance approach specific to individual facilities, operations and environments, similar to 
the ‘safety case’ approach in North Sea.”172 Despite the major potential hazards that are present in both 
onshore and offshore oil and gas operations, the safety case regime has not been implemented in the US 
for either sector. The US has instead implemented for major hazards at onshore facilities a more activity-
based approach, resulting in static regulations such as the PSM and RMP regulations that have not seen 
significant improvements173 since their inception, despite advances in technology and good industry 
practice. 
According to Dr. Hopkins and other renowned experts in the field, it is essential for an effective major 
accident prevention safety regime to take the form of a safety case, with adaptable goal-setting regulations 
that facilitate innovation and sustainability, and that drive industry to continuously improve and reduce 
risks to ALARP. To accomplish this, the regime must utilize sufficient numbers of highly competent 
personnel to effectively collect or promote industry use of process safety indicators174 and to provide 
knowledgeable oversight of industry operations. 
The CSB has determined that there are several key features of an effective major accident prevention 
regulatory approach such as the safety case regime: 
• 
Duty Holder Safety Responsibility, including a Written Case for Safety 
• 
Continuous Risk Reduction to ALARP 
• 
Adaptability and Continuous Improvement 
• 
Active Workforce Participation 
• 
Process Safety Indicators that Drive Performance 
• 
Regulatory Assessment, Verification, and Intervention; and an 
• 
Independent, Competent, Well-Funded Regulator 
As will be discussed in Section 5, California’s patchwork of regulations does not effectively implement 
these features, which are also illustrated in the figure below. Section 4 provides a detailed discussion of 
these features. 
 
170 President Barack Obama established the National Commission on the BP Macondo Oil Spill and Offshore 
Drilling through Executive Order 13543 on May 21, 2010, to examine the facts and circumstances concerning the 
root causes of the Macondo explosion and fire. For more information see 
http://www.oilspillcommission.gov/page/about-commission (accessed June 17, 2013). 
171 Available at http://www.oilspillcommission.gov/final-report (accessed June 17, 2013). 
172 National Commission on the BP Macondo Oil Spill and Offshore Drilling. Report to the President: Deep Water, 
The Gulf Oil Disaster and the Future of Offshore Drilling; January 2011; 252. 
173 OSHA did implement changes to 29 CFR §1910.106, creating a new Hazard Communication Standard. 
However, no changes have been made that impact the management of process safety under PSM. See 
https://www.osha.gov/dsg/hazcom/ (accessed August 6, 2013). 
174 Process safety indicators are also referred to as performance indicators, metrics, key process indicators (KPI), 
performance measures, indicators, etc. 
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Figure 1. Safety Case Attributes. 
4.1 
Duty Holder Safety Responsibility, including a Written Case for 
Safety 
Under the safety case regulatory regime, each individual company is responsible for the safety of each 
hazardous facility. The onus is on the duty holder175 to prove to the regulator that the company’s 
processes, methodologies used to assess risks, and reasoning for choosing one control over another have 
substantially reduced risks to as low as reasonably practicable (ALARP), or equivalent. The duty holder 
175 Duty holders are considered to be “those who create and/or have the greatest control of the risks associated with a 
particular activity. Those who create the risks at the workplace are responsible for controlling them.” HSE. 
Planning to do business in the UK offshore oil and gas industry? What you should know about health and safety; 
October 2011; p 2. http://www.hse.gov.uk/offshore/guidance/entrants.pdf (accessed June 5, 2013). These entities 
may include operators, contractors, and subcontractors. According to NOPSEMA, the idea is that those who create 
the risk must manage it. See http://www.nopsema.gov.au/safety/safety-case/what-is-a-safety-case/ (accessed July15, 
2013). 
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is required to prepare a written case for safety176 (“safety case report”) that identifies the hazards and risks 
and describes how they will be reduced to ALARP. The HSE has noted that the safety case report 
“demonstrates that the duty holder has arrangements in place which, if implemented, are capable of 
achieving compliance with legal objectives set out in other [] regulations…[and] provides a 
comprehensive core document that can be used as a check by both the duty holder and HSE that the 
accepted risk control measures and the health and safety management systems are in place and operate as 
they should.”177 The HSE has also stated: 
[t]he principal matters to be demonstrated in a safety case are that: a) the 
management system is adequate to ensure compliance with statutory 
health and safety requirements; and for management of arrangements 
with contractors and sub-contractors, b) that adequate arrangements have 
been made for audit and for audit reporting, [and] c) that all hazards with 
the potential to cause a major accident have been identified, their risks 
evaluated, and measures have been, or will be, taken to control those 
risks to ensure that the relevant statutory provisions will be complied 
with.178 
The safety case report must also demonstrate “how inherently 
safer design concepts have been applied in the design decisions 
taken.”179 This principle applies to all stages of the 
installation’s life cycle, and includes materials selection and 
managing corrosion in the design. 
It is also important to note that safety case reports are meant to 
be evergreen documents that reflect continuous improvement in 
risk reduction. For onshore operations in the UK, the duty 
holder is required to review the safety case report during the 
construction of a new facility, whenever new facts or technical 
knowledge about safety matters become known, or whenever 
the operator makes a change to the safety management system that could have significant impacts on the 
prevention of major accidents.180 The duty holder must revise the safety report to ensure that it “remains 
up to date and continues to provide an accurate representation of the major accident hazards…and the 
176 The HSE defines “safety case” as “a document that gives confidence to both the duty holder and HSE that the 
duty holder has the ability and means to control major accident risks effectively. It provides an extra level of 
regulatory control on top of regulations such as the Offshore Installations (Prevention of Fire and Explosion, and 
Emergency Response) Regulations 1995 (PFEER) and the Offshore Installations and Wells (Design and 
Construction, etc) Regulations 1996 (DCR), justified by the major accident potential of the offshore activities within 
scope.” HSE. A Guide to the Offshore Installations (Safety Case) Regulations 2005: Guidance on Regulations; 
2006; p 6. http://www.hse.gov.uk/pubns/priced/l30.pdf (accessed January 13, 2014). 
177 Ibid at 6. 
178 HSE. Assessment Principles for Offshore Safety Cases (APOSC); March 2006; p 7. 
http://www.hse.gov.uk/offshore/aposc190306.pdf (accessed August 6, 2013). 
179 Ibid at 16. 
180 COMAH Regulations, Part 3, Regulation 8 (1) (a)(b) and (c) (1999). 
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measures in place to control them.”181 According to HSE guidance on the offshore Safety Case 
Regulations, safety case reports are “intended to be living documents, kept up to date and revised as 
necessary during the operational life of the installation.”182 
In order for the facility to begin operation or remain in operation, the regulator must “accept” 183 the 
facility’s safety case report; however, the regulator’s acceptance of a safety case does not license the 
facility or installation as “fit,”184 nor does it shift the duty of risk control and reduction away from the 
facility owner or operator and onto the regulator; rather, the duty of major accident prevention and risk 
reduction to ALARP remains with the duty holder throughout the life of the facility. Following the 
regulator’s acceptance of the safety case report, the duty holder must ensure that the installation is 
operated in conformity with the management system and other provisions described in the safety case.185 
In the US, facilities commence operation before they are inspected or evaluated for complying with PSM 
or RMP regulations. In fact, the CSB has investigated incidents where the employer disputed that its 
process was covered by the PSM standard or RMP regulations. Regulators do not evaluate and approve 
PHAs or other hazard reviews and do not have the authority to license specific facilities for operation, 
based on the adequacy of their process safety programs. If an operating facility contains processes 
covered by the PSM standard, the facility must complete primarily activity-based regulatory requirements 
at least once every five years. The employer has no general duty to continually reduce risk. RMP-
covered facilities must submit fairly high-level information exhibiting compliance with RMP 
requirements at least once every five years. While the regulator ensures the RMP has been filed and 
contains the required sections, there is no analysis of the effectiveness of controls identified in the RMP to 
mitigate hazards. 
4.2 
Continuous Risk Reduction to ALARP 
As discussed above, a majority of the safety case regimes implemented globally impose a duty on owners 
or operators of covered facilities on and offshore to reduce risks to ALARP or equivalent. The Center for 
Chemical Process Safety (CCPS) defines ALARP as “a risk reduction goal, where risk reduction efforts 
are continued until the incremental effort to further reduce risk becomes grossly disproportionate to the 
level of additional risk reduction.”186 This principle provides the regulator with the main foundation on 
181 The Competent Authority. Revised guidance for operators of top tier COMAH establishments. Review and 
revision of COMAH safety reports. December 2009; p 5. http://www.hse.gov.uk/comah/report-review.pdf 
(accessed November 26, 2013). 
182 HSE. A Guide to the Offshore Installations (Safety Case) Regulations 2005: Guidance on Regulations; 2006; p 
7. http://www.hse.gov.uk/pubns/priced/l30.pdf (accessed May 7, 2013). 
183 “Acceptance requires satisfaction with the duty holder’s approach to identifying and meeting health and safety 
needs…HSE ‘accepts’ the validity of the described approach as being capable, if implemented as described, of 
achieving the necessary degree of risk control, but HSE does not confirm the outcomes of that approach.” 
Therefore, “HSE will accept a safety case or a revision…when duty holders demonstrate and describe specified 
matters to HSE’s satisfaction. Acceptance will be based on HSE’s judgment that the arrangements and measures 
described in the safety case taken as a whole are likely to achieve compliance if implemented as described. To give 
acceptance HSE does not need to be satisfied that compliance will be achieved.…” Ibid at 6. 
184 TAF Powell, SPE, UK Health & Safety Executive. US Voluntary Semp Initiative: Holy Grail or Poisoned 
Chalice? Proceedings of the Offshore Technology Conference, Houston, Texas, May 8-9, 1996; p 8. 
185 Ibid at 7. 
186 Center for Chemical Process Safety (CCPS). Inherently Safer Chemical Processes – A Life Cycle Approach; 2nd 
ed., 2009; p 46. 
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which to accept or reject a safety case report. In essence, the regulator ultimately determines whether 
ALARP has been achieved through the authority to accept or reject the safety case report. An advantage 
of ALARP as opposed to a prescriptive or activity-based approach is that ALARP results in the 
continuous reduction of risk to keep up-to-date with advancing technology and industry best practices.187 
Although two of the 14 PSM elements (PHA and mechanical integrity) contain performance-based or 
goal-setting requirements, 188 the PSM standard does not provide a specific risk reduction target such as 
ALARP. 
In reviewing the safety case report, the regulator may accept 
the application of relevant good practice as a sufficient 
demonstration of ALARP.189 As the HSE notes, “the 
measures in place to prevent or limit major accidents should 
be described in the safety report and be at least to ‘relevant 
good practice.’”190 According to Dr. Hopkins, the duty of 
ALARP “provides leverage for the regulator…[i]f an 
operator wishes to adopt a procedure or a standard that falls 
short of good or best practice, the regulator can reject it on 
the grounds that it does not reduce the risk as low as 
reasonably practicable.”191 As noted above, regulators such 
as HSE provide guidance on what is considered good 
practice, and publish documents containing good practice 
standards to assist operators with applying this concept. 
However, the duty holder must make the case for the standard or practice being utilized, and the regulator 
may determine that applying good practice alone is not sufficient to demonstrate that risks have been 
reduced to ALARP. In addition, if there is no directly applicable rule or standard, operators still have a 
duty to manage risk, and they therefore must maintain a reasonable level of risk awareness that goes 
beyond mere compliance.192 This raises a safety case regime above the compliance mentality of a more 
activity-based regime, such as PSM, and requires the duty-holder and the regulator to continuously ask 
whether there are other measures that would be effective in further reducing risks. 
The UK HSE provides ample guidance on determining what is considered to be ALARP, and many 
British courts have interpreted the concept as well. In the 1949 case Edwards v. National Coal Board, 
decided by the Court of Appeal, Judge Asquith wrote: 
‘Reasonably practicable’ is a narrower term than ‘physically possible’ 
and seems to me to imply that a computation must be made by the 
187 See http://www.hse.gov.uk/foi/internalops/hid_circs/permissioning/spc_perm_37/ (accessed December 9, 2013). 
188 29 CFR §1910.119(e)(1) requires the employer to “identify, evaluate, and control the hazards involved in the 
process.” 29 CFR §1910.119(j)(5) states that “[t]he employer shall correct deficiencies in equipment that are 
outside acceptable limits (defined by the process safety information in paragraph (d) of this section) before further 
use or in a safe and timely manner when necessary means are taken to assure safe operation.” 
189 HSE. Assessing compliance with the law in individual cases and the use of good practice; May 2003. 
http://www.hse.gov.uk/risk/theory/alarp2.htm (accessed June 12, 2013). 
190HSE. Guidance on ALARP Decisions in COMAH. 
http://www.hse.gov.uk/foi/internalops/hid_circs/permissioning/spc_perm_37/ (accessed November 26, 2013). 
191 Hopkins, Andrew. The Meaning of “Safety Case”; February 2013; p 6. 
192 Hopkins, Andrew. The Meaning of “Safety Case”; February 2013; p 6. 
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owner, in which the quantum of risk is placed on one scale and the 
sacrifice involved in the measures necessary for averting the risk 
(whether in money, time or trouble) is placed in the other; and that if it 
be shown that there is a gross disproportion between them – the risk 
being insignificant in relation to the sacrifice – the defendants discharge 
the onus on them.193 
While some critics in the US have argued that the determination of ALARP is strictly a quantitative risk 
assessment (QRA) calculation that is not sufficiently protective, the CSB has found that the HSE allows 
reliance upon qualitative assessments, QRA, and semi-quantitative risk assessments to determine 
ALARP.194 According to the HSE, essential considerations for determining whether a duty holder has 
reduced risks to ALARP include “the adoption of inherently safer designs…”195 and “[i]dentification of 
possible further measures that could be applied to lower the risk.”196 The HSE also notes that the 
guidance to COMAH Regulation 4 (General Duty) “describes the application of all measures necessary to 
reduce risk of a major accident to ALARP based on a hierarchical approach (inherent safety, prevention, 
control, mitigation).”197 In Norway, the PSA requires companies to “select technical, operational and 
organisational solutions that reduce the probability that harm, errors and hazard and accident situations 
occur.”198 PSA regulations require companies to choose the solutions that offer the best results, provided 
the costs are not significantly disproportionate to the risk reduction achieved.199 In Australia, the 
NOPSEMA enforces the Offshore Petroleum and Greenhouse Gas Storage Act 2006 and its regulations, 
which imposes a duty of care on the operator of a facility to “take all reasonably practicable steps” to 
ensure the facility is safe and all work and other activities are “carried out in a manner that is safe and 
193 Edwards, [1949] 1 K.B. at 704. 
194 Center for Chemical Process Safety (CCPS) guidance on risk assessment implies that as the predicted 
consequence of potential hazard scenarios increases, the level of analytical detail should also increase. Risk 
assessment approaches range in order of increasing analytical detail from qualitative, to semi-quantitative, to 
quantitative. Qualitative risk assessment is the simplest approach where judgments about consequence, likelihood, 
and the tolerability of risk are made on a subjective basis using the knowledge and experience of team members and 
may not be consistently applied within an organization. Semi-quantitative risk assessment is the second level of 
analytical detail, where organizations develop and provide to team members predetermined risk matrices and 
guidance for establishing numerical consequence and frequency levels. This approach is of greater value to team 
members as based upon their collective experience; the team typically has a sense of how frequently an event might 
occur and how great the potential consequence may be within the predetermined ranges. Layer of protection 
analysis (LOPA) is a semi-quantitative form of risk assessment, using order of magnitude categories for evaluating 
frequency, consequence, and adequacy of safeguards. Quantitative risk assessment involves the highest level of 
analytical detail and typically involves specialized expertise to perform. Complex models are commonly developed 
to evaluate frequency, consequence, and the effectiveness of safeguards in a quantitative risk assessment. Such 
approaches are typically standardized to minimize result variability within an organization and even between 
organizations in countries where a quantitative risk assessment is mandated by regulatory authorities. Center for 
Chemical Process Safety (CCPS). Guidelines for Developing Quantitative Safety Risk Criteria; August 2009. 
195 HSE. The Safety Report Assessment Manual, Sections 8 to 15. p 30. http://www.hse.gov.uk/comah/sram/s8-
15.pdf (accessed October 30, 2013). 
196 Ibid at 8. 
197 Ibid at 8. 
198 Regulations Relating to Health, Safety and the Environment in the Petroleum Activities and at Certain Onshore 
Facilities (The Framework Regulations). Section 11, Risk Reduction Principles. http://www.ptil.no/framework-
hse/category403.html (accessed November 26, 2013). 
199 Ibid. 
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without risk to the health of any person at or near the facility.”200 NOPSEMA explains that to achieve 
ALARP, the company “has to show, through reasoned and supported arguments, that there are no other 
practical measures that could reasonably be taken to reduce risks further.”201 
In the US, the NRC has “gradually revised its original scheme, giving an increasing importance to the 
‘economic and social factors’, in particular the involvement of all ‘stakeholders’ (authorities, 
management, staff, public) in the ALARA process.”202 For the regulator, the focus for whether ALARA 
has been achieved is on “processes, procedures, and judgments.”203 The duty holder must ensure that 
choices made to achieve ALARA are “fully documented together with the criteria which have brought to 
those choices. When the criteria are qualitative, it is more likely that subjective judgments play a large 
role, but those judgments must be equally recorded.”204 
There is no corresponding duty to reduce risks to ALARP in the PSM standard or RMP program. Rather, 
these regulations require that facilities “control” identified hazards, with no further dialogue on how far 
the operator must go to control those hazards. Neither the facility nor the regulator is required to 
determine whether more could be done to control hazards or reduce risks to comply with these 
regulations, and this may result in the implementation of insufficient controls relating to a hazard. 
While OSHA and the EPA do rely on general duty standards when implementing the PSM standard and 
the RMP program, these duties do not drive onshore companies toward reducing the risks of their 
activities to ALARP, and instead are utilized as enforcement tools typically after an incident has occurred, 
meant to cover those activities not specifically regulated. These standards may also be used by OSHA or 
EPA to cite a company for not following a specific RAGAGEP for 2 of the 14 process safety elements - 
mechanical integrity and PSI. 
OSHA enforces section 5(a) of the Occupational Safety and Health Act (OSHAct), which states the 
following: 
 
 
(a) Each employer – 
(1) shall furnish to each of his employees employment and a place of 
employment which are free from recognized hazards that are causing or 
are likely to cause death or serious physical harm to his employees; 
(2) shall comply with occupational safety and health standards 
promulgated under this act…205 
Section 5(a)(1), also known as OSHA’s General Duty Clause, has been described as a “catch-all” 
provision meant to fill gaps in OSHA law for recognized unregulated hazards.206,207 In order for OSHA to 
200 Offshore Petroleum and Greenhouse Storage Act 2006, Volume 3, Schedule 3, Clause 9. 
http://www.comlaw.gov.au/Details/C2012C00148/Html/Volume_3#_Toc315688204 (accessed October 30, 2013). 
201 ALARP Guidance Note N-04-300-GN0166, Rev. 3 (Dec. 2011) available at 
http://www.nopsema.gov.au/assets/document/N-04300-GN0166-ALARP.pdf (accessed May 15, 2013). 
202 Fasso, Alberto, and Rokni, S. Operational Radiation Protection in High Energy Physics Accelerators. 
Implementation of ALARA in Design and Operation of Accelerators. May 2009; p 6. 
 
203 Ibid at 6. 
204 Ibid at 6 and 7. 
205 29 U.S.C. §654(a)(1) and (2) (2004). 
206 Morrison, Kyle W. The General Duty Clause: What is it, how does OSHA use it and what should employers 
know? Safety + Health [Online]; May 1, 2011. 
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issue a General Duty Clause violation, the hazard must be recognized, the employer must have failed to 
keep the workplace free of the hazard to which his or her employees were exposed, a practical method 
must be available to correct the hazard, and the hazard must be causing or likely to cause death or serious 
injury.208 This duty would thus only apply if the absence or failure of one control in a series of controls 
makes an accident likely to occur (emphasis added). 
On the other hand, in a safety case regulatory regime, the regulator proactively reviews identified hazards 
and risk reduction strategies proposed by the operator to ensure that risks are being reduced to ALARP. 
The regulator may require the installation of an absent control if such a control is considered good 
industry practice, or if it goes further in reducing risks to ALARP. This is a key feature of the safety case 
approach in preventing major accidents. 
Under the CAA, the General Duty Clause requires owners and operators “to identify hazards which may 
result from such releases using appropriate hazard assessment techniques, to design and maintain a safe 
facility taking such steps as are necessary to prevent releases, and to minimize the consequences of 
accidental releases which do occur.”209 Similar to OSHA, the EPA can use its General Duty Clause 
enforcement authority to create legally binding requirements or enforce actions for hazards that have not 
been specifically regulated. The EPA can use this authority proactively (before an incident) or reactively 
(following an incident), and can enforce the clause where it finds the possibility of imminent and 
substantial endangerment.210 
According to EPA guidance on the RMP program, because it is the owner or operator’s duty to “prevent 
accidents and ensure safety at [their] source…” this may require steps to be taken “beyond those specified 
in the risk management program rule.”211 While this principle appears to be similar to ALARP 
requirements of the safety case, in practice whether this is done is not subject to regulation or review. In 
addition, it is permissive in that it uses the word “may.” Nothing additional, such as ALARP, is required. 
This will be addressed below in more detail in the discussion of implementation of the EPA RMP 
program in California. 
4.3 
Adaptability and Continuous Improvement 
A key strength of the safety case regulatory regime is that it provides the regulator with the tools to drive 
continuous improvement among facilities and ensure risks have been reduced to ALARP or equivalent, 
rather than focusing on compliance with activity-based regulatory requirements. Although complying 
with good practice may achieve ALARP, the regulator also has the ability under this regime to require 
facilities to go above and beyond good practices and standards to achieve ALARP without requiring 
http://www.nsc.org/safetyhealth/Pages/5%2011%20The%20General%20Duty%20Clause.aspx (accessed June 5, 
2013). 
207 According to the National Safety Council, General Duty Clause violations make up only about 1.5 percent of 
total violations issued annually by OSHA. Available at 
http://www.nsc.org/safetyhealth/Pages/5%2011%20The%20General%20Duty%20Clause.aspx (accessed June 5, 
2013). 
208 Ibid. 
209 42 U.S.C. §7412(r)(1) (1990). 
210 42 U.S.C. §7412(r)(9) (1990). 
211 EPA Office of Solid Waste and Emergency Response. General Guidance on Risk Management Programs for 
Chemical Accident Prevention (40 CFR Part 68); March 2009; p 7-7. 
http://www.epa.gov/osweroe1/docs/chem/Toc_final.pdf (accessed May 14, 2013). 
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rulemaking. The Baker Panel212 noted in its 2007 report (“the Baker Report”) on BP and its process 
safety performance following the 2005 BP Texas City disaster that an effective process safety 
management system builds upon an “improvement cycle” that “should include, in practice, continuous 
reduction of process risk and improvements in safety performance according to some measurable 
criteria.”213 
The Baker Panel defined “continuous improvement” as 
• 
improving controls for process hazards, including process safety knowledge 
and competence of workers; 
• 
improving process safety leadership of supervisors; 
• 
improving process engineering to identify and then design to remove or 
mitigate the effects of process hazards; 
• 
going beyond legal compliance to best practices to reduce risks; 
• 
going beyond mere compliance with internal standards, but learning from 
operating experiences, incident and near miss investigations, hazard studies, 
audits, and other assessments to improve those internal standards; and 
• 
identifying and implementing not only those external standards that must be 
observed, but also those that represent best practices that can lead to process 
safety excellence.214 
An independent review conducted of the Australian offshore safety case regime in 2000 echoes the 
importance of continuous improvement in process safety management, stating that “critical to the 
successful implementation of a safety case regime is the achievement of a qualitative shift in industry and 
regulatory safety cultures from the minimalist compliance of the prescriptive regime to the philosophy of 
best practice and continuous improvement.”215 Recently, Lord Cullen addressed the importance of 
adaptability as well, when he spoke at the 2013 Oil & Gas UK Piper 25 offshore safety conference in 
Aberdeen, Scotland.216 In his keynote speech, Lord Cullen quoted the Maitland panel, which examined 
the UK offshore safety regime after the Macondo incident, noting that “safety cases should be living 
documents [emphasis added] central to the way facilities are operated, with contents widely 
understood.”217 
212 In the aftermath of the BP Texas City Incident, BP followed the recommendation of the CSB and formed an 
independent panel known as the Baker Panel to conduct a thorough review of the company’s corporate safety 
culture, safety management systems, and corporate safety oversight at its US refineries. For a copy of their findings 
and recommendations see 
http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/SP/STAGING/local_assets/assets/pdfs/Bak
er_panel_report.pdf (accessed August 13, 2013). 
213 Baker, J. The Report of the BP U.S. Refineries Independent Safety Review Panel, 2007; p 166. 
214 Baker, J. The Report of the BP U.S. Refineries Independent Safety Review Panel, 2007; p 166. 
215 Department of Industry, Science and Resources; Offshore Safety and Security, Petroleum and Electricity 
Division. Australian Offshore Petroleum Safety Case Review: Report of the Independent Review Team. 2000; p 33. 
216 In June 2013, Oil & Gas UK held a large offshore safety conference in Aberdeen, which marked the 25th 
anniversary of the Piper Alpha disaster. For more information see 
http://www.oilandgasuk.co.uk/events/Piper25.cfm?frmAlias=/Piper25/ (accessed September 16, 2013). 
217 Finding Petroleum. Review: Lord Cullen – what have we learned from Piper Alpha? September 16, 2013. 
http://www.findingpetroleum.com/n/Review_Lord_Cullen_what_have_we_learned_from_Piper_Alpha/044b5113.as
px (accessed September 16, 2013). 
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As changes to regulatory requirements necessitate an extensive, lengthy rulemaking process in the US,218 
process safety-related regulations can remain static for decades, while industry standards (many of which 
are voluntary under the current US system), technologies, and improved procedures and practices 
continue to change and advance, and new chemicals come into production. In light of major accidents 
that have occurred, such as the BP Texas City explosion and fire which resulted in 15 fatalities, and the 
Motiva Enterprises sulfuric acid tank explosion, which fatally injured one worker and injured eight others, 
the CSB has made a number of key recommendations to OSHA and the EPA to revise the PSM and RMP 
regulations, respectively. However, agencies have failed to implement these recommendations and these 
regulations have remained static despite the important lessons learned from these incidents. In addition, 
the OSHA PSM standard’s Appendix A, which contains a list of toxic and reactive highly hazardous 
chemicals and the threshold quantity for each, was originally created using a number of older sources, 
including the EPA’s “Extremely Hazardous Substance List,” the 1982 Seveso Directive, the 1984 
CIMAH regulations, and others. A number of these sources have been revised, updated, and amended 
throughout the years, while Appendix A has not. In fact, no chemicals have been added to either the PSM 
or the RMP programs since the rules were initially adopted in the 1990s, even as numerous serious 
process incidents have occurred involving chemicals that were not listed. 
The U.S. Government Accountability Office (GAO) published a 2012 report on OSHA’s standard setting 
abilities, and noted that between 1981 and 2010, OSHA took anywhere from 15 months to 19 years to 
develop and issue 58 significant safety and health standards (averaging seven years).219 According to the 
report, OSHA reasoned that it must evaluate technological and economic feasibility of a potential 
standard using data gathered by visiting worksites in industries that will be affected, on an industry-by-
industry basis.220 This was described as “an enormous undertaking because, for example, it requires visits 
to multiple worksites.”221 In addition, Executive Order 12866222 requires that federal agencies, including 
OSHA, provide an assessment of the potential overall costs and benefits for significant rules to the Office 
of Management and Budget (OMB). OSHA will typically be required under the Small Business 
Regulatory Enforcement Fairness Act of 1996223 to initiate a panel process to receive and consider input 
218 5 U.S.C. Chapter 5, sections 511-599, also known as the Administrative Procedure Act, or APA, requires that 
federal agencies seeking to promulgate a rule or regulation submit to a lengthy notice and comment rulemaking 
process that includes publishing the proposed rule making in the Federal Register; providing the public with at least 
30 days to participate in the rulemaking process by submitting written comments or data, and then discussing the 
public comments and providing a rationale for accepting or rejecting them. The OSHAct Section 6(b) specifies the 
procedures OSHA must use to promulgate, modify, or revoke its standards (29 U.S.C. §655(b)). These procedures 
include publishing the proposed rule in the Federal Register, providing interested persons an opportunity comment, 
and holding a public hearing upon request. 
219 GAO. Workplace Safety and Health: Multiple Challenges Lengthen OSHA’s Standard Setting; April 19, 2012; p 
5. Available at http://gao.gov/assets/600/590210.pdf (accessed June 12, 2013). 
220 Ibid at 6. The Supreme Court has held that the OSHAct requires that standards be both technologically and 
economically feasible. Am. Textile Mfrs. Inst. V. Donovan, 452 U.S. 490, 513 n. 31 (1981). Also see United 
Steelworkers v. Marshall, 647 F. 2d 1189, 1301 (D.C. Cir. 1980), quoted in AFL-CIO v. OSHA, 955 F. 2d 962, 980 
(11th Cir. 1992). Assessing feasibility on an industry-by-industry basis requires that the agency research all 
applications of the hazard being regulated, as well as the expected cost for mitigating exposure to that hazard, in 
every industry. 
221 Ibid at 6. 
222 Exec. Order No. 12866, 48 Fed. Reg. 190 (September 30, 1993). 
http://www.whitehouse.gov/sites/default/files/omb/inforeg/eo12866/eo12866_10041993.pdf (accessed June 12, 
2013). 
223 5 U.S.C. §609(b), (d) (1996). 
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from representatives of affected small businesses, which could take eight months or more.224 Only 
OSHA, the EPA, and the Consumer Financial Protection Bureau are subject to this requirement.225 
Finally, the OSHAct directs courts to review OSHA’s standards using a more stringent legal standard 
than the Administrative Procedure Act’s (APA’s) “arbitrary and capricious” test226 when reviewing 
OSHA’s standards;227 an OSHA standard may only be upheld if it is supported by “substantial evidence 
in the record considered as a whole.”228 According to the GAO report, OSHA officials claim this more 
stringent standard (known as the “substantial evidence” standard) requires a higher level of scrutiny by 
the courts and as a result, OSHA staff must conduct a large volume of detailed research in order to 
understand all industrial processes involved in the hazard being regulated, and to ensure that a given 
hazard control would be feasible for each process.229 The GAO also found that although OSHA has the 
ability to address urgent hazards by issuing emergency temporary standards, the agency has not used this 
authority since 1983 because of the difficult hurdles the agency faces in presenting the evidence necessary 
to meet the statutory requirements.230 In summary, all of these extensive rulemaking constraints have 
resulted in OSHA’s inability to undertake many standard revisions or improvements. 
In Spring 2013, OSHA announced its new regulatory agenda, which stated that one of the things OSHA 
plans to consider is revising the PSM standard to “address gaps in safety coverage.”231 Potential revisions 
include “expanding coverage and requirements for reactivity hazards,” which the CSB addressed in its 
2002 report entitled “Improving Reactive Hazard Management,”232 and “expanding the scope of 
224 GAO. Workplace Safety and Health: Multiple Challenges Lengthen OSHA’s Standard Setting; April 19, 2012; p 
6. Available at http://gao.gov/assets/600/590210.pdf (accessed June 12, 2013). 
225 5 U.S.C. §609(d) (1996). 
226 Pursuant to the APA, agency decisions may be set aside only if “arbitrary, capricious, an abuse of discretion, or 
otherwise not in accordance with law.” 5 U.S.C. §706(2)(A). There is abundant case law that discusses this 
standard. Courts have held that a court “may reverse under the arbitrary and capricious standard only if the agency 
has relied on factors that Congress has not intended it to consider, entirely failed to consider an important aspect of 
the problem, offered an explanation for its decision that runs counter to the evidence before the agency, or is so 
implausible that it could not be ascribed to a difference in view or the product of agency expertise. See Greater 
Yellowstone Coalition v. Lewis, 638 F. 3d 1143, 1148 (9th Cir. 2010) (as amended) (relaying on The Lands Council 
v. McNair, 537 F.3d 981, 987 (9th Cir. 2008) (en banc), overruled on other grounds by Winter v. Natural Res. Def. 
Council, 555 U.S. 7 (2008)). 
227 GAO. Workplace Safety and Health: Multiple Challenges Lengthen OSHA’s Standard Setting; April 19, 2012; p 
9. http://gao.gov/assets/600/590210.pdf (accessed June 12, 2013). 
228 29 U.S.C. §655(f). 
229 GAO. Workplace Safety and Health: Multiple Challenges Lengthen OSHA’s Standard Setting; April 19, 2012; p 
9. http://gao.gov/assets/600/590210.pdf (accessed June 12, 2013). 
230 OSHA must demonstrate that workers are exposed to grave danger and establish that an emergency temporary 
standard is necessary to protect workers from that grave danger. OSHA is also required to replace an emergency 
temporary standard with a permanent standard within six months using the requirements laid out in OSHAct 6(b). 
Ibid at 11. 
231 See OSHA’s rulemaking abstract at 
http://www.reginfo.gov/public/do/eAgendaViewRule?pubId=201304&RIN=1218-AC82 (accessed September 17, 
2013). 
232 In this report, the CSB recommended to OSHA that it amend the PSM standard “to achieve more comprehensive 
control of reactive hazards that could have catastrophic consequences.” The report is available at 
http://www.csb.gov/assets/1/19/ReactiveHazardInvestigationReport.pdf (accessed September 17, 2013). The 
recommendations start on page 89 of the report. 
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paragraph (j) to cover the mechanical integrity of any safety-critical equipment….”233 However, OSHA 
has proposed changes to the PSM standard before, with no action ultimately being taken. On April 27, 
1998, OSHA announced that it was considering issuing an Advance Notice of Proposed Rulemaking234 
(ANPRM) “to address issues related to reactive chemicals raised by the explosion of a chemical plant in 
Lodi, New Jersey in 1995.”235,236 On May 14, 2001, OSHA clarified its intent to publish an ANPRM “to 
address the need to add reactive chemicals that are not currently covered by PSM…”237 On December 3, 
2001, however, the entry on reactives was withdrawn from the rulemaking agenda.238 Following the 
devastating ammonium nitrate explosion on April 17, 2013, in West, Texas, which resulted in at least 14 
fatalities and mass destruction in the town of West, CSB Chairperson Moure-Eraso urged both OSHA and 
the EPA to expand their standards to include reactive chemicals and hazards such as ammonium nitrate.239 
On July 25, 2013, the CSB held a public meeting in Washington, DC to discuss the status of key open 
recommendations the CSB has made to OSHA over the last decade to revise its PSM standard and create 
a new combustible dust standard. These recommendations, which include revising the PSM standard to 
require MOC reviews for organizational changes such as mergers and acquisitions that may impact 
process safety, and ensuring PSM coverage for atmospheric storage tanks that could be involved in a 
potential catastrophic release, have stemmed from major CSB investigations including its BP Texas City, 
Motiva, ConAgra, Kleen, Imperial Sugar, and Hoeganaes investigations, as well as its Combustible Dust 
Study.240 OSHA’s failure to implement these recommendations, which can be attributed to its lack of 
rulemaking activities over the last decade, led the CSB to reclassify seven key open recommendations as 
“Open-Unacceptable.” The CSB also adopted the OSHA Combustible Dust Standard recommendation as 
a CSB “Most Wanted Chemical Safety Improvement.” OSHA formally responded and cited to the GAO 
report discussed above, noting that on average, it takes OSHA seven years to issue a standard, a process 
233 See OSHA’s rulemaking abstract at 
http://www.reginfo.gov/public/do/eAgendaViewRule?pubId=201304&RIN=1218-AC82 (accessed September 17, 
2013). 
234 Most federal agencies develop rules through “informal rulemaking.” Under the Administrative Procedure Act, or 
APA, informal rulemaking requires a publication of a “Notice of Proposed Rulemaking” (NPRM) in the Federal 
Register; opportunity for public participation by submission of written comments; consideration by the agency of the 
public comments and other relevant material; and publication of a final rule not less than 30 days before its effective 
date, with a statement explaining the purpose of the rule. Under the APA, an agency may publish an Advance 
Notice of Proposed Rulemaking (ANPRM) when the agency wants to test out a proposal or solicit ideas before it 
drafts its NPRM. For more information see http://www.foreffectivegov.org/node/226 (accessed September 17, 
2013). 
235 See https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=13792 
(accessed September 17, 2013). 
236 This incident took place on Friday, April 21, 1995, at a chemical facility occupied by Napp Technologies. The 
explosion and fire resulted in five fatalities. 
237 See https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=16776 
(accessed September 17, 2013). 
238 See https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=16946 
(accessed September 17, 2013). 
239 In a 2002 study entitled Improving Reactive Hazard Management, the CSB made recommendations to OSHA 
and the EPA to expand their regulations to include reactive chemicals and hazards. To date, neither agency has 
acted on the recommendations. See http://www.csb.gov/in-safety-message-csb-chairperson-rafael-moure-eraso-
calls-for-regulatory-coverage-of-reactive-chemicals-following-the-west-fertilizer-explosion-and-fire-/ (accessed 
September 23, 2013). 
240 For more information on this meeting, see http://www.csb.gov/events/csb-public-meeting-to-vote-on-key-safety-
recommendations-and-initiate-most-wanted-program/ (accessed July 29, 2013). 
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that is only getting longer. Hence, OSHA reserves rulemaking for “widespread and serious hazards.” 
Needed petroleum refinery and chemical process safety improvements may never fall under this category. 
OSHA noted at the meeting that it would be utilizing a Request for Information241 (RFI) to aid in the 
revision of its PSM standard, aimed at addressing a number of issues that have developed in the 21 years 
since the PSM standard was promulgated in 1992. On December 9, 2013, OSHA published its RFI in the 
Federal Register.242 The RFI requests comment on potential revisions to OSHA’s PSM standard, among 
other regulations. The RFI identifies seventeen topics for potential rulemaking and enforcement changes, 
including clarifying the PSM exemption for atmospheric storage tanks and expanding PSM coverage and 
requirements for reactive hazards. The RFI also cites a number of CSB investigation reports and 
recommendations, including the CSB Reactive Hazard Study entitled Improving Reactive Hazard 
Management, the BP Texas City Investigation Report, and the Donaldson Enterprises, Inc., Investigation 
Report.243 Although the RFI is an important opportunity to enhance the dialogue on implementation of 
the safety case regulatory approach to enhance process safety management and risk reduction in the US, it 
does not specifically mention the safety case approach.244 
On January 3, 2014, OSHA released a response to Section 6(a) of Executive Order 13650,245 which 
tasked the Chemical Facility Safety and Security Working Group, created by the Order and consisting of 
federal agencies such as OSHA, the EPA, and PHMSA,246 with considering options to improve chemical 
safety regulation. The document provides separate responses from each member agency of the group, and 
notes that the group is seeking public input on potential areas where standards could be improved. 
According to the document, three agencies – OSHA, the EPA, and PHMSA – have all included 
“[e]valuating the implementation of best practices and lessons learned such as the ‘safety case’ regulatory 
241 An RFI is a tool used by a federal agency to help develop a proposed rule. Federal agencies generally use RFIs 
when they want public input on whether a new rule or changes to an existing rule are needed, and comments on 
what course the agency should take should it decide to move forward. More information available at 
http://www.dol.gov/regulations/participate.htm (accessed July 29, 2013). 
242 78 Fed. Reg. 73756 (2013). 
243 A full copy of the OSHA RFI is available at https://www.federalregister.gov/articles/2013/12/09/2013-
29197/process-safety-management-and-prevention-of-major-chemical-accidents (accessed January 7, 2014). 
244 OSHA has released on its website a separate document responding to Executive Order 13650, Section 6(a) – 
Solicitation of Public Input on Options for Policy, Regulation, and Standards Modernization. OSHA states in this 
document that it is seeking public input on potential areas where it could improve its standards, and includes 
“[e]valuating the implementation of best practices and lessons learned such as the ‘safety case’ regulatory model to 
reduce risk in complex industrial processes” as an area to consider. 
https://www.osha.gov/chemicalexecutiveorder/Section_6ai_Options_List.html (accessed January 7, 2014). 
However, the safety case regulatory model is not mentioned in the RFI that was released for public comment. 
245 This document is available at https://www.osha.gov/chemicalexecutiveorder/Section_6ai_Options_List.html 
(accessed January 7, 2014). 
246 The Chemical Facility Safety and Security Working Group is co-chaired by the Secretary of Homeland Security, 
the Administrator of the EPA, and the Secretary of Labor. The Working Group must consist of the head or a 
designated representative of the Department of Justice, Department of Agriculture, and the Department of 
Transportation. The Working Group must also consult with representatives from the Council on Environmental 
Quality; the National Security Staff; the Domestic Policy Council; the Office of Science and Technology Policy; the 
Office of Management and Budget; the White House Office of Cabinet Affairs; and other agencies designated by the 
President. http://www.whitehouse.gov/the-press-office/2013/08/01/executive-order-improving-chemical-facility-
safety-and-security (accessed January 13, 2014). 
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model to reduce risk in complex industrial processes” in a preliminary list of options to consider for 
improving chemical facility and safety.247 
OSHA’s ability to adapt to process safety-related new or revised codes, standards, technology, and 
lessons learned is mainly limited to RAGAGEP requirements, which OSHA included in the mechanical 
integrity and PSI elements of its PSM standard in part to “provide flexibility for the employer to choose 
the frequency which would provide the best assurance of equipment integrity.”248 OSHA meant for 
RAGAGEP to include “both appropriate internal standards and applicable codes and standards.…”249 
However, the concept of RAGAGEP only applies to 2 of the 14 PSM standard elements (mechanical 
integrity and PSI),250 only addresses equipment and mechanical integrity, and is usually utilized by 
OSHA as a mechanism to issue citations to companies post-incident. 
In addition, OSHA has had difficulty enforcing RAGAGEP citations. In a recent OSHA Review 
Commission proceeding, Secretary of Labor v BP Products North America, Inc., & BP-Husky Refining, 
LLC,251 and United Steelworkers Local 1-346, the Administrative Law Judge (ALJ) vacated OSHA 
RAGAGEP citations issued to BP for violations of 29 CFR §1910.119(d)(3)(ii)252 for failure to comply 
with a specific RAGAGEP, holding that OSHA impermissibly adopted a specific RAGAGEP, thereby 
diminishing the performance aspect of the RAGAGEP requirements contained within the OSHA PSM 
standard. The ALJ concluded that by citing to only one specific RAGAGEP, OSHA impermissibly 
adopted a prescriptive standard; in the ALJ’s view, OSHA should have acknowledged other possible 
RAGAGEPs for BP to comply with, including BP’s own internal standards. If upheld, this ruling may 
limit OSHA’s ability to utilize RAGAGEP as a means of requiring companies to implement industry 
good practices in the future.253 
The cumbersome rulemaking process and lack of flexibility that has resulted in stagnant and static OSHA 
standards can be contrasted with the structure of the safety case regulatory regime, which facilitates 
adaptability and enables the regulator to improve industry safety performance and practices without 
requiring a major rule change. The safety case essentially provides the regulator with the tools to 
recognize more rigorous standards and practices that exist and drive a company to implement those 
practices to further reduce risks, as well as work with industry to improve existing standards and practices 
if necessary. It also enables companies to implement new, more efficient or safer technologies that do not 
necessarily meet strict prescriptive regulations, but that drive risk reduction. 
This adaptability is illustrated by the HSE’s recommendations following the 2004 Buncefield incident. 
On December 11, 2005, a number of explosions occurred at Buncefield Oil Storage Depot in Hemel 
Hemptstead, Hertfordshire, England following the overfilling of a gasoline tank. Over 40 people were 
injured and there was significant offsite damage to homes and businesses. An independently chaired 
Major Incident Investigation Board led by Lord Newton of Braintree was set up to investigate the 
incident. Between 2006 and 2008 the Board issued a number of reports and recommendations. In the 
247 Ibid. 
248 57 Fed. Reg. 6390-6391 (1992). 
249 Ibid at 6390-6391. 
250 29 CFR §§1910.119(d)(3)(ii) and (j)(4)(ii) and (iii). 
251 BP Products North America, Inc. operates a refinery in Oregon, Ohio. BP-Husky is a joint venture with a 
business interest in the refinery. 
252 29 CFR 1910.119(d)(3)(ii) requires the employer to document that equipment complies with RAGAGEP. 
253The Occupational Safety and Health Review Commission is scheduled to review the decision. 
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report issued in March 2007 entitled “Recommendations on the design and operation of fuel storage 
sites,” the Board highlighted the adaptability of the existing regulatory regime by noting that the 
recommendations to improve standards and revise guidance should not require actual changes to the law, 
because the existing legal framework was “sufficient to ensure that necessary improvements are put in 
place.”254 The Board followed by making its first recommendation of the report to the COMAH CA and 
operators of Buncefield-type sites to develop and agree on a methodology to determine safety integrity 
level requirements for overfill prevention systems, which takes account of, among other things, nearby 
resources or populations.255 The Board also recommended that the sector “develop guidance to 
incorporate the latest knowledge on preventing loss of primary containment and on inhibiting escalation if 
loss occurs.”256 Another key recommendation was made to the CA to “ensure that safety reports 
submitted under the COMAH Regulations contain information to demonstrate that good practice in 
human and organisational design, operation, maintenance and testing is implemented as rigorously as for 
control and environmental protection engineering systems.”257 Finally, the Board recommended in this 
report that the “sector agree with the Competent Authority on a system of leading258 and lagging259 
performance indicators for process safety performance…” based on HSE’s guidance on Developing 
process safety indicators.260 
Spurred by recommendations made surrounding the Buncefield incident, the BP Texas City incident, and 
the BP Grangemouth incident,261 the COMAH CA developed an Operational Delivery Guide entitled 
“COMAH Competent Authority Workstream 2e: Process safety performance indicators,”262 which was 
“designed to continue the promotion and development of site level process safety performance indicators 
(PSPIs) as part of the monitoring arrangements for an effective process safety management system at 
major hazard sites.”263 The guide states that by the end of March 2013 all “Buncefield-type” sites would 
“have effective monitoring of process safety performance in place and that site specific leading and 
lagging performance indicators have been developed…”264 and that by the end of 2015 “all major hazard 
establishments and duty holders will measure their performance on the control of major hazard risks by 
way of key leading and lagging performance indicators.”265 It lays out in detail a six-step process for 
implementing a process safety measurement system; how inspectors will assess a duty holder’s 
254 Buncefield Major Incident Investigation Board. Recommendations on the design and operation of fuel storage 
sites; March 2007; p 3. http://www.buncefieldinvestigation.gov.uk/reports/recommendations.pdf (accessed May 21, 
2013). 
255 Ibid at 8. 
256 Ibid at 15. 
257 Ibid at 19. 
258 Leading indicators are measurements that predict future performance to ensure that safety protection layers and 
operating discipline are being maintained, including unsafe behaviors or insufficient operating discipline equipment 
selection, engineering design, specification of inspection frequency, and technique. See Center for Chemical 
Process Safety (CCPS), Guidelines for Process Safety Metrics; October 2009; p 20. 
259 Lagging indicators are facts about previous events, such as process safety incidents, that meet the threshold of 
severity and should be reported as part of the process safety metric. Ibid at 20. 
260 Ibid at 13. 
261 Between May 29 and June 10, 2000, three incidents occurred at the BP Grangemouth Petrochemical Complex in 
Scotland, which is one of the largest of the 950 COMAH sites in the UK. 
262 Available at http://www.hse.gov.uk/comah/guidance/process-safety-performance-indicators.pdf (accessed May 
21, 2013). 
263 COMAH Competent Authority, “Workstream 2e: Process safety performance indicators,” 2012; page 3. 
264 COMAH Competent Authority, “Workstream 2e: Process safety performance indicators,” 2012; page 6. 
265 Ibid at 3. 
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performance; and adds that full implementation of this program could take between 18 months and two 
and a half years from when the initial introduction takes place – all without requiring any fundamental 
changes to the COMAH regulations themselves. 
The COMAH CA Investigation Team noted in its publication summarizing the conclusions of the 
Buncefield investigation that following the incident, the CA, industry, and trade unions worked together 
to “drive forward high standards at fuel storage sites…[which] has resulted in agreement on improved 
standards of safety and environmental protection for all UK sites storing large volumes of gasoline and to 
systematically upgrade sites to meet these standards….”266 
In another example following the Buncefield incident, the Board recommended significantly higher 
standards than were generally in place in the sector. For example, the Board recommended that fuel 
storage tanks be fitted with automatic overfill protection equipment that would cut off supply if an overfill 
event occurs, rather than continuing to rely on operators to interrupt flow manually in the case of an 
event. In response, the UK Petroleum Industry Association and the Tank Storage Association adopted the 
recommendation, and the British government announced that it would require all sites to move to fully 
automatic shutdown systems on tanks storing gasoline. The Process Safety Leadership Group (PSLG) 
was formed to help develop the details of the new rule, and to “meet the need for an effective framework 
for interaction between industry, trade unions and the COMAH Competent Authority (CA).…”267 As 
will be discussed in the next section, workforce involvement is a key element of an effective safety case 
regulatory regime. In 2009, HSE published the PSLG’s work in a document entitled Safety and 
Environmental Standards for Fuel Storage Sites. The document lays out precisely which tanks must 
utilize automatic overfill protection equipment, and also allows for duty holders to demonstrate technical 
reasons as to why automatic overfill protection would not be appropriate by “prepar[ing] a robust 
demonstration that alternative measures are capable of achieving an equivalent ALARP outcome to an 
overfill protection system that is automatic…”268 This document in essence was developed as an industry 
good practice, and compliance with its requirements would likely ensure that the duty holder is complying 
with the law and reducing risks to ALARP.269 
This can be contrasted with an even larger release of gasoline and a subsequent explosion that occurred in 
the 2009 tank overfill at the Caribbean Petroleum Corporation near San Juan, Puerto Rico. This incident 
severely damaged surrounding buildings and impacted moving vehicles. However, the incident has not 
resulted in any re-evaluation of safety rules by the EPA or OSHA, despite the fact that tank terminals 
largely fall outside the PSM and RMP program regulations, (let alone the more rigorous requirements of a 
major hazard safety case regulatory regime, as practiced in the UK). 
These post-Buncefield examples highlight one of the most important attributes of the safety case 
regulatory approach: it is a regulatory framework that implements a balance of goal-setting and 
prescriptive elements which enable the regulator to drive facilities to continuously improve practices 
266 The Competent Authority. Buncefield: Why did it happen? The underlying causes of the explosion and fire at 
the Buncefield oil storage depot, Hemel Hempstead, Hertfordshire on 11 December 2005; February 2011; p 3. 
http://www.hse.gov.uk/comah/buncefield/buncefield-report.pdf (accessed May 21, 2013). 
267 Process Safety Leadership Group. Safety and environmental standards for fuel storage sites; London, 2009; p 7. 
http://www.hse.gov.uk/comah/buncefield/fuel-storage-sites.pdf (accessed August 1, 2013). 
268 Ibid at 29. 
269 For a detailed discussion of rule-compliance and the safety case, see Hopkins, Andrew. Risk-management and 
rule-compliance: Decision-making in hazardous industries; Safety Science 49 (1011) 110-120. 
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aimed at reducing risks to ALARP, without having to adhere to the extensive and time-consuming 
rulemaking requirements that exist in the US. This flexibility and adaptability encourages facilities to 
focus on improving practices and technology rather than on completing activity-based requirements, 
which can have the effect of stifling innovation and technological advancement. 
Critics argue that because there have been significant industry problems with the maintenance of safety 
critical equipment and aging equipment in the UK, 270 the safety case regime is not operating effectively. 
Regulators and commissions in the UK have found degradation of pipes, valves, and other equipment at 
many facilities due to company deferral of maintenance, insufficient testing of safety-critical elements, 
and a continuing industry culture of responding to disasters. However, the HSE has worked to make 
improvements to these areas. In 2010, the UK HSE initiated Key Programme 4 to address the issue of 
aging equipment offshore and the operation of installations beyond their design life.271 The same year, 
the HSE published a report intended to inform industry and aid in the prevention of major accidents 
entitled Managing Ageing Plant: A Summary Guide,272 which provides an overview of ageing plant 
mechanisms and their management. This document presents analysis and findings for loss of containment 
incidents to demonstrate how aging plant equipment may be a factor. The HSE has been able to take this 
type of programmatic proactive approach in the UK thanks to the safety case regime’s adaptive nature, 
which is lacking in the US both on and offshore. This is positive evidence of a competent and effective 
regulator with the tools under the safety case regime to identify and proactively address industry gaps in 
safety performance. 
4.4 
Active Workforce Participation 
As the CSB noted in its Interim Report on the Chevron incident, workforce participation is a key element 
of process safety and effective major accident prevention. In one of its publications, the Center for 
Chemical Process Safety (CCPS) lists workforce involvement as one of 20 essential management 
components necessary to reduce process safety risks and prevent chemical accidents.273 According to 
CCPS, 
…workers are potentially the most knowledgeable people with respect to 
the day-to-day details of operating the process and maintaining the 
equipment and facilities and may be the sole source for some types of 
knowledge gained through their unique experiences. Workforce 
involvement provides management a mechanism for tapping into this 
valuable expertise.274 
This CCPS publication discusses general areas of workforce involvement in risk assessments, inspections, 
audits, and performance reviews, and notes that participation leads to empowerment, management 
270 The HSE published a report to communicate the results and conclusions of the Asset Integrity Key Programme 
carried out between 2004 and 2007 by the Health and Safety Executive’s Offshore Division. See 
http://www.hse.gov.uk/offshore/kp3.pdf, (accessed August 28, 2013). 
271 The UK launches Key Programmes to address poor performance in specific areas. Access the report entitled Key 
Programme 4 (KP$): Ageing and life extension at http://www.hse.gov.uk/offshore/ageing/kp4-interim-report.pdf 
(accessed November 1, 2013). 
272 See http://www.hse.gov.uk/research/rrpdf/rr823-summary-guide.pdf (accessed November, 1, 2013). 
273 CCPS. Guidelines for Risk Based Process Safety; March 2007; p liv. 
274 Ibid at 124. 
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responsiveness, and process safety performance improvement. 275 The OSHA PSM standard requires 
employers to consult with employees and their representatives on the conduct and development of PHAs 
and on the development of the 13 remaining PSM elements, and to develop a written plan of action 
regarding the implementation of the employee participation required under this section.276 During facility 
inspections, OSHA inspectors must request and evaluate these written plans of action regarding the 
implementation of employee participation as well as interview employees and their representatives to 
verify that the employer is satisfying the requirements.277 
In previous investigation reports, the CSB has identified that workers and their representatives play a very 
important role in major incident prevention. For example, as will be discussed in the next section on 
performance indicators, the CSB recommended in its BP Texas City Final Investigation Report that BP 
and the United Steelworkers Union (USW) establish a joint program to report incidents and near misses, 
and to ensure that recommendations made during investigations were implemented. The CSB also 
recommended that API and the USW work together to develop a safety standard addressing leading and 
lagging process safety indicators.278 However, representatives from the USW have stated to the CSB that 
it is a constant struggle for workers and their representatives to have a voice or play a role in the 
management of safety in US petroleum refineries. 
The law in the UK also requires employers to consult with their employees or their safety representatives 
on health and safety matters. The Safety Representatives and Safety Committees Regulations 1977 and 
the Health and Safety (Consultation with Employees) Regulations 1996 set out the legal framework for 
such consultation and worker involvement at both unionized and non-unionized onshore facilities.279 
However, these regulations go further than the OSHA PSM standard in that they provide for the election 
of safety representatives by the workers to serve many health and safety-related functions, including 
investigating complaints and accidents and carrying out inspections. In his keynote speech at the Oil and 
Gas UK Piper 25 conference, Lord Cullen stated that the safety representative positions have “important 
functions, such as the power to carry out investigations and reporting safety concerns to management, 
without fear of recrimination,” noting that they “help[] reinforce the principle that each employee is 
responsible for his own safety.”280 The regulations also require employers to establish a safety committee 
when one is requested by at least two health and safety representatives. The 1996 regulations require 
employers to consult with employees not represented by safety representatives under the 1977 
275 Ibid at 125. 
276 29 CFR §1910.119(c) (2012). 
277 See OSHA CPL 02-02-045. Process Safety Management of Highly Hazardous Chemicals – Compliance 
Guidelines and Enforcement Procedures. September 13, 1994. 
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=1558&p_table=directives (accessed September 
6, 2013). 
278 Process safety indicators are also referred to as safety performance indicators, metrics, key process indicators, 
performance measures, indicators, etc… 
279 The 1977 regulations apply to workplaces where the employer recognizes trade unions and trade unions are 
recognized for collective bargaining purposes. Regulations available at 
http://www.legislation.gov.uk/uksi/1977/500/contents/made (accessed September 4, 2013). The 1996 regulations 
apply to workplaces where employees are not in a trade union and/or the employer does not recognize the trade 
union, or the trade union does not represent those employees not in the trade union. Regulations available at 
http://www.legislation.gov.uk/uksi/1996/1513/contents/made (accessed September 4, 2013). 
280 Finding Petroleum. Review: Lord Cullen – what have we learned from Piper Alpha? September 16, 2013. 
http://www.findingpetroleum.com/n/Review_Lord_Cullen_what_have_we_learned_from_Piper_Alpha/044b5113.as
px (accessed September 16, 2013). 
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Regulations on a number of health and safety-related matters, such as the introduction of any measure 
which may substantially affect their health and safety at work, the planning and organization of health and 
safety training, and the health and safety consequences of introducing new technology.281 The law in the 
UK protects employees from being penalized for taking part in health and safety consultation.282 
The UK’s existing regulations and policies regarding worker involvement offshore were developed and 
strengthened as a result of the Piper Alpha incident. In the Piper Alpha Report, Lord Cullen emphasized 
the importance of workforce involvement in safe operations, and noted that a safety committee system is 
“the most visible instrument for the involvement of the workforce in safety.”283 He concluded by 
recommending that “the regulatory body, operators and contractors should support and encourage the 
involvement of the offshore workforce in safety.”284 The HSE developed guidance in response to Lord 
Cullen’s recommendations entitled Play your part! How offshore workers can help improve health and 
safety, intended to encourage workforce participation offshore.285 The most current version of this 
guidance document, which was prepared by the Workforce Involvement Group,286 located within the 
HSE’s Offshore Industry Advisory Committee,287 utilizes good practice and examples of successful 
workforce involvement in improving health and safety with the goal of assisting operators, contractors, 
safety representatives, and others in effectively utilizing workforce involvement in their workplaces. It 
encourages companies to facilitate workforce involvement by providing information, improving 
communication at all levels, good training, and ensuring that all workers are represented in the decisions 
that affect them.288 
The Piper Alpha incident also resulted in the swift development of the SI971 Offshore Regulations 
(Safety Representatives and Safety Committees) Regulations 1989 (“the SI971 Regulations”), which 
provide for the nomination and election of safety representatives and require offshore installations to 
establish safety committees.289290 The HSE has published a guidance document entitled A guide to the 
281 See HSE. Consulting employees on health and safety: A brief guide to the law; 2013. 
http://www.hse.gov.uk/pubns/indg232.pdf (accessed September 4, 2013). 
282 See Employment Rights Act 1996. Section 44. Health and safety cases. 
http://www.legislation.gov.uk/ukpga/1996/18/section/44 (accessed September 4, 2013). 
283 Department of Energy. The Public Inquiry into the Piper Alpha Disaster; Presented to Parliament by the 
Secretary of State for Energy by Command of her Majesty; November 1990; p 301. 
284 Department of Energy. The Public Inquiry into the Piper Alpha Disaster; Presented to Parliament by the 
Secretary of State for Energy by Command of her Majesty; November 1990; p 392. 
285 See HSE. Play your part! How offshore workers can help improve health and safety; 2013. 
http://www.hse.gov.uk/pubns/indg421.pdf (accessed June 17, 2013). 
286 The Workforce Involvement Group’s mission is to improve safety “by stimulating lateral learning and best 
practice across the offshore industry through involvement of the whole workforce.” It looks at ways to increase 
worker involvement in health and safety matters offshore and is chaired by HSE. For more information see 
http://www.hse.gov.uk/aboutus/meetings/iacs/oiac/wig.htm (accessed June 17, 2013). 
287 The Offshore Industry Advisory Committee is a tripartite committee that includes members representing 
employers, employees, unions, trade associations and other government departments. It is focused solely on the 
offshore sector. More information is available at 
http://www.hse.gov.uk/aboutus/meetings/iacs/oiac/information.htm (accessed June 17, 2013). 
288 HSE. Play your part! How offshore workers can help improve health and safety; 2013; p 4. 
http://www.hse.gov.uk/pubns/indg421.pdf (accessed June 17, 2013). 
289 Under Regulation 16, safety representatives are responsible for investigating potential hazards and incidents, 
examining causes of accidents, investigating complaints by any member of his or her constituency relating to 
occupational health and safety, representing members of the workforce in consultations on the offshore installation 
with inspectors, and consulting constituency members on any matters arising out of the Regulation. Under 
Regulation 17, a safety representative may inspect any part of the offshore installation or its equipment either on a 
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Offshore Installations (Safety Representatives and Safety Committees) Regulations 1989291 designed to 
assist duty holders, employers, installation managers, safety representatives, safety committee members 
and all members of the workforce in the offshore industry with what the regulations require and what 
must be done to comply with them. The document explains that although the primary responsibility for 
health and safety resides with the duty holder, “all members of the workforce must play their part if risks 
are to be eliminated or minimized.”292 It also emphasizes the importance of training of safety 
representatives, which enables them to effectively represent workers and fulfill their responsibilities and 
functions under these Regulations. 
In April 2010, the HSE launched an inspection project to examine the effectiveness of the SI971 
Regulations and the effectiveness of those regulations, as well as to collect examples of best practice to 
present to the offshore industry.293 Forty-one inspections were completed in a six-month period on 
offshore installations operated by 25 different duty holders. The project helped focus on the power of 
safety representatives and how to strengthen their ability to effectively perform their duties. It also was 
well-received by the safety representatives, as it gave them encouragement and recognition, and sent a 
message to management on the importance of SI971 and the key role of 
safety representatives and committees in workplace health and safety. 
The HSE has placed great emphasis and importance on the role of 
worker involvement and consultation in improving workplace health 
and safety and reducing major accidents on and offshore. In June 2009, 
HSE launched a new strategy entitled Be part of the solution, which 
lists workforce involvement as one of its main priorities, and the 
agency has published a significant amount of guidance on worker 
involvement and consultation on its website.294 
The Norwegian Working Environment Act addresses the rights and 
duties of safety representatives and committees in Norway. It applies 
to nearly all workers in Norway, including onshore and offshore oil 
workers. The Act provides for the election of government recognized safety representatives whose duty 
is to “safeguard the interests or employees in matters of the working environment.”295 These 
regular basis or following an incident. According to HSE, “this can be of great benefit to the duty holder because it 
brings an independent look at health and safety factors from the workforce viewpoint. Workers are in the front line 
and are often well placed to see problems and put forward practical suggestions.” HSE. A guide to the Offshore 
Installations (Safety Representatives and Safety Committees) Regulations 1989; 2012; p 20. 
http://www.hse.gov.uk/pubns/priced/l110.pdf (accessed September 4, 2013). 
290 Under Regulation 22, safety committees are responsible for reviewing the system of constituencies so as to 
ensure adequate representation of the workforce on health and safety matters, reviewing training of safety 
representatives, reviewing the frequency of safety committee meetings and the circumstances under which they may 
be called, and considering causes of accidents and making recommendations to the installation manager. 
291Third edition published in 2012. Available at http://www.hse.gov.uk/pubns/priced/l110.pdf (accessed September 
4, 2013). 
292 Ibid at 7. 
293 See HSE. Offshore workforce involvement and consultation: Compliance Inspection Project. Available at 
http://www.hse.gov.uk/offshore/si971.pdf (accessed September 4, 2013). 
294 See http://www.hse.gov.uk/involvement/hsrepresentatives.htm (accessed September 4, 2013). 
295 Act Relating to Working Environment, Working Hours and Employment Protection, Etc. (Working Environment 
Act). December 2012. Section 6-1. Obligation to elect safety representatives. 
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representatives have the right to information, consultation, and participation in inspections.296 Unlike in 
the UK currently, they also have the legal authority to halt unsafe work until the regulator decides when 
the work may continue.297 
A fundamental element in effective safety management for major accident prevention is active and equal 
participation from the regulator, industry, and labor. Each entity provides unique and essential insights, 
and removing the participation of these entities removes a critical voice in health and safety matters. In 
the UK and Norway, tripartite systems consisting of industry, the regulator, and the workforce have been 
established to deal with safety and health issues at the highest levels beyond just site workforce 
representation. 
The CSB investigation staff has had extensive discussions with worker representatives who have voiced 
their opinions on their systems to the CSB. Roy Furre, a Representative from the Norwegian Union of 
Energy Workers, spoke at the CSB’s 2010 public hearing on the Regulatory Approaches to Offshore Oil 
and Gas Safety, and stated that the Norwegian working environment and the accompanying petroleum 
regulations empower unions and safety delegates in all phases of the petroleum activities.298 He also 
noted that the Norwegian petroleum regulations require that all necessary information about risks and 
decisions be given to the workers’ representatives.299 During the CSB’s public hearing on Safety 
Performance Indicators in July 2012, Jake Molloy, the Regional Organizer for the National Union of Rail, 
Maritime and Transport Workers in the UK, stated that the input of workers is “crucial” in major accident 
prevention and that “if the people operating these systems and delivering these results are unable for any 
reason to tell you what the true picture is, everything else is worthless.”300 When speaking at a “Step 
Change for Safety” Conference in Aberdeen, Scotland, on September 5, 2012, Mr. Molloy noted that 
attending the public hearing in Houston was “eye opening” and that hearing about the US system was like 
a “walk back in time.”301 
 
 
 
 
 
296 Ibid at Section 6-2. Duties of safety representatives. 
297 Ibid at Section 6-3. The safety representative’s right to halt dangerous work. See also the Regulations Relating 
to Health, Safety and the Environment in the Petroleum Activities and at Certain Onshore Facilities (The Framework 
Regulations) Section 35. It states that “[t]he responsible safety delegate can, pursuant to Section 6-3 of the Working 
Environment Act, demand that a work operation or work process be halted by the person responsible for the 
operation or process. The operation or work shall stop immediately if the safety delegate does not accept the 
implementation of alternative measures.” 
http://www.ptil.no/framework-hse/category403.html#_Toc357595266 (accessed April 14, 2014). 
 
298 CSB. Public Hearing: Regulatory Approaches to Offshore Oil and Gas Safety. December 15, 2010; p 300. 
http://www.csb.gov/assets/1/19/Transcript_of_Public_Meeting_12_15_2010.pdf (accessed December 10, 2013). 
299 Ibid at 300. 
300 CSB. Public Hearing: Safety Performance Indicators. July 23, 2013; p 143. 
http://www.csb.gov/assets/1/19/CSB_20Public_20Hearing.pdf (accessed December 10, 2013). 
301 http://www.youtube.com/watch?v=-xDzb4x8t_c (accessed December 10, 2013). 
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4.5 
Process Safety Indicators that Drive Performance 
As the CSB noted in both its July 2012 public hearing on Safety 
Performance Indicators and its Chevron Interim Report, leading and 
lagging process safety indicators help drive continuous process safety 
improvement, as long as regulators utilize these indicators to focus 
inspections, audits, and investigations, and organizations focus attention 
on them in a way that makes a difference. Process safety indicators are a 
significant element of process safety management systems. They 
measure the strengths and weaknesses of these systems to achieve and 
maintain safe and reliable operations302 and, if properly defined, collected 
and used, can identify the successes and flaws of the system.303 
Lagging indicators are a “form of reactive monitoring”304 that includes 
events such as major spills, fires, or gas releases. Leading indicators, on 
the other hand, are a “form of active monitoring,”305 and are described as events that do not result in 
severe consequences and usually address safety system performance, such as deviations from safe 
operating limits or timely maintenance on safety critical equipment.306 Leading indicators “can be 
considered as measures of process or inputs essential to deliver the desired safety outcome.”307 The 
general thinking globally is that if companies rely primarily on lagging indicator data, which is 
retrospective, they are not effectively managing process safety to ensure major accidents are prevented. 
According to the HSE, “[t]oo many organizations rely heavily on failure data to monitor performance, so 
improvements or changes are only determined after something has gone wrong. Discovering weaknesses 
in control systems by having a major incident is too late and too costly.”308 Rather, facilities must 
identify critical controls to monitor and set leading indicators against each one to show that the system is 
operating as intended. 
The HSE was one of the earliest regulators to adopt process safety indicators regulations. In 1995, the 
agency began requiring companies to report health and safety data, and then published annual reports 
based on those statistics. In 2006, the HSE developed a step-by-step guidance document entitled 
Developing process safety indicators309 to assist industry. The guide establishes and discusses in detail 
six main steps necessary to implement a process safety measurement system, including developing 
leading and lagging indicators. It also defines leading and lagging indicators for each of the controls in 
the risk control system. According to Jake Molloy, “[i]t is our firm belief that the most influential and 
302 CCPS. Guidelines for Process Safety Metrics; October 2009; p 109. 
303 Ibid. 
304 HSE. Developing process safety indicators: A step-by-step guide for chemical and major hazard industries; 
2006; p 7. http://www.hse.gov.uk/pubns/books/hsg254.htm (accessed May 28, 2013). 
305 Ibid. 
306 Hopkins, Andrew. Disastrous Decisions: The Human and Organisational Causes of the Gulf of Mexico 
Blowout; CCH Australia Limited, 2012; p 83. 
307 HSE. Developing process safety indicators: A step-by-step guide for chemical and major hazard industries; 
2006; p 7. http://www.hse.gov.uk/pubns/priced/hsg254.pdf (accessed October 30, 2013). 
308 Ibid at 1. 
309 Full title is Developing process safety indicators: A step-by-step guide for chemical and major hazard 
industries; first published in 2006. http://www.hse.gov.uk/pubns/books/hsg254.htm (accessed May 28, 2013). 
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effective schemes using indicators to measure improvements and major accident prevention are those 
initiatives generated by our regulator, the Health and Safety Executive [HSE].”310 
As discussed in the previous section, a number of large incidents, including BP Texas City and BP 
Grangemouth, have highlighted the need for the chemical and other major hazard sectors to demonstrate 
that risks are being adequately controlled. In response to recommendations stemming from such 
incidents, the COMAH CA developed an Operational Delivery Guide in 2010 on process safety 
performance indicators setting out four stages to aid facilities in the development of process safety 
indicators. The document sets out a goal that by the end of 2015 major hazard establishments and duty 
holders will measure their safety performance and control of risk by way of key leading and lagging 
performance indicators. 
Following the 2005 BP Texas City incident, BP developed company-wide process safety indicators, and 
now includes process safety metrics in performance contracts for its US refinery managers.311 However, 
existing guidance in the US pertaining to safety performance indicators does not adequately aid 
companies in managing major hazards onshore. The CSB has noted that in virtually every incident it 
investigates in the US, process safety indicators are either not used at all or not used effectively.312 
Millions of workplaces around the US primarily measure their safety performance using OSHA 
recordable injury and illness rates, which include slips, trips, and falls. While collecting this type of data 
is also necessary in hazardous operations, it is not sufficient. Injury rates do not depict the effectiveness 
of a high hazard facility’s process safety management program.313 For example, the CSB noted in its BP 
Texas City investigation that BP’s personal injury metrics were described as being at the best level on 
record; yet, around this same time, in March 2005, BP Texas City experienced the devastating 15-fatality 
incident, which resulted from a progressive erosion of process safety performance that was not reflected 
in injury statistics. 
Following the BP Texas City incident, a number of key recommendations were made to strengthen 
guidance on indicators in the US. For example, the Baker Panel314 issued the Baker report, which 
recommended the incorporation of safety indicators to measure safety performance, and stated: 
The Panel believes that relying exclusively or predominantly on lagging 
indicators to assess process safety performance is ill-advised. … BP’s 
reliance on lagging, after-the-fact indicators of process safety 
performance rather than leading, predictive measures…impaired BP’s 
ability to measure, monitor and detect deteriorating or degraded process 
safety conditions and performance… This failure to use a set of effective 
performance metrics that includes leading indicators increased the 
310 Molloy Testimony. CSB Indicators Public Hearing Transcript; July 24, 2012; p 139. 
311 Hopkins, Andrew. Disastrous Decisions: The Human and Organisational Causes of the Gulf of Mexico 
Blowout; CCH Australia Limited, 2012; p 84. 
312 Donald Holmstrom. CSB Indicators Public Hearing Transcript; July 24, 2012; p 13. 
313 Ibid. 
314 In the aftermath of the BP Texas City Incident, BP followed the recommendation of the CSB and formed an 
independent panel known as the Baker Panel to conduct a thorough review of the company’s corporate safety 
culture, safety management systems, and corporate safety oversight at its US refineries. For a copy of their findings 
and recommendations see 
http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/SP/STAGING/local_assets/assets/pdfs/Bak
er_panel_report.pdf (accessed August 13, 2013). 
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likelihood that the organisation would identify the need for 
improvements or additional controls only after something had gone 
wrong.315 
The Baker Panel also noted that it was not enough just to develop process indicators: these indicators 
needed to be meaningful to the company. As such, the Baker Panel also recommended that “a significant 
proportion of total compensation of refining line managers and supervisors [be] contingent on 
satisfactorily meeting process safety performance goals….”316 
In its final investigation report on the incident, the CSB made a recommendation to API and the USW to 
jointly lead development of a consensus standard for leading and lagging process safety indicators to 
drive performance improvements in the prevention of major incidents. API responded by issuing RP 754, 
Process Safety Performance Indicators for the Refining and Petrochemical Industries. However, this 
voluntary standard, which defines a framework of four tiered indicators that incorporate the concepts of 
lagging to leading measures, has significant shortcomings, as the CSB described in a two-day public 
hearing on Safety Performance Indicators that was held in July 2012. The CSB analysis found that the 
ability of RP 754 to drive performance improvement and inform key stakeholders will be hampered by 
• 
lagging indicators with insufficient statistical rigor needed to allow for trending or incremental 
performance improvements; 
• 
the lack of well-defined standardized and normalized leading indicators that are needed for 
comparison among sites, corporations, or to national averages; 
• 
weak employee protection requirements; public reporting requirements that will be ineffective to 
adequately inform stakeholders; and 
• 
the lack of broadly based consensus in the standard’s development process.317 
As a result, in 2012 the CSB Board designated the response to the CSB’s recommendation as “open-
acceptable,”318 meaning that the recommendations recipient is moving in the right direction, but more 
remains to be done. 
The CSB also noted in the Chevron Interim Report the important role the public plays in monitoring 
safety management systems, and referenced CCPS as promoting the sharing of process safety indicators 
with the public: 
Sharing performance metrics and results broadly can engage the public 
as a partner in holding the organization accountable for process safety 
performance. Making metrics and performance public can be an 
especially powerful way of maintaining upper management commitment 
since it will likely be the CEO or other senior managers who will be 
called to account by the public if goals are not met or performance 
declines. Communicating process safety successes also demonstrates to 
315 Baker, J. The Report of the BP U.S. Refineries Independent Safety Review Panel, 2007; p 194. 
316 Ibid at 251. 
317 CSB Public Hearing: Safety Performance Indicators. July 23-24, 2012; p 26. http://www.csb.gov/events/csb-
public-hearing-safety-performance-indicators/ (accessed August 14, 2013). 
318 For more information on recommendations status designations, see http://www.csb.gov/recommendations/faq/#5 
(accessed June 21, 2013). 
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employees and the public that positive change can be, and are being, 
made within an organization.319 
The Petroleum Safety Authority (PSA) in Norway provides annual reports to the public on its website 
assessing indicators it has collected directly from offshore and onshore major hazard facilities since 2000 
and 2006, respectively. The PSA utilizes the indicators data found in these reports to identify critical 
safety areas that must be targeted for improvement in order to prevent near misses and accidents.320 The 
onshore report, Risk level in the petroleum industry, Onshore facilities,321, 322 includes a description and 
explanation of the indicators collected and analysis of these data. In this report the PSA notes a 
decreasing trend in the number of reported hydrocarbon leaks on offshore production facilities between 
2007 and 2010.323 However, it is too soon for PSA to assess trends in the onshore indicators data, 
because the time period for onshore data collection has been relatively short and there are fewer data 
points with only eight facilities onshore. The PSA also indicated that it will take time for the onshore 
data to improve as indicators are refined, but recognized that the same approach has already yielded 
good results in the offshore sector.324 Additional information on data and trends based on safety case 
regime implementation are provided in Appendix C. 
 
 
319 Center for Chemical Process Safety (CCPS). Guidelines for Process Safety Metrics. 2010; p 109. 
320 PSA. Trends in Risk Level: Summary Report 2012 – Norwegian Continental Shelf. 2012; p 1. 
321 The CSB had the 2010 version of the onshore report translated into English. 
http://www.ptil.no/getfile.php/PDF/RNNP_2012/Trends%20in%20risk%20level_2012.pdf (accessed September 17, 
2013. (accessed September 17, 2013). 
322 The corresponding report discussing offshore indicator data is entitled Trends in Risk Level. 
http://www.ptil.no/getfile.php/PDF/RNNP_2012/Trends%20in%20risk%20level_2012.pdf (accessed September 17, 
2013. 
323 PSA. Risk level in the petroleum industry, Onshore facilities. 2010; p 80. 
324 Ibid. 
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4.6 
Regulatory Assessment, Verification, and Intervention 
To effectively oversee covered facilities and enforce safety case 
regulations, technically competent regulators review and 
assess325 safety case reports and utilize preventative inspections 
and audits to effectively intervene before high-risk activities 
commence. According to the HSE, “[t]he assessment process is 
only a part of the COMAH regime and examines at face value 
the factual information and examines arguments and 
demonstrations contained in the report against the requirements 
of the regulations.”326 The HSE places great emphasis during 
the assessment phase on the adoption of inherently safer 
designs327 and notes that “[m]ajor accident hazards should be 
avoided or reduced at source through the application of 
principles of inherent safety.”328 Conclusions on the adequacy of the safety case report are developed at 
the end of the assessment process, and, if deficiencies are found, an intervention strategy for the facility is 
developed to addresses those deficient measures. According to the HSE, assessment of a safety case 
report or document “is not a discrete activity but leads to further action under the intervention plan for the 
operator at that establishment.”329 Intervention by the regulator ensures that the facility and its operations 
are consistent with information provided in the safety case report, and that there are robust systems in 
place to “reduce the likelihood of hazards and to mitigate their consequences until the associated risks are 
ALARP.”330,331 Under the safety case regulatory regime, the regulator has the authority to accept the 
safety case report or reject it and require additional measures to further reduce risks. 
Preventative inspections and audits by a technically competent regulator can also result in deep challenges 
to industry, which does not typically happen under the PSM or RMP regulations. In the UK, the 
COMAH regulations authorize the CA to 
 
 
325 According to the HSE, the “assessment reviews the documentary evidence in the report and further 
documentation, as appropriate, which is referred to in the report or requested by the assessor.” HSE. The Safety 
Report Assessment Manual, Sections 2 to 7. p 3. http://www.hse.gov.uk/comah/sram/s2-7.pdf (November 26, 
2013). 
326 HSE. The Safety Report Assessment Manual, Sections 8 to 15. p 9. http://www.hse.gov.uk/comah/sram/s8-
15.pdf (accessed October 30, 2013). 
327 Ibid at 30. 
328 HSE. The Safety Report Assessment Manual, Sections 2 to 7. p 3. http://www.hse.gov.uk/comah/sram/s2-7.pdf 
(November 26, 2013). 
329 HSE. The Safety Report Assessment Manual, Sections 8 to 15. p 4. http://www.hse.gov.uk/comah/sram/s8-
15.pdf (accessed October 30, 2013). 
330 HSE. The Safety Report Assessment Manual, Sections 8 to 15. p 30. http://www.hse.gov.uk/comah/sram/s8-
15.pdf (accessed October 30, 2013). 
331 According to HSE, essential considerations to ensure ALARP are “the scope of hazard elimination, the adoption 
of inherently safer designs, whether good practice has been, or is to be adopted, [and] the application of risk-
reducing measures where relevant good practice is not yet established.” Ibid at 30 and 31. 
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organize an adequate system of inspections of establishments or other 
measures of control appropriate to the type of establishment 
concerned…[that are] sufficient for a planned and systematic 
examination of the systems being employed at the establishment, 
whether of a technical, organisational or managerial nature, so as to 
ensure…(a) that the operator can demonstrate that he has taken 
appropriate measures to prevent major accidents; (b) that the operator 
can demonstrate that he has provided appropriate means for limiting the 
consequences of major accidents both inside and outside the 
establishment; (c) that the information contained in any report sent to the 
competent authority by the operator of the establishment adequately 
reflects the conditions in the establishment…332 
The CSB noted in its BP Texas City Final Investigation Report that in the UK, HSE inspectors thoroughly 
inspect high hazard facilities annually, and all COMAH-covered facilities are inspected every five years. 
For the approximately ten petroleum refineries in the UK, detailed planned inspections (ranging from 80 
to 150 days) are conducted annually for each refinery by a multidisciplinary team (regulatory inspectors, 
process safety, mechanical engineering, electrical and instrumentation, and human factors specialists).333 
The HSE lists its offshore priorities as safety case assessment;334 verification;335 inspection; investigation; 
and enforcement.336 In its business plan for 2012-2015, the HSE set out a goal of assessing 72 safety 
cases onshore and 100 safety cases offshore for 2013 and 2014.337 The work required to assess a safety 
case report both on and offshore is very resource-intensive (a typical new offshore safety case assessment 
requires anywhere from 100 to 300 hours of work), and demands that the regulator hire and retain 
individuals with significant oil and gas experience, specifically in areas such as process safety, human 
factors, engineering, and organizational performance. 
In Australia, the Offshore Petroleum and Greenhouse Gas Storage Act 2006 authorizes NOPSEMA to 
conduct planned inspections of offshore installations to ensure compliance with the Act.338 NOPSEMA 
notes that planned inspections “are a critical examination of aspects of a facility, its systems and 
332 COMAH Regulations 1999 Part 6, Regulation 19(1) and (2). 
333 The CSB. Investigation Report: BP Texas City Refinery Explosion and Fire. March 2007; p 205. 
http://www.csb.gov/assets/1/19/CSBFinalReportBP.pdf (accessed October 29, 2013). 
334 An owner or operator (i.e. the duty holder) is required to submit a safety case to HSE for each offshore 
installation. HSE then assesses the safety case using both regulations and HSE’s “Assessment Principles for 
Offshore Safety Cases (APOSC) and must accept it before an installation can operate. See 
http://www.hse.gov.uk/offshore/aposc190306.pdf (accessed July 31, 2013). 
335 Duty holders have a duty under the Offshore Installations (Safety Case) Regulations 2005 to put in place and 
keep under continual review a verification scheme by which assurance is obtained from an independent competent 
person (ICP) that safety critical elements and the PFEER (Offshore Installations (Prevention of Fire and Explosion, 
and Emergency Response) specified plant are suitable and remain suitable for the life of the installation. For more 
information see http://www.hse.gov.uk/offshore/verification.htm (accessed July 31, 2013). 
336 See http://www.hse.gov.uk/offshore/priorities.htm (accessed July 15, 2013). 
337 HSE. HSE Business Plan 2012-15; June 2012; p 14. 
http://www.hse.gov.uk/aboutus/strategiesandplans/businessplans/plan1215.pdf (accessed June 3, 2013). 
338 Offshore Petroleum and Greenhouse Gas Storage Act 2006, Sections 600 and 601. See 
http://www.comlaw.gov.au/Series/C2006A00014 (accessed July 15, 2013). 
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operations with information obtained from the facility safety case.”339 Subjects of planned inspections 
include risk control measures related to either a Major Accident Event340 or Occupational Health and 
Safety controls, or both. NOPSEMA states that it conducts at least two per year for each normally 
manned offshore installation.341 NOPSEMA distinguishes between two types of planned inspections: 
field-based inspections, which focus on implementation of control measures described in a facility’s 
safety case, and themed audits, which deal with inspection of organizational issues by following a 
common theme to direct lines of questioning.342 
In a 1992 compliance directive,343 OSHA stated that the primary enforcement model for the PSM 
standard would be planned, comprehensive, and resource-intensive Program Quality Verification (PQV) 
inspections.344 These inspections consist of three parts: determining if the elements of a PSM program 
are in place; evaluating if the programs comply with the requirements of the standard; and verifying 
compliance with the standard through interviews, data sampling, and field observations. However, 
OSHA does not make planned inspections, which have the most opportunity for prevention, a high 
priority. Rather, OSHA lists its inspection priorities as 1) imminent danger situations; 2) fatalities and 
catastrophes; 3) complaints; 4) referrals; 5) follow-ups; and 6) planned inspections.345 
The CSB noted in its BP Texas City Final Investigation Report that for the 10-year period prior to the 
Texas City incident, federal OSHA had conducted no planned PQV inspections in oil refineries. As a 
result, CSB recommended in its report that OSHA strengthen the planned enforcement of the OSHA 
Process Safety Management (PSM) standard by developing more highly trained and experienced 
inspectors to conduct more comprehensive inspections, such as the PQV audits envisioned in the 1992 
directive, at facilities presenting the greatest risk of a catastrophic accident. The intent of the 
recommendation was to establish a permanent, ongoing planned comprehensive inspections program. 
Spurred in part by the CSB’s recommendations, OSHA issued the Petroleum Refinery Process Safety 
Management National Emphasis Program (NEP) on June 7, 2007.346 The NEP was a federal program that 
established guidelines for inspecting petroleum refineries to assure compliance with the PSM standard. 
Unlike the PQV approach to inspections, which “employs a broad, open-ended inspection strategy and 
uses a more global approach to identify compliance deficiencies…,” the NEP “provide[d] a specific tool 
to evaluate compliance with the [PSM] standard…[which] identifies a particular set of requirements from 
the PSM standard from which CSHOs [Compliance Safety and Health Officers] are to review documents, 
339 NOPSEMA. Inspection Policy; p 2. http://www.nopsema.gov.au/assets/document/N-02000-PL0025-
Inspection.pdf (accessed July 15, 2013). 
340 Australia’s Offshore Petroleum and Greenhouse Gas Storage Regulations 2009 define a Major Accident Event as 
“an event connected with a facility, including a natural event, having the potential to cause multiple fatalities of 
person at or near the facility.” Chapter 1.5. See 
http://www.comlaw.gov.au/Details/F2009L04578/Html/Text#param5 (accessed July 15, 2013). 
341 For more information, see http://www.nopsema.gov.au/safety/inspections/ (accessed July 15, 2013). 
342 For more information, see http://www.nopsema.gov.au/assets/document/N-02000-PL0025-Inspection.pdf 
(accessed July 15, 2013). 
343 Compliance directives are the main method OSHA uses to communicate plans, inspection methods, and 
compliance expectations to their Compliance Safety and Health Officers (CSHOs) for enforcing a new regulation. 
344 OSHA Instruction CPL 02-02-045 (1994). 
345 “OSHA Fact Sheet: OSHA Inspections,” available at 
http://www.osha.gov/OshDoc/data_General_Facts/factsheet-inspections.pdf (accessed on May 20, 2013). 
346 Originally Directive Number CPL 03-00-004. Extended August 18, 2099 as Directive Number CPL 03-00-010 
to allow more time to complete NEP inspections under the original CPL 03-00-004. 
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interview employees, and verify implementation for specific processes, equipment, and procedures.”347 
The NEP inspections were meant to be more targeted and efficient than PQV inspections. However, the 
inspections being conducted pursuant to the NEP were ended in 2011 partly because they were very time-
consuming and resource-intensive.348 OSHA has publicly stated349 that NEP inspection hours were 
roughly 40 times greater than average OSHA inspection hours. OSHA described the NEP as its most 
effective emphasis program in its history, citing a disturbing number of issues and subsequent citations. 
In 1999, EPA established an audit350 program to help ensure compliance with the RMP program. The 
audits were intended to provide an independent verification of the information in the RMP and include 
on-site inspections. Under these requirements, the implementing agency (EPA or a correlating state 
agency) must “periodically audit” RMPs to review their adequacy and require revisions when necessary 
to ensure compliance. 351 
Between fiscal years (FYs) 2010 and 2012, each EPA Region responsible for implementing the RMP 
program was mandated by EPA to perform inspections352 at five percent of the total number of regulated 
facilities in the regions, and a certain percentage of these facilities were required to be high-risk.353 In FY 
347 CPL 03-00-004, Section X(D)(1). 2007. 
348 Jordan Barab, Deputy Assistant Secretary of Labor for Occupational Safety and Health, stated the following 
during a symposium at the Mary K O’Connor Process Safety Center: “As our refinery NEP comes to an end, we are 
engaged in a process of trying to figure out how we will address refinery PSM issues in the future. Clearly OSHA's 
past practice of targeting inspection according to injury and illness numbers is not adequate. However, because of 
resource limitations, we are also unable to commit to a full-time NEP.” “Saving Lives and Transforming 
Workplaces: OSHA and Process Safety.” Remarks for Jordan Barab, Deputy Assistant Secretary of Labor for 
Occupational Safety and Health. Mary Kay O’Connor Process Safety Center International Symposium. Texas 
A&M University, College Station, Texas. Wednesday, October 27, 2010. 
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=SPEECHES&p_id=2311 (accessed January 
13, 2014). 
349 See Barab, Jordan. OSHA’s Refinery & Chemical National Emphasis Programs. Power Point presentation 
made at CSB Public Hearing on Process Safety Indicators; July 20, 2012. 
http://www.csb.gov/UserFiles/file/Barab%20%28OSHA%29%20PowerPoint.pdf (accessed August 14, 2013). Also 
see Transcript of CSB Public Hearing on Safety Performance Indicators; p 52. 
http://www.csb.gov/assets/1/19/CSB_20Public_20Hearing.pdf (accessed August 14, 2013). 
350 Within Part 68, the term “audit” refers to the process that implementing agencies may use to verify the quality of 
the RMP submitted to EPA and require revisions when necessary to ensure compliance. RMP audits will generally 
involve on-site verification of a facility’s underlying risk management program. Section 68.220 of the RMP rule 
requires implementing agencies to select facilities for audits based on specific criteria, and to follow a specific 
process for resolving audit findings prior to any enforcement action. See EPA. Guidance for Conducting Risk 
Management Program Inspections under Clean Air Act Section 112(r); January 2011; p 4. Available at 
http://www.epa.gov/osweroe1/docs/chem/clean_air_guidance.pdf (accessed June 11, 2013). 
351 40 CFR §68.220 (1999). 
352 RMP inspections “are different from audits in that facilities are not necessarily selected for inspection based on 
Part 68 regulatory criteria, and inspections can lead directly to implementing agency enforcement actions for 
regulatory violations. Also, RMP inspections always involve on-site verification activities.” See EPA, “Guidance 
for Conducting Risk Management Program Inspections under Clean Air Act Section 112(r).” January 2011; page 4. 
Available at http://www.epa.gov/osweroe1/docs/chem/clean_air_guidance.pdf (accessed June 11, 2013). 
353 Criteria used to determine high-risk includes the number of people in the footprint (if it is more than 100,000); 
accidental releases reported in the RMP; the hazard index (percentage of chemical quantity above threshold and 
number of chemicals onsite); and the number of Program Levels 2 or 3. US EPA Region 9 Emergency Prevention 
and Preparedness Program; Stanislaus County Powerpoint; March 2013. See http://www.condorearth.com/files/08-
Enforcement_Priorities-Mary_Wesling.pdf (accessed May 14, 2013). 
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2010, regions were to conduct 10 percent of the inspections at high-risk facilities, and in FYs 2011 and 
2012, 25 percent at high-risk facilities.354 
Although EPA has acknowledged that “full compliance with the Risk Management Program regulations 
cannot be determined without on-site or independent verification of all or part of the information 
submitted in an RMP[,]”355 the EPA has not effectively implemented the audit and inspection elements of 
the Risk Management Program. As mentioned above in Section 3.2.2.3.2, the EPA Office of Inspector 
General (OIG) concluded in 2009 that over half of the RMP-covered facilities identified in the US as 
high-risk356 had never received an on-site inspection or audit, and over 65 percent of all active RMP 
facilities had not received an on-site inspection or audit since inception of the RMP program in 1999.357 
The EPA OIG also noted that of the 296 uninspected high-risk facilities managed by EPA, 151 of these 
could each impact 100,000 people or more in a worst-case accident scenario.358 
4.7 
Independent, Competent, Well-Funded Regulator 
As noted by NOPSEMA, a safety regulator “provides ‘independent’ assurance to society, governments 
and industry that companies have identified the risks to health and safety and have put appropriate 
measures in place to control these risks.”359 To ensure that companies are managing risks and employing 
the best available standards and technologies, the regulator must be independent,360 well-resourced, and 
retain a sufficient number of technically competent, experienced, and well-trained staff that can critically 
assess companies’ safety case reports and performance. Without independent and competent 
examinations, the safety case report becomes a meaningless document in terms of controlling risk and 
preventing major accidents. Offshore regulators in the UK and Australia also utilize independent third 
party specialist safety companies recognized by the regulator. Third party inspectors review important 
aspects of the safety case, such as safety critical elements361 and performance standards.362 Third party 
inspections, however, do not take the place of rigorous inspections by the regulator. 
354 EPA OIG. Improvements Needed in EPA Training and Oversight for Risk Management Program Inspections; 
March 21, 2013; p 7. http://www.epa.gov/oig/reports/2013/20130321-13-P-0178.pdf (accessed June 11, 2013). 
355 EPA. Guidance for Conducting Risk Management Program Inspections under Clean Air Act Section 112(r); 
January 2011; p 4. http://www.epa.gov/osweroe1/docs/chem/clean_air_guidance.pdf (accessed June 11, 2013). 
356 A high-risk facility is one that meets one of more of the following characteristics established by the EPA Office 
of Emergency Management: 1) Facilities whose reported RMP worst-case scenario population exceeds 100,000 
people; 2) Any RMP Program facility with a hazard index greater than or equal to 25; and/or 3) Facilities that have 
had one or more significant accidental releases within the previous five years. See “EPA Office of Inspector 
General, “Improvements Needed in EPA Training and Oversight for Risk Management Program Inspections.” 
March 21, 2013; Page 5. Available at http://www.epa.gov/oig/reports/2013/20130321-13-P-0178.pdf (accessed 
June 11, 2013). 
357 EPA OIG. Evaluation Report: EPA Can Improve Implementation of the Risk Management Program for 
Airborne Chemical Releases; February 10, 2009; p 15. 
358 Ibid. 
359 See http://www.nopsema.gov.au/safety/safety-case/safety-case-approach/ (accessed May 31, 2013). 
360 You will find a more detailed discussion of regulator independence in the CSB’s upcoming investigation report 
on the Macondo incident. 
361 The UK HSE requires offshore installations to define “safety critical elements,” which are the technical barriers 
in place for the prevention, detection, control, and mitigation of major accident risks. Lauder, Bob. Major Hazard 
(Asset Integrity) Key Performance Indicators in use in the UK Offshore Oil and Gas Industry. Paper at the CSB 
Indicators Public Hearing. July 24, 2012. 
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As of June 2012, the HSE employed roughly 3,300 staff, of which 1,381were front-line inspectors,363 
whose responsibilities include conducting preventative inspections of roughly 950 COMAH facilities 
throughout the UK. The HSE employs roughly 105 inspectors to inspect approximately 300 offshore 
installations, in effect a one to three ratio. As such, the HSE, with a budget of roughly $472 million,364 
has the authority to offer higher specialist salaries to attract and retain more experienced, competent 
personnel. According to information obtained from the HSE, in 2011 and 2012 their onshore specialist 
inspector pay ranged from $85,806 to $102,344, and their offshore inspector pay ranged from $134,387 to 
$148,423 at the highest grade and $116,288 to $131,499 at the next highest grade.365 
A safety case regime requires regulators to conduct preventative facility inspections and audits against the 
safety case to ensure that specified controls are functioning as intended. Regulators must be capable of 
interacting as equals with company risk managers when conducting these inspections. Former HSE staff 
have communicated to the CSB that the HSE seeks new employees with good communication skills in 
addition to education and experience, as the job of a safety case regulator requires encouraging companies 
to aspire to make safety improvements that they may not want to make. One message that current and 
former HSE staff have repeated is that the industry believes having competent regulatory staff adds 
significant value to their business.366 In any country, competent offshore regulatory staff can persuade 
companies to manage risks in a rigorous manner, knowing that if not done properly, their risk 
management practices will be challenged.367 This competence is also essential for companies’ confidence 
in the accuracy of the regulatory staff’s advice, inspections, and citations. According to a literature 
review on the safety case in the UK, “[s]ome companies see as positive the requirement to have ‘someone 
external to the company keeping you on your toes by regularly asking if you have done all you can,’ and 
that it ‘forces you to convince yourself’ that you have covered all the risks.”368 
362 In the UK, duty holders have a duty under the Offshore Installations (Safety Case) Regulations 2005 to “put in 
place and keep under continual review a verification scheme by means of which assurance is obtained from an 
independent competent person (ICP) that safety critical elements and PFEER [Offshore Installations ) Prevention of 
Fire and Explosion, and Emergency Response] specified plant are suitable and remain suitable for the lifetime of the 
installation.” See http://www.hse.gov.uk/offshore/verification.htm (accessed November 14, 2013). 
363 HSE. The Health and Safety Executive Annual Report and Accounts 2011/12; July 2012; p 30. 
http://www.hse.gov.uk/aboutus/reports/1112/ar1112.pdf (accessed June 3, 2013). 
364 For 2013/2014, HSE’s budget is listed as 308.1 £million. HSE recovers approximately 40 percent of its costs 
through income mainly in the nuclear, offshore, and chemical sectors, and the remainder is funded from Grant-in-
Aid pursuant to the Health and Safety at Work etc. Act 1974, and fee for intervention (FFI).364 See HSE, “HSE 
Business Plan 2012-15,” July 2012; page 17. Available at 
http://www.hse.gov.uk/aboutus/strategiesandplans/businessplans/plan1215.pdf (accessed June 3, 2013). Conversion 
of UK Pounds to US Dollars is based on 1£ = 1.5313$. See http://wsj.com/mdc/public/page/2_3021-forex.html 
(accessed June 4, 2013). 
365 Conversion of UK Pounds to US Dollars is based on 1£ = 1.5313$. See http://wsj.com/mdc/public/page/2_3021-
forex.html (accessed June 4, 2013). 
366 Based on conversations between the CSB staff and Magne Ognedal (Norway PSA), Ian Whewell (the UK HSE), 
Peter Wilkinson (Australia NOPSA [forerunner of NOPSEMA]), and John Clegg (inaugural CEO of NOPSA). 
367 Peter Wilkinson, Manager Review Implementation Team, Offshore Safety Section, Australia Department of 
Industry, Tourism and Resources and “architect” of NOPSA. Presentation to the National Research Centre for 
Occupational Health and Safety, ANU (May 15, 2002). 
368 Vectra Group Limited. Literature Review on the Perceived Benefits and Disadvantages of UK Safety Case 
Regimes; 2003; p 40. 
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In the US, the federal government has used extensive resources to retain the best available talent to focus 
on health and safety oversight of US commercial and defense nuclear facilities.369 For instance, many 
nonsupervisory technical staff at the US Nuclear Regulatory Commission370 (NRC) and the Defense 
Nuclear Facilities Safety Board are paid at the top of the General Schedule pay schedule.371 Virtually all 
technical staff at the Defense Nuclear Facilities Safety Board hold technical master’s degrees and 
approximately 25 percent hold doctoral degrees.372 
The federal government has a unique category of non-executive positions that involve high-level research 
and development in the physical, biological, medical, or engineering sciences, or a closely-related field.373 
These are known as “Scientific or Professional” positions, and they are classified above the highest 
general schedule pay level.374 These special salary authorizations contribute to the technical agencies’ 
ability to compete with private industry to recruit and retain highly competent staff. The NRC also has a 
type of funding mechanism that ensures that the agency’s budget adequately covers its regulator 
activities, as the NRC is required by law to recover at least 90 percent of its budget through licensing and 
inspection fees.375 
Another method by which the NRC is able to attract and retain competent technical staff is its extensive 
training programs. For new inspection staff, the NRC requires a series of courses, assessments, and 
simulation, all of which takes approximately two years to complete.376 Inspectors must have a bachelor’s 
degree in engineering or a degree in a relevant scientific field and Professional Engineer certification.377 
The agency operates a technical training center in Chattanooga, Tennessee, with various control room 
simulators that mirror licensees’ facilities. The NRC staff is expected to sufficiently understand this 
equipment so that they are able to conduct sufficient audits and investigations.378 Before he or she is fully 
qualified to conduct inspections, inspector candidates must be recommended by the NRC inspector 
qualification board and certified by the regional administrator or division director.379 
As will be discussed in greater detail under Section 5.0, at the time of the Chevron incident, a majority of 
the regulators responsible for oversight of Chevron and other petroleum refineries in California did not 
have sufficient, sustainable funding or staffing to oversee major accident prevention activities. An 
effective safety case regulatory system would necessitate that the California industry regulator be well-
369 DNFSB FY2013 Budget Justification at p. 100 
http://www.dnfsb.gov/sites/default/files/About/Budget%20Requests/2013/FY%202013_CONG%20BUDGET_FIN
AL.PDF (accessed May 15, 2013). 
370 Presentation by NRC Executive Director Bill Borchardt, January 2011. 
371 $123,758 to $155,500 per year in 2012 in Washington, DC. See https://www.opm.gov/oca/12tables/html/dcb.asp 
(accessed May 15, 2013). 
372 DNFSB FY2013 Budget Justification at p. 100 
http://www.dnfsb.gov/sites/default/files/About/Budget%20Requests/2013/FY%202013_CONG%20BUDGET_FIN
AL.PDF (accessed May 15, 2013). 
373 http://www.opm.gov/ses/recruitment/stpositions.asp (accessed May 15, 2013). 
374 http://www.opm.gov/ses/recruitment/stpositions.asp (accessed May 15, 2013). 
375 Section 6101 “NRC User Fees and Annual Charges,” Omnibus Budget Reconciliation Act, Pub. L. 103-66. 107 
Stat. 312 (Aug. 10, 1993). 
376 NRC Inspection Manual, Qualification Program for Operating Reactor Programs (Ch. 1245) at 4, available at 
http://pbadupws.nrc.gov/docs/ML1110/ML11105A153.pdf (accessed May 28, 2013). 
377 NRC Reactor Inspector Job Posting No. R-I/DRS-2013-0001 
378 See, e.g., http://www.iaea.org/ns/tutorials/regcontrol/regbody/reg2124.htm (accessed May 28, 2013). 
379 NRC Inspection Manual, Qualification Program for Operating Reactor Programs (Ch. 1245) available at 
http://pbadupws.nrc.gov/docs/ML1110/ML11105A153.pdf 
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resourced and retain a sufficient number of competent, well-trained and experienced staff to critically 
assess a company’s safety case. The overall knowledge and expertise of the regulator must at a minimum 
match that of industry in order for the regulator to successfully assess a company’s safety case with the 
ultimate goal of preventing major accidents. 
 
 
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5.0 Oversight of Petroleum Refineries in California 
 
In California, there currently exists a patchwork of primarily activity-based federal, state, and local laws 
and regulations aimed at preventing harmful releases of hazardous materials at facilities such as 
petroleum refineries. This regulatory framework does not foster continuous improvement by driving 
companies to reduce risks of their hazardous activities to ALARP, nor does it have the requisite number 
of regulatory staff with the skills, knowledge, and experience to provide sufficient oversight. 
5.1 
Cal/OSHA 
5.1.1 
 Background Information 
Section 18 of the OSHAct380 encourages states to develop and implement their own job safety and health 
programs. Twenty-five states (including California), Puerto Rico and the Virgin Islands currently 
implement OSHA-approved State Plans.381 States must set job safety and health standards that are “at 
least as effective as” comparable federal standards; most adopt standards that are identical to the federal 
standards.382 
California was certified as an OSHA State Plan state on August 12, 1977.383 California’s Division of 
Occupational Safety and Health (Cal/OSHA) administers the California Occupational Safety and Health 
Program. A PSM District Office384 within Cal/OSHA enforces California’s PSM standard, which is 
established under Title 8, Section 5189 of the California Code of Regulations (CCR) and entitled Process 
Safety Management of Acutely Hazardous Materials.385,386 The PSM District Office is comprised of 
seven inspectors, known as Associate Safety Engineers, and one District Manager to regulate nearly 1,700 
PSM-covered facilities in California, including 14 petroleum refineries. Only one of these individuals has 
a technical background, with a degree in Chemical Engineering. Appendix B of this report summarizes 
the key differences between the federal and California PSM standards and the safety case regulatory 
regime. A more detailed analysis of those differences will be provided in the remainder of Section 5.1. 
 
The CSB in its Interim Report identified a number of weaknesses of Chevron’s process safety 
performance. In many of these causal issues, Chevron was not required to perform at a more effective 
level by the existing California PSM regulations. In Table 1 below, the CSB identifies the causal issues 
or findings, which highlight the gaps in the California and federal PSM regulations, and how each issue is 
more effectively managed in the safety case regulatory regime. In this section of the report, some of these 
examples will be examined in relation to key features of an effective regulatory approach such as the 
380 29 U.S.C. §667 (2004). 
381 These are referred to informally as OSHA State Plans. OSHA approves and monitors State plans and provides up 
to 50 percent of an approved plan's operating costs 
382 29 U.S.C. §667 (c)(2) (2004). Also see http://www.osha.gov/dcsp/osp/faq.html (accessed May 13, 2013). 
383 See http://www.osha.gov/dcsp/osp/stateprogs/california.html (accessed June 17, 2013). 
384 The California PSM District Offices were established in 2001 after the February 1999 Tosco refinery incident in 
which four workers were fatally injured following the ignition of a highly flammable material during a turnaround 
operation. In January 2012 the two district offices were combined into one PSM District Office. 
385 See http://www.osha.gov/dcsp/osp/stateprogs/california.html (accessed May 13, 2013). 
386 8 CCR §5189 (2012). 
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safety case. More information on these causal findings can also be found in the CSB Chevron Interim 
Report. 
 
 
Process Safety 
Element 
Causal Finding 
California PSM 
Regulation∗ 
The Safety Case 
Regulatory Regime** 
MOC 
Inspection recommendation 
to upgrade pipe to 9-
Chrome not implemented. 
The MOC to implement the 
recommendation narrowed 
the scope allowing the 52-
inch component that failed 
to remain in service. 
Implementation of 9-
Chrome could have 
prevented the incident.387 
MOC element requires 
implementation of written 
procedures to manage 
changes that shall address 
the impact of the change on 
health and safety; however 
the element is activity 
based and there is no 
requirement to implement 
effective recommendations 
or control hazards. There is 
no requirement in the MOC 
element to consider 
inherent safety. Cal/OSHA 
did not cite Chevron for 
this issue. 
Duty holder is required to 
drive risk to ALARP. 
Description of MOC 
procedures and 
demonstration of their 
effectiveness in managing 
major accident hazard 
risk are a key requirement 
of the safety case. 
Implementation of the 
concept of inherent safety 
is required.388 
∗ Unless otherwise noted, California and federal PSM requirements are nearly identical. 
** Regulatory regimes such as offshore in Norway have many attributes of the safety case regulatory regime but are 
not called the safety case regulatory regime. 
387 For more information, see CSB’s Chevron Richmond Refinery Interim Investigation Report. April 2013; p 41 
and 42. http://www.csb.gov/assets/1/19/Chevron_Interim_Report_Final_2013-04-17.pdf (accessed October 30, 
2013). 
388 According to the HSE, essential considerations for determining whether a duty holder has reduced risks to 
ALARP include “the adoption of inherently safer designs…”. HSE. The Safety Report Assessment Manual, 
Sections 8 to 15. p 30. http://www.hse.gov.uk/comah/sram/s8-15.pdf (accessed October 30, 2013). The HSE also 
notes that the guidance to COMAH Regulation 4 (General Duty) “describes the application of all measures 
necessary to reduce risk of a major accident to ALARP based on a hierarchical approach (inherent safety, 
prevention, control, mitigation).” Ibid at 8. 
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Process Safety 
Element 
Causal Finding 
California PSM 
Regulation∗ 
The Safety Case 
Regulatory Regime** 
MOC 
Chevron conducted MOCs 
to evaluate proposed 
changes to crude feed that 
introduced higher sulfur 
concentration. However, 
Chevron failed to 
thoroughly evaluate the 
change of increasing sulfur 
weight percentage in crude 
oil feed and to assess how it 
might affect corrosion rates 
within the 4-sidecut piping 
circuit. Cal/OSHA did not 
issue any citations for 
failing to consider the 
impact of corrosion in the 
MOC process when sulfur 
composition in the crude oil 
feed was increased.389 
MOC element is activity-
based rather than 
performance based and 
requirements in RAGAGEP 
such as API 570390 do not 
apply to the MOC element 
of PSM. Cal/OSHA did not 
cite Chevron for this issue. 
Duty holder is required to 
drive risk to ALARP. 
Duty holder must identify 
in the safety case report 
the standards that they are 
using to reduce risk such 
as API 570. The 
implementation of those 
standards can be enforced 
by the regulator to 
achieve ALARP. 
PHA 
In its 2009 crude unit PHA, 
Chevron simply cited non-
specific, judgment-based 
qualitative safeguards such 
as: utilizing metallurgy to 
minimize corrosion, having 
effective maintenance and 
inspection programs, and 
providing pipe wall 
corrosion allowances. The 
effectiveness of these 
safeguards was neither 
evaluated nor documented; 
instead the safeguards were 
merely listed in the PHA. 
While the PHA element 
requires addressing the 
control of hazards, it does 
not require addressing the 
effectiveness of the controls 
or using the hierarchy of 
controls. For example, the 
standard would not require 
the use of improved 
metallurgy or inherent 
safety to mitigate corrosion 
hazards. Cal/OSHA did not 
cite Chevron for this issue. 
Requires the use of the 
most effective practical 
safeguards to achieve 
ALARP. The safety case 
requires the use of 
inherently safer design 
and the hierarchy of 
controls.391 
389 For more information, see CSB’s Chevron Richmond Refinery Interim Investigation Report. April 2013; p 34, 35 
and 36. http://www.csb.gov/assets/1/19/Chevron_Interim_Report_Final_2013-04-17.pdf (accessed October 30, 
2013). 
390 API 570. Piping Inspection Code: In-service Inspection, Rating, Repair, and Alteration of Piping Systems. 
November 2009. 
391 According to the HSE, essential considerations for determining whether a duty holder has reduced risks to 
ALARP include “the adoption of inherently safer designs…”. HSE. The Safety Report Assessment Manual, 
Sections 8 to 15. p 30. http://www.hse.gov.uk/comah/sram/s8-15.pdf (accessed October 30, 2013). The HSE also 
notes that the guidance to COMAH Regulation 4 (General Duty) “describes the application of all measures 
necessary to reduce risk of a major accident to ALARP based on a hierarchical approach (inherent safety, 
prevention, control, mitigation).” Ibid at 8. 
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Process Safety 
Element 
Causal Finding 
California PSM 
Regulation∗ 
The Safety Case 
Regulatory Regime** 
PHA 
The 4-sidecut line was 
analyzed in the most recent 
crude unit PHA. Corrosion 
was not identified as a 
potential cause of a 
leak/rupture in the piping. 
Damage mechanism hazard 
reviews are not required by 
the PSM regulation. The 
process hazard analysis 
element does not require 
consideration of 
RAGAGEP such as API RP 
571, Damage Mechanisms 
Affecting Fixed Equipment 
in the Refining Industry. 
Cal/OSHA did not cite 
Chevron for this issue. 
For example in the UK 
the HSE has worked with 
the industry to develop 
guidance on damage 
mechanism hazard 
reviews in the UK's 
offshore petrochemical 
industry. The 
implementation of best 
practice standards 
referenced by a duty 
holder’s safety case report 
may be enforced by the 
regulator to achieve 
ALARP. 
Incident 
Investigations 
Chevron made 
recommendations following 
its investigation of 
sulfidation incidents at 
Richmond, Salt Lake City 
and Pascagoula refineries 
requiring 100 percent 
component inspection in 
high risk piping systems. 
These recommendations 
were not implemented in 
the Richmond refinery 
crude unit prior to the 
incident. In 2007 Chevron 
identified the inherently 
safer solution of improved 
metallurgy to prevent 
sulfidation corrosion but 
only applied it to the crude 
unit small spool piece that 
failed. 
Neither California nor 
federal PSM regulations 
require root cause 
investigations or 
recommendations to be 
developed as the result of 
incident investigations. 
While California does 
require taking action to 
prevent reoccurrence, (goes 
beyond federal OSHA) it 
does not drive risk to 
ALARP. Cal/OSHA did 
not cite Chevron for this 
issue. Federal PSM does 
not require the development 
of recommendations or the 
prevention of future 
incidents. 
Investigation of incidents 
is required to demonstrate 
legal compliance with 
framework legislation. 
ALARP requirement 
would require remedial 
action including cross-
company learning from 
incident investigations. 
HSE can require safety 
case duty holder 
compliance with 
investigation report 
recommendations (e.g. 
Buncefield Report-
“determine SIL level 
requirements for overfill 
protection”). 
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Process Safety 
Element 
Causal Finding 
California PSM 
Regulation∗ 
The Safety Case 
Regulatory Regime** 
Mechanical 
Integrity 
Chevron was instrumental 
in the development of API 
RP 939-C, which suggests 
("should") but does not 
require ("shall") that 100 
percent component 
inspection be performed. 
API states that the use of 
"shall" denotes minimum 
requirements in the use of 
the standard - API RP 939-
C has no minimum 
requirements (no 
substantive "shalls" are 
used in the recommended 
practice). 
The mechanical integrity 
element of PSM requires 
that for inspection and 
testing procedures, 
employers follow 
RAGAGEP. However, API 
RP 939-C has no minimum 
requirements. Nonetheless, 
Cal/OSHA cited Chevron 
for failure to follow API RP 
939-C under this 
mechanical integrity 
provision. In the federal 
regulatory context, this 
approach has been called 
into question by the recent 
administrative law judge 
decision in BP Products. 
This case is scheduled for 
review by the full 
commission. 
In a safety case regime, 
the regulator can reject 
the use of weak and 
inadequate standards 
referenced in a safety case 
report (by rejecting the 
report) and can require 
more rigorous 
performance to achieve 
ALARP. 
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Process Safety 
Element 
Causal Finding 
California PSM 
Regulation∗ 
The Safety Case 
Regulatory Regime** 
Inherent 
Safety 
Chevron employees have 
recommended 
implementing inherently 
safer designs through the 
MOC process, incident 
investigations, technical 
reports, and past employee 
recommendations. 
However, the CSB has not 
identified any documented, 
thorough analysis of the 
proposed inherently safer 
solutions. In addition, 
Chevron has repeatedly 
failed to implement 
proposed inherently safer 
recommendations. Had 
Chevron implemented these 
recommendations, the 
incident could have been 
prevented. 
Neither California nor 
federal PSM regulations 
require the use or 
implementation of inherent 
safety. Cal/OSHA did not 
cite Chevron for this issue. 
In its Interim Report, the 
CSB made a 
recommendation to the 
California legislature and 
the Governor of California 
to use inherently safer 
systems analysis and the 
hierarchy of controls to the 
greatest extent feasible in 
establishing safeguards for 
identified process hazards. 
Safety case requires the 
implementation of 
inherently safer systems 
analysis.392 
Regulator 
Enforcement 
Despite numerous safety 
system deficiencies the 
Cal/OSHA regulator failed 
to identify these issues prior 
to the incident. Cal/OSHA 
conducted three planned 
inspections prior to the 
incident that resulted in no 
citations or fines. 
The CSB determined 
Cal/OSHA lacked sufficient 
resources and numbers of 
highly qualified inspectors. 
California is adding 15 
additional inspectors to its 
PSM unit. The Governor's 
Interagency Task Force on 
Refinery Safety will be 
proposing to implement 
additional 
recommendations from 
their draft report. 
A key feature of the 
safety case is a rigorous 
review of the safety case 
report that may be 
accepted or rejected by 
the regulator. 
Preventative audits of 
covered facilities are 
regularly performed by 
technically competent, 
well resourced regulators. 
392 According to the HSE, essential considerations for determining whether a duty holder has reduced risks to 
ALARP include “the adoption of inherently safer designs…”. HSE. The Safety Report Assessment Manual, 
Sections 8 to 15. p 30. http://www.hse.gov.uk/comah/sram/s8-15.pdf (accessed October 30, 2013). The HSE also 
notes that the guidance to COMAH Regulation 4 (General Duty) “describes the application of all measures 
necessary to reduce risk of a major accident to ALARP based on a hierarchical approach (inherent safety, 
prevention, control, mitigation).” Ibid at 8. 
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Process Safety 
Element 
Causal Finding 
California PSM 
Regulation∗ 
The Safety Case 
Regulatory Regime** 
Workforce 
Involvement 
The workers in previous 
loss of containment 
incidents raised concerns 
about the level of corrosion 
in the Crude and RLOP 
incidents, but their concerns 
were not effectively 
addressed prior to the 
August 6, 2012, incident. 
The workforce participation 
element requires an 
employer to develop a 
written plan to "ensure 
employee participation in 
process safety 
management…” including 
"consultation with 
employees and their 
representatives on the 
conduct and development 
of the elements of process 
safety management...” 
However, development of a 
written plan to satisfy the 
regulatory requirements 
does not ensure that 
workers and their 
representatives in practice 
are able to effectively 
participate in a company's 
safety management system 
such as PHAs, MOCs, and 
investigation activities. 
Safety case sets out a 
legal framework for the 
participation of 
employees on health and 
safety-related matters, the 
election of safety 
representatives, and the 
establishment of safety 
committees to serve 
health and safety related 
functions. Workforce 
participation practices are 
documented by the duty 
holder and submitted to 
the regulator. 
 
Table 1. CSB Causal Findings. 
 
5.1.2 
Analysis 
5.1.2.1 
ALARP 
Unlike the OSHAct, the California Occupational Safety and Health Act does not have a General Duty 
Clause. Rather, Section 5189 was established to “eliminate to a substantial degree, the risks to which 
employees are exposed in petroleum refineries, chemical plants and other facilities.”393 By focusing on 
the significant reduction of risk, this language supports the principle of ALARP, which requires a 
showing by the company that “there are no other practical measures that could reasonably be taken to 
reduce risks further.”394 However, this section, which lays out the “scope and purpose” of the regulation, 
is not an enforceable element of the regulation that is subject to citations, and the remaining PSM 
regulation elements do not lead in practice to that result. Rather, California’s PSM standard has remained 
activity-based, with many activity-based elements almost identical to the federal PSM standard. For 
example, an employer must “perform a hazard analysis [PHA] appropriate to the complexity of the 
393 8 CCR §5189 (a) (2012). 
394 ALARP Guidance Note N-04-300-GN0166, Rev. 3 (Dec. 2011) available at 
http://www.nopsema.gov.au/assets/document/N-04300-GN0166-ALARP.pdf (accessed May 15, 2013). 
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process for identifying, evaluating, and controlling hazards involved in the process....”395 The PHA must 
address hazards of the process; engineering and administrative controls applicable to the hazards and their 
relationships; consequences of failure of these controls; facility siting; human factors; a qualitative 
evaluation of a range of the possible safety and health effects of the failure of controls on facility 
employees; and the identification of any previous incident which had a likely potential for catastrophic 
consequences in the workplace.”396 This language does not support the principle of ALARP, and makes 
no mention of risk or continuous improvement in any way. As a result, PHAs satisfy the California PSM 
regulatory requirement by merely listing safeguards; there is no requirement to evaluate or document the 
effectiveness of these safeguards, or to show that the safeguards in place are effectively reducing risks. 
As discussed in the CSB’s Interim Report on the Chevron incident, Chevron cited in its 2009 crude unit 
PHA non-specific, judgment-based qualitative safeguards such as: utilizing metallurgy to minimize 
corrosion, having effective maintenance and inspection programs, and providing pipe wall corrosion 
allowances.397 The effectiveness of these safeguards was neither evaluated nor documented. Had the 
adequacy of these safeguards been verified, improved safeguards intended to protect against sulfidation-
induced failure of carbon steel piping could have been recommended. In addition, while the 4-sidecut 
line was analyzed in this PHA, corrosion was not identified as a potential cause of a leak/rupture in the 
piping (emphasis added). A corrosion review, also referred to as a damage mechanism hazard review, 
analyzes hazards presented by all process failure mechanisms such as corrosion and cracking. This type 
of review, while considered to be good practice,398 is not required by the PSM regulations either federally 
or in California, and as such the CSB made a recommendation in its Interim Report to require these in 
future California PHAs. Under a safety case regulatory regime, the regulator has the ability to drive 
industry to adapt new technologies and safer practices as soon as they are developed; new rulemaking is 
not required for immediate improvements, because companies are obligated to continually work toward 
specified performance goals such as reducing risks to ALARP. Therefore, under a safety case regulatory 
regime the regulator could require these types of reviews to be conducted to reduce risk without requiring 
additional legislation. 
Cal/OSHA does not typically review a company’s PHA as part of its routine oversight of process safety 
management unless there is a specific complaint, accident, or targeted inspection. Nor does it “accept” a 
company’s PHA and proposed hazard mitigations. Therefore, prior to the August 2012 incident, 
Cal/OSHA inspectors did not require any additional information or analysis to be provided in the Chevron 
crude unit PHA. Highlighting the reactive nature of the PSM standard, Cal/OSHA inspected the Chevron 
facility post-incident and issued 17 citations related to the incident and eight additional citations, with a 
total proposed fine of nearly $1 million. Only one citation related to PHAs, and it was not associated with 
evaluating the effectiveness of safeguards or failure to control the 4-sidecut corrosion hazard. Rather, the 
emphasis was that Chevron’s PHA did not adequately account for hazards caused by other units 
395 8 CCR §5189 (e)(1) (2012). 
396 8 CCR §5189 (e)(2) (A) through (G) (2012). 
397 Corrosion allowance refers to extra wall thickness added as a safety factor to the design of a piece of equipment 
beyond that needed solely for mechanical considerations such as design temperature and pressure. This extra 
thickness is provided to accommodate for expected loss of wall thickness due to corrosion over the life of the 
equipment. 
398 API RP 571, Damage Mechanisms Affecting Fixed Equipment in the Refining Industry, describes common 
process failure mechanism and is considered to be good practice for analyzing risks presented by process failure 
mechanisms such as corrosion and cracking. 
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associated with the crude unit. This again highlights the lack of a requirement for Chevron to 
demonstrate that risks have been reduced to ALARP, or for Chevron to provide this type of analysis to 
Cal/OSHA to review. 
 
5.1.2.2 
Adaptability and Continuous Improvement 
 
Of the 25 Cal/OSHA citations mentioned above, two were issued to Chevron for its failure to follow API 
RP 939-C, Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries as 
RAGAGEP. This voluntary API standard will be discussed in greater detail in the CSB’s Final 
Investigation Report on the Chevron incident. However, it is important to note for purposes of this report 
that API RP 939-C is a permissive and voluntary standard merely intended to provide guidance to 
industry personnel on how to address sulfidation corrosion in petroleum refining operations. Existing 
safety guidelines use words “shall” and “should” to denote either requirements or recommendations. API 
RP 939-C does not use the word “shall”; as such, it contains no requirements for industry. While the 
regulator in a safety case regulatory regime has the authority to analyze and challenge the requirements of 
API RP 939-C with the goal of driving continuous improvement and risk reduction (note the Buncefield 
examples discussed in Section 4.3), in the present case Cal/OSHA utilized the voluntary practice as an 
opportunity to issue a citation to Chevron post-incident. Cal/OSHA did not analyze API RP 939-C to 
determine whether its provisions are sufficient to reduce risks and manage hazards. It also remains to be 
seen whether this citation will be upheld considering the permissive language contained within the 
standard. 
Chevron has investigated a number of sulfidation incidents at its refineries over the years, including 
Richmond, Salt Lake City, and Pascagoula. Figure 2 shows a timeline of Chevron’s key sulfidation 
events. In January 2007, a failure due to sulfidation corrosion caused a serious fire in the Chevron 
Richmond Refinery crude unit resulting in a CWS Level 3 alert, injuring one worker and initiating a 
shelter-in-place for the surrounding community. As a result of these investigations, Chevron made 
internal recommendations to require 100 percent component inspections in high-risk piping systems. 
However, these recommendations were not implemented in the Richmond Refinery crude unit prior to the 
incident, highlighting a lack of learning from previous incidents by Chevron. 
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Figure 2. Chevron's key sulfidation events between 1974 and 2013. 
 
In addition, as a result of the January 2007 incident, Chevron informed Contra Costa Health Services’ 
Hazardous Materials Program399 (CCHMP) in a letter that the crude unit piping metallurgy had been 
upgraded following this incident as an inherently safer solution. However, the CSB learned that this 
upgrade was limited to only the immediate piping spool400 that failed. Cal/OSHA also did not require 
Chevron to update the crude unit PHA to address the findings from this incident. Under a safety case 
regulatory regime, the regulator would work with the company to improve its practices following such an 
incident. The company would also be required to update its safety case report to address these corrosion 
hazards and demonstrate how the company has reduced risks to ALARP. 
 
The CSB also noted in its Chevron Interim Report that despite internal recommendations to replace the 
entire #4 sidecut piping with an inherently safer, more corrosion-resistant material of construction, 
Chevron’s 2006 Management of Change (MOC) analysis limited the application of those 
recommendations. Instead of replacing the entire piping segment identified by the original 
recommendation, the 2006 MOC considered only the replacement of a small section. Although the 
recommendation was intended to more broadly apply inherently safer materials of construction, the final 
implementation under the 2006 MOC limited the application of this more corrosion resistant 
399 Contra Costa Health Services’ Hazardous Materials program is designed to respond to emergencies and monitor 
hazardous materials within Contra Costa County. See http://cchealth.org/hazmat/ (accessed April 17, 2013). 
CCHSHMP also implements the CalARP and ISO programs, which will be discussed in greater detail later on. 
400 A piping spool is a small, removable section of piping. In some cases, a piping spool is installed or removed in 
order to provide a temporary connection or complete disconnection between two piping circuits. 
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metallurgy.401 As the mere completion of an MOC and the implementation of any action item satisfy the 
California PSM standard requirements, regardless of its adequacy or effectiveness, Cal/OSHA did not 
evaluate the MOC or cite Chevron for narrowing the scope of the MOC, despite its disregard of internal 
recommendations. Neither the California nor the federal PSM standards allow citations for inadequate 
MOCs. In addition, RAGAGEP does not apply to the MOC PSM element. 
 
This can be contrasted with the safety case regulatory regime in the UK, where the HSE includes the 
adoption of inherently safer designs as an essential consideration for determining whether a duty holder 
has reduced risks to ALARP.402 The HSE also notes that the guidance to COMAH Regulation 4, (the 
COMAH General Duty provision) “describes the application of all measures necessary to reduce risk of a 
major accident to ALARP based on a hierarchical approach (inherent safety, prevention, control, 
mitigation).”403 
5.1.2.3 
Process Safety Indicators 
As the CSB has noted in its BP Texas City Investigation Report, Chevron Interim Report, and Section 4.5 
of this report, process safety indicators are a significant element of process safety management systems 
and are critical for reducing process safety incidents. A major goal of process safety indicators is to drive 
continuous process safety improvement. Regulators can utilize these indicators to focus inspections, 
audits, and investigations. 
 
Federally and in the state of California, neither the PSM standard nor the RMP rule require companies to 
utilize or report process safety indicators. Chevron voluntarily utilizes both leading and lagging 
indicators internally in its US petroleum refineries, in a system called Operational Excellence and 
Reliability Intelligence (OERI), which tracks 26 different process safety indicators. OERI was 
implemented in May 2009. However, Chevron is not required to report the status of its indicators to 
California regulators. Nor is Chevron held accountable to use the indicators to drive performance or 
continuous improvement. As a result, the CSB made a recommendation in its Chevron Interim Report to 
the California State Legislature to identify and require the reporting of leading and lagging process safety 
indicators to state and local regulatory agencies, with the goal of improving mechanical integrity and 
process hazard analysis performance at all California petroleum refineries, and preventing major chemical 
incidents. 
5.1.2.4 
Inspections 
As noted in Section 4.6, safety case regulators utilize preventative inspections and audits to monitor 
compliance with legislation and to ensure that the facility and its operations are consistent with 
information provided in the safety case. However, like federal OSHA, California regulations require 
Cal/OSHA to prioritize accident, complaint, and referral-based inspections over planned inspections. As 
such, Cal/OSHA’s inspection program of the nearly 1,700 PSM-regulated facilities in California, 
401 As discussed in the Interim Report, only the section of piping downstream of the pumps was replaced with 9-
Chrome. 
402 HSE. The Safety Report Assessment Manual, Sections 8 to 15. p 30. http://www.hse.gov.uk/comah/sram/s8-
15.pdf (accessed October 30, 2013). 
403 Ibid at 8. 
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including 14 petroleum refineries, 404 has been reactive in nature rather than proactive to maximize 
prevention. 
OSHA State Plan states405 were strongly encouraged but not required to implement the federal Petroleum 
Refinery NEP. Cal/OSHA did not adopt the NEP “because of its dedicated PSM Unit.”406 Between 2006 
and August 6, 2012, the Cal/OSHA PSM District Office conducted only three planned inspections of the 
Chevron Richmond facility, totaling only 150 inspector hours of effort. Cal/OSHA has acknowledged 
that these were not PQV inspections, as envisioned in its mission statement and in the federal PSM 
compliance directive. None of these inspections resulted in citations or fines. According to statistics 
provided by OSHA, federal NEP refinery inspections conducted between 2007 and the end of 2011 
required roughly 1,000 inspector hours each and resulted in an average of 11.2 violations and $76,821 in 
penalties per inspection. OSHA noted that hours spent on a typical federal refinery NEP inspection were 
40 times greater than the average OSHA inspection. These numbers indicate a major disparity in 
thoroughness and comprehensiveness between the planned inspections conducted by Cal/OSHA and the 
NEP inspections conducted by OSHA and other OSHA State Plan States. The federal NEP, which 
represented a more robust and intensive inspection program, ended in 2011 due to the stated great demand 
on OSHA resources. 
5.1.2.5 
Workforce Participation 
Like the federal PSM standard, California’s PSM standard provides for workforce participation in a 
company’s process safety management program. 8 CCR §5189 (p) requires an employer to develop a 
written plan to “ensure employee participation in process safety management” including “consultation 
with employees and their representatives on the conduct and development of the elements of process 
safety management…”407 However, developing a written plan to satisfy the regulatory requirements does 
not ensure that workers and their representatives in practice are able to effectively participate in a 
company’s process safety management systems. 
In its investigation of the Chevron incident, the CSB noted that the Chevron Richmond Refinery 
workforce and its representatives, the United Steelworkers (USW), had expressed concerns regarding 
sulfidation corrosion and broader workplace safety issues, but were not consistently listened to by 
Chevron managers, and their concerns regarding corrosion were not adequately acted upon. In November 
2011, Cal/OSHA investigated a complaint of unsafe working conditions during the fourth quarter 
Richmond Lube Oil Plant (RLOP) turnaround at the Richmond Refinery. The RLOP receives feedstock 
from the crude unit where the August 6th incident occurred and has similar sulfidation corrosion concerns. 
During the shutdown of the RLOP, a fire occurred at one of the RLOP furnaces. According to 
Cal/OSHA’s inspection report, Chevron employees told Cal/OSHA that “OPERATORS GET 
IGNORED.” Many of the employees were concerned about increased corrosion they were finding during 
the turnaround, and believed that increased temperatures and throughput rates had an adverse effect on 
404 Also see the California Labor Code Sections 6309 to 6315 (The California Occupational Safety and Health Act of 
1973). 
405 Section 18 of the Occupational Safety and Health Act of 1970 encourages States to develop and operate their 
own job safety and health programs, referred to informally as an OSHA State Plan. OSHA approves and monitors 
State plans and provides up to 50 percent of an approved plan's operating costs. 
406 Department of Industrial Relations, Division of Occupational Safety and Health, California, Process Safety 
Management District Office. Mission Statement: Goals Reached in 2011 & Strategic Plan for 2012. 
407 8 CCR §5189(p)(1) (2012). 
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equipment integrity. According to the interview notes, many operators had raised issues of corrosion in 
the RLOP to higher level supervisors to no avail; according to one, if you raise an issue a couple of times, 
“you get labeled a ‘pest.’” The CSB has not identified evidence indicating that Cal/OSHA took further 
action to respond to these concerns, and Cal/OSHA did not issue any citations as a result of its 
investigation.408 Post-incident, significant sulfidation corrosion was found in the RLOP and piping and 
equipment were replaced. 
The CSB found other significant evidence that increased workforce participation could have reduced the 
likelihood that unchecked corrosion would lead to the August 2012 incident. As discussed in the CSB’s 
Interim Report on the Chevron incident, Chevron technical staff has considerable knowledge and 
expertise regarding sulfidation corrosion, specifically with respect to corrosion rate variations caused by 
differing silicon concentration in carbon steel piping. Chevron employees have authored industry papers 
on sulfidation corrosion and had significant influence in the development of the industry sulfidation 
corrosion recommended practice, API RP 939-C. In 2009, Chevron Energy Technology Company 
(Chevron ETC)409 created an internal document on the subject of sulfidation corrosion. Chevron ETC 
metallurgists released a formal report dated September 30, 2009 (nearly 3 years prior to the incident) to 
Chevron refinery-based reliability managers and chief inspectors entitled Updated Inspection Strategies 
for Preventing Sulfidation Corrosion Failures in Chevron Refineries. 
Sulfidation experts explained in the Chevron ETC report that, “[u]ntil now, Chevron has not directly 
addressed the risk of low Si[licon] carbon steel…”410 and that the report introduced a program that “seeks 
to close these gaps, and to maximize the effectiveness of our inspection.” The report clearly indicates that 
Chevron understood both the potential consequence and the high likelihood of a rupture or catastrophic 
failure from sulfidation corrosion and calls out Chevron’s need for action. 
The Chevron ETC report specifically recommended that inspectors perform 100 percent component 
inspection on high temperature carbon steel piping susceptible to sulfidation corrosion. However, this 
100 percent component inspection program was not implemented at the Richmond refinery prior to the 
August 6, 2012, incident. The Chevron ETC report defined a priority ranking system to help focus the 
inspection implementation efforts. The process conditions of the 4-sidecut pipe placed it in the highest 
priority for inspection. 
Chevron ETC technical experts issued a corporate newsletter in 2010 that again warned of the potential 
consequence of sulfidation failures. In this newsletter, the 100 percent component inspection 
recommendation from the 2009 report was reiterated for piping systems such as the crude unit 4-sidecut 
piping. The newsletter stated: 
Sulfidation corrosion failures … are of great concern because of the 
comparatively high likelihood of ‘blowout’ or catastrophic failure. This 
typically happens because corrosion occurs at a relatively uniform rate 
over a broad area, so a pipe can get progressively thinner until it actually 
bursts rather than leaking at a pit or local thin area. In addition, the 
408 Post-incident, there were significant mechanical integrity improvements and piping replaced in the RLOP unit. 
409 The Chevron Energy Technology Company is a separate business unit within the Chevron Corporation that 
provides technology solutions and technical expertise for Chevron operations worldwide. See 
http://richmond.chevron.com/home/aboutchevronrichmond.aspx (accessed April 4, 2013). 
410 A 2003 corporate technical newsletter recommended 100 percent component inspection of carbon steel piping 
susceptible to sulfidation corrosion following a 2002 Chevron Salt Lake City sulfidation corrosion incident. 
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process fluid is often above its auto ignition temperature. The 
combination of these factors means that sulfidation corrosion failures 
frequently result in large fires. Chevron and the industry have 
experienced numerous failures from this mechanism and recent incidents 
have reinforced the need for revised inspection strategies and a robust 
PMI (Positive Materials Identification) program. 
The Chevron ETC 100 percent component inspection recommendation for high risk piping systems, 
established in 2009, was not implemented at Richmond, and the thin-walled low silicon 4-sidecut piping 
component remained in service until it catastrophically failed on August 6, 2012. 
Chevron and Chevron ETC metallurgists, materials engineers, and piping inspectors had expertise 
regarding sulfidation corrosion. They educated personnel and advocated for identification and control of 
damage mechanisms, including sulfidation corrosion. However, they had limited practical influence to 
implement their recommendations. These individuals did not participate in the crude unit PHA and did 
not affect decisions concerning control of sulfidation corrosion during the crude unit turnaround 
process.411 
Despite the history of sulfidation corrosion incidents and the recommendations by Chevron’s workforce 
to implement better inspection methodologies, Cal/OSHA did not evaluate these recommendations or 
determine whether Chevron management ensured that the hazards of this damage mechanism were 
addressed and mitigated in Chevron’s PHAs. In addition, Cal/OSHA issued no citations to Chevron post-
incident regarding the failure to address sulfidation corrosion in its crude unit PHA. Finally, when 
Chevron employees raised concerns, Cal/OSHA did not effectively address them. The examples 
highlighted in this section speak to the need for California to develop more effective regulation similar to 
the UK legislation discussed in Section 4.4, to ensure strong workforce involvement in health and safety 
matters at petroleum refineries. This will not only help prevent incidents such as the one that occurred at 
Chevron, but it will also help improve communication and ensure that workers are represented in the 
decisions that affect them. 
5.1.2.6 
Funding and Regulator Competency 
Cal/OSHA has not received sufficient funding to employ a well-staffed, multi-disciplinary team capable 
of conducting thorough inspections of PSM-covered facilities in California. This is apparent when 
examining the lack of preventative, planned inspections of petroleum refineries being conducted by the 
PSM team in the state. In order for a safety regulatory regime to successfully regulate with the goal of 
major accident prevention, there must be a technically competent, well-resourced regulator in place to 
sufficiently review, scrutinize, and challenge the hazard identification and evaluation that has been 
conducted and controls that have been put in place to reduce risk, to help drive continuous improvement 
and ensure that risks are being controlled. It is not an acceptable outcome for society that petroleum 
refineries with the potential for catastrophic accidents be inspected only after an accident occurs or a 
complaint is filed. 
 
411 The turnaround process includes both the planning stage prior to the shutdown and the activities staged during the 
shutdown. 
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Compensation is one important factor for recruiting and retaining technically competent personnel. The 
CSB found that California regulators are significantly less compensated when compared to their industry 
counterparts. Based on information Chevron provided to the CSB, the average annual salary of refinery 
personnel who would interact with a California regulator performing an audit or safety inspection is 
$187,630. Table 2 below provides the 2012 salaries of California regulatory personnel that the CSB 
determined would likely perform a safety inspection or a hypothetical safety case assessment. These 
figures indicate a substantial compensation gap between the regulator and the regulated. A Cal/OSHA 
PSM team of associate safety engineers receive an average annual salary that is 46 percent lower than the 
refinery employees they would likely interface with during an inspection. EPA RMP inspectors receive 
an annual salary that is 33 percent lower than their facility counterparts and Contra Costa County 
accidental release prevention engineers and their supervisor are paid 48 percent less than these industry 
personnel.412 
 
Entity 
Average Annual Salary 
Refinery Personnel 
$187,630 
Cal/OSHA 
$100,536 
Contra Costa County 
$96,875 
EPA 
$125,000 
Table 2. Average 2012 salary for individuals selected by the CSB as representative of the 
professional staff within each California regulator and of the refinery professional staff who interface 
with the regulators regarding audits or safety inspections at the Chevron Richmond Refinery. 
As noted in the introduction of this report, the California State Legislature approved a 2013-2014 state 
budget bill (AP 110) that allows the California Department of Industrial Relations to charge state 
petroleum refineries a fee by March 31, 2014, to support an increase in funding and to pay for at least 15 
new positions in Cal/OSHA’s PSM Unit.413 The CSB considers this to be a positive step towards 
improving process safety management in the state of California, as it will provide the team the 
opportunity to conduct more thorough inspections. However, it is imperative that these additional 
inspectors have the skills, knowledge, and experience to provide sufficient direct oversight over PSM-
covered facilities. Despite the additional funding, there remains a longstanding salary cap on associate 
safety engineers within Cal/OSHA. This will continue to make it difficult for Cal/OSHA to consistently 
attract or retain the necessary talent and expertise to effectively oversee these facilities. 
412 Compensation information is based on salary only. It does not take into account non-salary information such as 
bonuses, retirement programs, or benefit programs. 
413 See http://www.caltax.org/homepage/062113_Legislature_Approves.html (accessed July 9, 2013). 
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5.2 
U.S. Environmental Protection Agency 
According to the EPA OIG, as of May 2012, only eight states and five local agencies had accepted full or 
partial RMP program delegation from EPA.414 As such, EPA regions directly implement the RMP 
program in most states. As no state agency has requested or received delegation to implement the RMP 
program within EPA Region 9, the federal EPA regional office is responsible for RMP program 
implementation for California as well as Arizona, Nevada, Hawaii, the Pacific Islands, and 148 Tribal 
Nations. 
5.2.1 
Risk Management Plan (RMP) Program 
As of March 2013, there were 1,137 RMP-covered facilities in Region 9: 957 in California; 118 in 
Arizona; 42 in Nevada; 16 in Hawaii; and four in Guam.415 The Chevron Richmond Refinery has many 
processes covered by the RMP rule, including Program 3 processes, 416 such as the crude unit. As such, 
Chevron is required to submit an RMP every five years to EPA Region 9, and EPA is expected to audit 
the facility against this RMP to ensure compliance. According to Chevron’s most recent RMP submitted 
to EPA Region 9 in October 2011, its crude unit contained 400,000 pounds of a flammable mixture of 
propane, pentane, butane, ethane, and methane, well above the 10,000-pound threshold quantity for 
flammables.417 
EPA Region 9 employs four full-time and two part-time RMP inspectors to implement the RMP program 
for the roughly 1,100 RMP-covered facilities in the entire region. Region 9 staff informed the EPA OIG 
that to most effectively utilize their resources, they “place an additional focus on facilities in States, such 
as Arizona, that do not have their own risk management or accident prevention programs.418 The EPA’s 
mandates to conduct a certain number of inspections at high-risk facilities plus a lack of resources and 
staffing prevent the inspectors from fully auditing many of the petroleum refineries in each state; thus, the 
inspectors aim to visit each refinery every three years, where they pick one process to evaluate for two to 
three days. These inspectors target their inspections towards a specific industry issue during these visits. 
For example, when they last inspected Chevron in 2010, the inspectors focused on the issue of high 
temperature hydrogen attack (HTHA) due to the Tesoro incident that occurred in April 2010.419 
414 EPA OIG. Improvements Needed in EPA Training and Oversight for Risk Management Program Inspections; 
March 21, 2013; p 2. 
415 US EPA Region 9 Emergency Prevention and Preparedness Program; Stanislaus County Powerpoint; March 
2013. See http://www.condorearth.com/files/08-Enforcement_Priorities-Mary_Wesling.pdf (accessed May 14, 
2013). 
416 Processes not eligible for Program 1 and either subject to OSHA’s PSM standard or classified in one of ten 
specified North American Industrial Classification System (NAICS) codes are placed in Program 3, which imposes 
OSHA’s PSM standard as the prevention program as well as additional hazard assessment, management, and 
emergency response requirements. 
417 EPA List of Regulated Chemicals and Threshold Quantities for RMP program available at 
http://www.epa.gov/R5Super/cepps/pdfs/rmp-listed-chemicals-200708.pdf (accessed May 17, 2013). 
418 California has its own RMP program, called CalARP. See EPA OIG. Evaluation Report: EPA Can Improve 
Implementation of the Risk Management Program for Airborne Chemical Releases; February 10, 2009; p 23. 
419 On April 2, 2010, a heat exchanger ruptured due to high temperature hydrogen attack, resulting in seven worker 
fatalities at the Tesoro Anacortes Refinery in Anacortes, Washington. The CSB is set to release its investigation 
report on this incident near the end of January 2014. 
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5.2.2 
Implementation of the RMP Program 
In order for a safety regime to function well, there must be a competent, well-resourced regulator in place 
to implement the regime. However, the EPA Region 9 RMP group is extremely understaffed and under-
resourced, as there are only six full-time inspectors to cover over 1,100 facilities across many states. 
Instead of fully inspecting or auditing petroleum refineries, the group is able to inspect one process at 
each refinery for two to three days every three years, which makes fully inspecting these facilities or 
auditing against the RMPs submitted by these facilities impossible. In addition, this group has other 
responsibilities beyond the RMP program, including the management of contracts, emergency prevention 
and preparedness training and outreach, and reporting violations under the Comprehensive Environmental 
Response, Compensation, and Liability Act (CERCLA). The CSB has learned that because this group 
has such limited resources, it hopes to delegate RMP inspection authority to other agencies throughout the 
region, as long as it maintains power to enforce violations. 
Like the federal and California PSM standards, the RMP regulations provide for workforce 
participation420 and require facilities to prepare a written plan of action regarding employee participation. 
It is the RMP program’s policy to invite employee representatives to participate in all parts of onsite 
inspections. EPA Region 9 RMP staff told the CSB, however, that the limited amount of time they were 
able to spend onsite at refineries made speaking with facility inspectors and operators a difficult task. 
They expressed that a lesson learned from the Chevron incident was that EPA RMP inspectors should 
commit more time onsite during facility inspections and audits, which will allow them more time to speak 
with workers to gain a better insight into how any issues within the facility are being addressed and 
resolved.421 
As mentioned above, EPA guidance on the RMP program states that the owner or operator’s duty to 
“prevent accidents and ensure safety at [their] source…” may require steps to be taken “beyond those 
specified in the risk management program rule.”422 While this principle appears to be similar to ALARP 
requirements of the safety case, in practice this is not required, and whether this is done is not subject to 
regulation or review. Similar to the PSM standard, RMP regulations require each facility with Program 3 
processes to conduct a PHA as part of its prevention program that is “appropriate to the complexity of the 
process…and[] identify, evaluate, and control the hazards involved in the process.”423 However, these 
regulations do not require facilities to include these analyses in the RMPs they submit to EPA. Rather, 
facilities with Program 2 or 3 processes are only required to include in the RMP very high-level, 
simplified information on their prevention programs and their PHAs. The Chevron Richmond Refinery’s 
most recent RMP submission from October 2011 included the following information on the PHAs for 
each relevant process: the date of the last PHA for that process; what technique was used; what major 
hazards were identified; what process controls were in use (i.e. automatic shutoffs, interlocks, alarms, 
emergency power); what mitigation systems were in use (i.e. dikes, fire walls, water curtain); what 
monitoring/detection systems were in use (i.e. process area detectors); date of the most recent review or 
420 See 40 CFR §68.83 (2000). 
421 This need for greater interface with worker is a professional opinion by EPA staff, but has not resulted in EPA 
policy modifications to ensure effective worker input in future inspections. 
422 EPA Office of Solid Waste and Emergency Response. General Guidance on Risk Management Programs for 
Chemical Accident Prevention (40 CFR Part 68); March 2009; p 7-7. See 
http://www.epa.gov/osweroe1/docs/chem/Toc_final.pdf (accessed May 14, 2013). 
423 40 CFR §68.67(a) (1998). 
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revision of training programs; and maintenance. Chevron included one paragraph entitled “E.5. General 
Accidental Release Prevention Program,” which stated that PSM is applied to the entire refinery, and the 
PSM program is documented in Refinery Instruction (RI)-360, “Richmond Refinery PSM Policy.” No 
additional information or analysis could be located concerning the identification or control of hazards, or 
risk reduction, as, unlike the safety case model, there is no requirement for the company to demonstrate to 
the regulator that it is effectively ensuring that the safety systems are functioning as intended. 
Under the EPA RMP program, there is no regulatory requirement to reduce risks to ALARP. In addition, 
there is no requirement to submit to the regulator detailed information relating to risk reduction or hazard 
assessments. Finally, the Region 9 EPA RMP inspection team does not have the resources to fully audit 
petroleum refineries and other high hazard facilities subject to the RMP program. As a result, the EPA 
RMP program is not comprehensive or rigorous enough to control major accident hazards and reduce 
risks. Instead, facilities submit high-level summary information providing evidence that the activity-
based requirements contained within the RMP regulations have been completed by the facility. 
5.3 
Unified Program 
Chevron’s Richmond refinery was also subject to process safety regulatory requirements at the county 
and city level. The facility had to adhere to additional requirements above the PSM and RMP regulations, 
but these requirements were not sufficient to prevent the Chevron incident. The following sections will 
discuss those county and city requirements. 
In 1993, Chapter 418, Statutes of 1993 (Senate Bill 1082) established Chapter 6.11 of the California 
Health and Safety Code (HSC), which required the Secretary of the California Environmental Protection 
Agency (Cal/EPA) to adopt regulations creating a “unified hazardous waste and hazardous materials 
management” regulatory program, or Unified Program, by January 1, 1996, to consolidate and make 
consistent six existing hazardous materials and hazardous waste programs within the state.424 The 
Secretary of Cal/EPA was charged with ensuring that the Unified Program was established and 
implemented by a Certified Unified Program Agency, or CUPA, in all counties in California. Cal/EPA 
adopted the Unified Program regulations under Title 27, Division 1 of the California Code of Regulations, 
which integrated six existing programs: the Hazardous Waste Generator and Onsite Hazardous Waste 
Treatment programs; the Aboveground Storage Tank program; the Underground Storage Tank program; 
the Hazardous Materials Release Response Plans and Inventory program; the California Accidental 
Release Prevention (CalARP) program; and the California Uniform Fire Code.425 The CalARP program, 
which was created through Assembly Bill AB1889 with the goal of major accident prevention, will be 
discussed at greater length below. There are currently 83 CUPAs in the state of California that implement 
the Unified Program at a local level.426 
5.3.1.1 
Contra Costa County Hazardous Materials Programs 
The Chevron Richmond Refinery is located in the City of Richmond, within Contra Costa County. The 
local CUPA responsible for implementing the Unified Program in all areas of the country is the Contra 
424 California Health and Safety Code §25404(b) (1993). Also see 
http://www.calepa.ca.gov/cupa/Reports/2002/ReimbAcct.pdf (accessed May 16, 2013). 
425 27 CCR §15100 (a)(1) through (6) (1994). 
426 See http://www.calepa.ca.gov/cupa/Documents/2012/FactSheet.pdf (accessed May 16, 2013). 
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Costa Health Services’ Hazardous Materials Programs (CCHMP).427 CCHMP is responsible for 
implementing the Unified Program in all areas of Contra Costa County. 
CCHMP implements two programs that are relevant to this investigation: the CalARP program and the 
City of Richmond Industrial Safety Ordinance (RISO). CCHMP also implements the county’s own 
Industrial Safety Ordinance (ISO), which covers seven facilities. CCHMP has five full-time engineers, 
known as accidental release prevention engineers, who are responsible for implementing these programs 
for the county. While all have technical degrees in engineering, only two of these engineers have past 
refinery experience. 
5.3.1.1.1 CalARP 
The California Health and Safety Code Article 2 (Chapter 6.95, Sections 25531 – 25543.3) was amended 
effective January 1, 1997, to implement EPA’s RMP program at the state level through the creation of the 
CalARP program regulations. Modeled after EPA’s RMP program and California’s Risk Management 
and Prevention Plan, which was enacted in 1986, the CalARP regulations (Title 19, Chapter 4.5 of the 
CCR) were implemented with the goal of preventing accidental releases of substances that can cause 
serious harm to the public and the environment, minimizing damage caused by a release, and to satisfy 
community right-to-know laws.428 California is one of at least three states that implement a state RMP 
program without delegation of the federal program from EPA.429 
The CalARP regulations, including PHA requirements, are essentially duplicative in nature to EPA’s 
RMP program, with a few exceptions: the list of toxic chemicals covered is 276 instead of 77; the 
threshold quantities of some chemicals are smaller; CalARP requires a seismic analysis; and there is more 
interaction with the public and other agencies.430 The CalARP regulations require that businesses that 
produce, handle, process, distribute, or store certain chemicals over a certain threshold quantity develop a 
Risk Management Plan (RMP) and submit the RMP to a local CUPA for review. Like the EPA RMP 
program, facilities with a Program 3 process must develop a management system that includes a PHA and 
emergency response program.431 State oversight authority and responsibility for the CalARP program is 
with the California Emergency Management Agency.432 
The CalARP regulations apply to roughly 45 facilities in Contra Costa County, including the Chevron 
refinery in Richmond. Each covered facility is required to submit an updated RMP to CCHMP at least 
once every five years.433 The group of CCHMP engineers reviews these plans and is required to 
427 Contra Costa County’s Hazardous Materials program is responsible for responding to emergencies and 
monitoring hazardous materials in Contra Costa County. It is the duty of CCC to safeguard the Contra Costa 
County ecosystem from the release of hazardous materials and other pollutants. For more information see 
http://cchealth.org/hazmat/ (accessed May 21, 2013). 
428 Information available at http://www.calema.ca.gov/HazardousMaterials/Pages/Accidental-Release-Prevention-
(CalARP).aspx (accessed May 16, 2013). 
429EPA OIG. Evaluation Report: EPA Can Improve Implementation of the Risk Management Program for Airborne 
Chemical Releases; February 10, 2009; p 20. 
430 Information on differences between EPA’s RMP program and CalARP available at 
http://cchealth.org/hazmat/differences-rmp-calarp-iso.php (accessed May 16, 2013). 
431 22 CCR §2735.5(f) (2004). 
432The California Emergency Management Agency is responsible for the coordination of overall state agency 
response to major disasters in support of local government. For more information see 
http://www.calema.ca.gov/Pages/default.aspx (accessed May 21, 2013). 
433 22 CCR §2745.10(a)(1) (2004). 
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“periodically audit RMPs”434 against the regulations to ensure compliance. This group has told the CSB 
that it audits each facility at least once every three years. It last audited Chevron in February 2011, and 
has been conducting another audit in October and November 2013. 
Although CCHMP is authorized to issue enforcement actions for violations uncovered during facility 
audits, in practice CCHMP engineers issue “ensure” action items that list the deficiencies and recommend 
improvements. They then work with the facility to make sure that these action items are implemented. 
CCHMP has rarely issued fines or citations to facilities for violations. If the engineers identify other gaps 
or areas for improvement that are not actual regulatory violations, they can issue “consider” action items, 
which are essentially suggestions to the facility for improvements that are not technically required to be 
implemented by the regulation. Whether these types of action items are issued is dependent upon the 
knowledge and experience of the engineer conducting the audit. Once CCHMP engineers have 
completed the audit, CCHMP issues a final audit report on the facility, which they also supply to 
Cal/OSHA’s PSM District Office and the EPA Region 9 RMP group. 
5.3.1.1.2 Industrial Safety Ordinance 
The Contra Costa County Industrial Safety Ordinance (ISO) became effective January 15, 1999. Adopted 
as County Ordinance Chapter 450-8, the ISO expands on the CalARP program in Contra Costa County 
for facilities meeting the following criteria: 1) the facility is within an unincorporated area of the County; 
2) the facility is either a petroleum refinery or chemical plant; 3) the facility is required to submit a Risk 
Management Plan (RMP) to the EPA and the Contra Costa County Health Service; and 4) the facility has 
at least one Program 3 process.435 Seven of the 45 CalARP facilities in the county are currently required 
to comply with the ISO requirements. 
The ISO was adopted to improve industrial safety by, among other things, requiring more comprehensive 
coverage of the whole facility rather than only certain processes; providing review, inspection, auditing 
and safety requirements more stringent than are currently in effect; requiring the development and 
implementation of a human factors program; and preventing and reducing the number, frequency and 
severity of accidental releases in Contra Costa County.436 
Facilities subject to the ISO are essentially required to treat every process as subject to the CalARP 
Program 3 prevention program requirements. Covered facilities have additional requirements as well, 
including developing and implementing a human factors program, considering inherently safer 
technologies and systems for new and existing facilities or processes, submitting a safety plan to 
CCHMP, and conducting a Management of Organizational Change (MOOC) prior to changes in 
permanent staffing levels or reorganization in operations, maintenance, health and safety, or emergency 
response.437 
 
 
434 22 CCR §2775.2(a) (2004). 
435 See http://cchealth.org/hazmat/pdf/iso/2006_iso_official_code_complete.pdf (accessed January 13, 2014). 
436 County Ordinance Chapter 450-8.004(a)(1) through (10) (2006). 
http://cchealth.org/hazmat/pdf/iso/2006_iso_official_code_complete.pdf (accessed January 13, 2014). 
437 Information available at http://cchealth.org/groups/hazmat/industrial_safety_ordinance_risk_management.php 
(accessed May 22, 2013). 
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5.3.1.1.3 City of Richmond Industrial Safety Ordinance 
On December 18, 2001, the City of Richmond adopted an Industrial Safety Ordinance (RISO) under 
Municipal Code Chapter 6.43 that was almost identical to the ISO. In February 2013, the City of 
Richmond Council amended the RISO to make it equivalent to the ISO. Chevron is one of two facilities 
subject to RISO requirements. Pursuant to an agreement with the City of Richmond, CCHMP 
implements and enforces the RISO within the city. 
Like the ISO, the RISO requires that a covered facility submit a safety plan to CCHMP that includes 
safety elements such as process safety information (PSI), operating procedures, mechanical integrity, 
employee participation, and management of change (MOC).438 CCHMP has posted a Safety Plan 
Guidance Document on its website to assist facilities in developing these plans. Each facility is also 
required to comply with safety requirements including performing PHAs, and must include a description 
of the manner of compliance with these in the safety plan.439 In performing a PHA, facilities are required 
to address the hazards of the process, identify any previous incident, identify controls applicable to the 
hazards, and identify consequences of failure of those controls, human factors, and a qualitative 
evaluation of a range of possible safety and health effects of failure of controls.440 
The CCHMP engineers are required to review each facility’s safety plan as well as audit each facility to 
determine compliance with ISO or RISO. CCHMP engineers conduct the CalARP and ISO/RISO audits 
concurrently at each covered facility. CCHMP generally audits each facility once every three years. To 
aid in the auditing process, CCHMP engineers have entered all the CalARP program requirements into a 
database. They have taken each of these requirements and turned them into questions. When the 
engineers go onsite, they perform three main functions: 1) they identify and review any policy statement 
that directs how people should handle a particular piece of equipment; 2) they identify and review records 
of procedures, such as MOCs and permits; and 3) they randomly select and interview individuals about 
their familiarity with various aspects of different programs. If the engineers find a regulatory deficiency, 
they issue an ensure action item to the facility. 
Once the engineers have completed their facility audit, they issue a preliminary determination to the 
facility. The facility has 90 days to review the draft and provide a proposed remedy with specifics on 
how they will fix each deficiency, and the timeline. Once the report is finalized it goes out for public 
comment. Following public comment, it is issued to the facility and provided to Cal/OSHA’s PSM 
District Office and the EPA Region 9 RMP group. 
5.3.1.2 
Analysis 
Chevron submitted its most updated safety plan to CCHMP on February 25, 2013. Section 3.12 of the 
plan discusses PHAs and Action Items. Under this section, Chevron lists eight objectives of its PHAs, 
including identifying possible failures or releases, evaluating potential consequences, and proposing 
recommendations that would reduce the risks. Chevron also discusses its possible justifications for 
declining recommendations from PHAs, including the fact that an alternative measure would be 
sufficient, and that the recommendation may be infeasible. There was no additional information or 
438 Richmond Municipal Code Section 6.43.090 (a) (2013). 
439 Ibid at Sections (a) through (e) (2013). 
440 Ibid at (d) (2013). 
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analysis contained in this section concerning the identification or control of hazards, or risk reduction, as 
there is no requirement to do so. 
The RISO and CalARP regulations require that PHAs list controls and possible consequences of failure of 
those controls, but there is no specific requirement to include evaluations of the safeguards and controls in 
the PHA. As CCHMP engineers are only required to audit against the regulatory requirements, they 
would only examine the evaluation of safeguards if such an evaluation were performed and documented 
in the facility’s PHAs. As noted previously, Chevron’s most recent crude unit PHA ineffectively listed 
qualitative safeguards for corrosion and mechanical integrity. 
While CCHMP engineers are able to issue “consider” action items to the facility recommending actions 
above and beyond regulatory requirements, CCHMP engineers did not do this regarding Chevron’s Crude 
Unit PHA or its evaluation of safeguards. After reviewing CCHMP’s most recent audit of Chevron, the 
CSB could find nothing referring to sulfidation corrosion, reduction of risk, or safeguard evaluation. 
While CCHMP is able to utilize these “consider” action items to encourage facilities to go above and 
beyond regulatory requirements to reduce risk, CCHMP engineers have stated to the CSB that they do not 
make sufficient use of this mechanism. Rather, they tend to audit against the existing regulatory 
requirements to ensure compliance. 
Unlike the safety case regulatory approach, which requires a reduction of risk to ALARP or equivalent, 
facilities covered by RISO or ISO are only required to “consider [emphasis added] the use of inherently 
safer systems in the development and analysis of mitigation items resulting from a process hazard 
analysis [PHA] and in the design and review of new processes and facilities.”441 Despite multiple internal 
recommendations to replace its piping due to the risk of sulfidation corrosion, Chevron failed to replace 
the piping prior to the incident with an inherently safer material. Again, the CSB has not found evidence 
that CCHMP effectively encouraged Chevron to go above and beyond regulatory requirements by 
utilizing inherently safer systems to reduce risk. 
As emphasized repeatedly in this report, a regulatory regime is only as strong as its regulators, and must 
employ individuals with the requisite skills, knowledge, and experience to provide sufficient oversight 
over facilities. In the case of CCHMP, there are only five engineers for nearly 45 facilities in the county, 
and only two have previous refinery experience.442 In addition, while the CCHMP is funded mostly 
through CUPA fees, ISO fees, and other means of cost recovery, the engineers are part of a bargaining 
unit and their salaries are paid through the county’s general fund, which has experienced annual budget 
reductions in the millions.443 This has unnecessarily resulted in a decrease in the CCHMP engineers’ 
salaries and has made it extremely difficult for CCHMP to fill a current position that has been open over 
three years because of its inability to offer competitive salaries to attract its engineers. Overall, CCHMP 
suffers from a lack of resources and funding, limiting its ability to hire additional highly qualified staff to 
oversee the petroleum refineries in Contra Costa County. 
 
 
441 City of Richmond Municipal Code §6.43.050(g) (February 5, 2013). 
442 Two of the other engineers have chemical plant experience and have led or participated in refinery compliance 
audits in the past ten years. 
443 More information available at http://www.co.contra-costa.ca.us/DocumentCenter/Home/View/8917 (accessed 
May 23, 2013). 
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6.0 Conclusion 
 
This report has focused on several attributes of more robust process safety management regulatory 
regimes from around the world that the CSB believes would greatly enhance existing federal and 
California process safety regulations. Some attributes discussed include: an enhanced process hazard 
analysis; continuous risk reduction to ALARP; active workforce participation; the effective use of process 
safety indicators that drive performance; regulatory assessment, verification, and intervention; and an 
independent, competent, well-funded regulator. These attributes together enable industry and the 
regulator to ensure that facilities are developing and implementing comprehensive, robust safety 
management systems to prevent major accidents. 
Implementation of a more comprehensive process safety management regulatory approach in California 
for petroleum refineries will require a commitment of extensive resources to fund a regulator that has the 
requisite skills, knowledge, and experience to ensure petroleum refineries in the state continually assess 
their practices and reduce risks to ALARP. However, the CSB believes that effective implementation of 
this regulatory approach will achieve greater major accident prevention in California and, in the process, 
provide greater protection for its workers and the public. 
An enhanced process safety management regulatory model provides the adaptability necessary to keep 
current with improving standards and advancing technology, without requiring lengthy and often 
unproductive rulemaking on the part of the regulator. A competent regulator will independently ensure 
that California refineries have taken all practical measures that can be reasonably taken to reduce risks. 
For example, the regulator would have the ability to work with these facilities to implement 
recommendations and lessons learned from significant petroleum refinery incidents throughout the world 
without requiring extensive rulemaking or legislation, as regulators have done post-incident in the UK, 
Norway, and Australia. (Additional information and discussion of the safety case type regime is included 
in Appendix C). 
 
 
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7.0 Process Safety Management Reform at the Federal Level: A 
Path Forward 
 
As this report discusses, process safety management in the US has undergone little reform since its 
inception in the 1990s despite advancing best practices and technology. On July 25, 2013, the CSB held a 
public meeting to discuss the status of three key CSB safety recommendations made to OSHA in the last 
decade to revise and improve the Process Safety Management (PSM) standard.444 While acknowledging 
some positive steps taken by OSHA, such as including process safety management in its regulatory 
agenda, the CSB expressed at the meeting its disappointment with OSHA’s lack of progress with 
implementation of open CSB recommendations to improve the PSM standard.445 As a result of the 
meeting, the Board voted to change the status of the three recommendations made to OSHA concerning 
the PSM standard to “Open-Unacceptable”.446 
 
Recent significant incidents such as the April 2013 explosion and fire that occurred at a fertilizer storage 
and distribution facility in West, Texas, and resulted in fifteen fatalities and hundreds of injuries, have 
resulted in an increased national dialogue on the issue of process safety management reform.447 As 
mentioned in Section 2.0 above, President Obama has issued a number of Executive Orders focused on 
improving chemical safety in the US. On January 18, 2011, President Obama issued Executive Order 
13563,448 which called for improvements in the nation’s regulatory system to promote predictability and 
reduce uncertainty and to use the best, most innovative, and least burdensome tools for achieving 
regulatory ends. 
444 The CSB made a fourth recommendation (2001-01-H-R1) to OSHA in its 2002 reactive hazards study to modify 
the PSM standard to more comprehensively manage reactive hazards. On January 28, 2004, the Board voted 
unanimously to designate the status of this recommendation as “Open-Unacceptable”. 
445 For a copy of the public meeting transcript see http://www.csb.gov/assets/1/7/0725CSB-OSHA_(2).pdf (accessed 
October 27, 2014). 
446 “Open-Unacceptable” means that the recommendation recipient responds by expressing disagreement with the 
need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask 
the recipient to reconsider. The three open recommendations concerning the PSM standard are: 1) 
Recommendation to ensure coverage under the Process Safety Management (PSM) standard for atmospheric storage 
tanks that could be involved in a potential catastrophic release as a result of being interconnected to a covered 
process with 10,000 pounds of a flammable substance. The recommendation was issued in 2002 following the 
CSB’s investigation of a 2001 explosion of a poorly maintained, corroded storage tank containing spent sulfuric 
acid and flammable hydrocarbons at the Motiva refinery in Delaware City, Delaware. A worker was conducting 
hot work which ignited vapor through holes in the deteriorated tank. 2) Recommendation to revise the PSM 
standard to require management of change (MOC) reviews for organizational changes such as mergers and 
acquisitions that may impact process safety. This recommendation, issued in 2007, followed the 2005 explosions 
and fire at the BP Texas City refinery which killed 15 workers and injured 180 others. 3) Recommendation that 
OSHA issue a fuel gas safety standard for construction and general industry. This recommendation, issued in June 
2010 followed two catastrophic accidents that occurred that year: In one, an explosion caused a roof collapse at the 
ConAgra Slim Jim facility in Garner, North Carolina, killing four workers and injuring 67 others. A worker had 
been attempting to purge new natural gas piping during the installation of an industrial water heater, resulting in a 
large release of natural gas indoors. In the other, at the Kleen Energy power plant in Middletown, Connecticut, high 
pressure natural gas was being used to clean new piping and was released in a congested outdoor area. It ignited, 
killing six workers and injuring at least 50. 
447 See CSB investigation of West, Texas, fertilizer incident at http://www.csb.gov/west-fertilizer-explosion-and-
fire-/ (accessed October 27, 2014). 
448 Improving Regulation and Regulatory Review. Exec. Order No. 13563, 76 Fed. Reg. 14 (January 21, 2011). 
http://www.archives.gov/federal-register/executive-orders/2011.html (accessed July 10, 2013). 
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Following the incident in West, Texas, President Obama issued Executive Order 13650, Improving 
Chemical Facility Safety and Security , on August 1, 2013.449 The Executive Order established the 
Chemical Facility Safety and Security Working Group, a working group of federal agencies450 tasked 
with, among other things, developing options for enhancing and modernizing policies, regulations, and 
standards to improve the safety and security of chemical facilities.451, 452 
 
Consistent with Executive Order 13650, both OSHA and the EPA issued Requests for Information, or 
RFIs, in the last year, requesting comment on potential revisions to several standards, including the 
Process Safety Management (Standard) and the Risk Management Plan (RMP) Program regulations, 
respectively.453 These are all positive steps toward significant improvements in process safety 
management at the federal level. CSB Chairperson Rafael Moure-Eraso has publicly advocated for 
Executive Order 13650 implementation, including requirements for safer technologies, regulation of 
reactive chemicals like the ammonium nitrate stored at West's fertilizer site, public reporting of process 
safety indicators, and regulatory coverage for hazardous oil drilling and production operations.454 
 
The CSB believes that it is important to continue to build upon this significant national dialogue. In the 
coming months, the CSB will consider adding the issue of federal process safety management reform and 
modernization to its Most Wanted Chemical Safety Improvements Program (“Most Wanted Program”).455 
The purpose of the Most Wanted Program is to: 
• 
identify the most important chemical safety improvement goals of the CSB in the form of a “Most 
Wanted List” of Chemical Safety Improvements, which will be based on recommendations 
resulting from CSB investigations, studies, hearings, and similar fact-finding activities; 
 
449 Improving Chemical Facility Safety and Security. Exec. Order No. 13650, 78 Fed. Reg. 48029 (August 1, 2013). 
https://www.federalregister.gov/articles/2013/08/07/2013-19220/improving-chemical-facility-safety-and-security 
(accessed January 7, 2014). 
450 The working group includes the EPA, the Department of Justice, the Department of Agriculture, the Department 
of Transportation, and the Department of Labor. 
451 See Section 6 of the Executive Order. 
452 The group has included the safety case regulatory model in a list of potential actions it may consider taking to 
improve chemical safety regulation. See Working Group response to Executive Order 13650, Section 6(a) – 
Solicitation of Public Input on Options for Policy, Regulation, and Standards Modernization. 
https://www.osha.gov/chemicalexecutiveorder/Section_6ai_Options_List.html (accessed January 7, 2014). 
453 OSHA issued its RFI on potential revisions to its standards, including the PSM standard, on December 9, 2013 
(at 78 FR 73756). The CSB issued its formal response to the RFI on March 31, 2014. View the CSB’s response at 
http://www.csb.gov/assets/1/16/CSB_RFIcomments.pdf (accessed October 27, 2014). The EPA issued its RFI on 
potential revisions to the RMP program regulations and related programs on July 31, 2014 (at 79 FR 44603). View 
the EPA RFI at https://www.federalregister.gov/articles/2014/07/31/2014-18037/accidental-release-prevention-
requirements-risk-management-programs-under-the-clean-air-act-section (accessed October 27, 2014). Responses 
to the RFI are due on or before October 29, 2014. 
454 Moure-Eraso, Rafael. Effective regulation of chemical industry still elusive since 1989 accident: The 25 years 
after disaster at Pasadena’s Phillips 66 plant have brought reform, but more vigilance needed. The Houston 
Chronicle; October 23, 2014. http://www.houstonchronicle.com/opinion/outlook/article/Moure-Eraso-Effective-
regulation-of-chemical-5843582.php (accessed October 27, 2014). 
455 The CSB adopted the Most Wanted Program on June 12, 2012. Board Order 046, Most Wanted Chemical Safety 
Improvements Program, discusses the policies of the program in detail. See 
http://www.csb.gov/assets/Record/Order_046_(06122012).pdf (accessed October 27, 2014). 
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• 
make efficient use of limited resources to pursue implementation of changes that are most likely 
to achieve important national-level safety improvements; 
 
• 
focus special advocacy efforts by Board Members and staff on the Most Wanted List; 
 
• 
inform the CSB’s deployment decisions and strategic allocation of staff resources; and 
 
• 
issue periodic reports of the activities of the Program. 
 
Consistent with Executive Order 13650, the CSB will also hold a public hearing to discuss the need for 
process safety management regulatory reform at the federal level. The public hearing will include 
discussion of various models for high hazard facility safety regulation from around the US and the world 
– including consideration of safety case type models. Presentations, or written comments, regarding 
various regimes should discuss, at a minimum, the following: 
 
• 
The role of transparency and community involvement; 
 
• 
The effectiveness of worker (union and non-union) involvement programs and the effectiveness 
of protecting workers from retaliatory actions; 
 
• 
The methods for measuring process safety performance and for reporting of process safety 
indicator data (to regulators, the public, third parties, or industry groups); 
 
• 
The approach used to strive for risk reduction and continuous improvement; 
 
• 
The approach for establishing a “tolerable” risk level; and 
 
• 
The effectiveness of enforcement methods. 
 
The CSB will hold this public hearing in the Spring of 2015, following the publication of this 
report. Upon completion of the public hearing the CSB will publish a document summarizing 
the proceedings. 
 
 
 
 
 
 
 
 
 
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8.0 Recommendations 
 
Pursuant to its authority under 42 U.S.C. §7412(r)(6)(C)(i) and (ii), and in the interest of promoting safer 
operations at California petroleum refineries and protecting workers and communities from future 
accidents, the CSB makes the following safety recommendations: 
 
California State Legislature, 
Governor of California 
 
2012-03-I-CA-R21 
 
Based on the findings in this report, enhance and restructure California’s process safety management 
(PSM) regulations for petroleum refineries by including the following goal-setting attributes: 
 
a. Require a comprehensive process hazard analysis (PHA) written by the company that includes: 
 
i. Systematic analysis and documentation of all major hazards and safeguards, using the 
hierarchy of controls to identify hazards and significantly reduce risks to a goal of as low as 
reasonably practicable (ALARP) or similar; 
 
ii. Documentation of the recognized methodologies, rationale and conclusions used to claim that 
inherently safer systems have been implemented to as low as reasonably practicable (ALARP) or 
similar, and that additional safeguards intended to control remaining hazards will be effective; 
 
iii. Documented damage mechanism hazard review conducted by a diverse team of qualified 
personnel. This review shall be an integral part of the process hazard analysis (PHA) cycle and 
shall be conducted on all covered processes, piping circuits and equipment. The damage 
mechanism hazard review shall identify potential process damage mechanisms and consequences 
of failure, and shall ensure effective safeguards are in place to prevent or control hazards 
presented by those damage mechanisms. Require the analysis and incorporation of applicable 
industry best practices and inherently safer design to the greatest extent feasible into this review; 
and 
iv. Documented use of inherently safer systems analysis and the hierarchy of controls to the 
greatest extent feasible in establishing safeguards for identified process hazards. The goal shall 
be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP) or similar. 
Include requirements for inherently safer systems analysis to be automatically triggered for all 
management of change (MOC) and process hazard analysis (PHA) reviews, as well as prior to the 
construction of new processes, process unit rebuilds, significant process repairs, and in the 
development of corrective actions from incident investigation recommendations. 
 
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b. Require a thorough review of the comprehensive process hazard analysis by technically competent 
regulatory personnel; 
 
c. Require preventative audits and preventative inspections by the regulator to ensure the effective 
implementation of the comprehensive process hazard analysis (PHA); 
 
d. Require that all safety codes, standards, employer internal procedures and recognized and generally 
accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain 
adequate minimum requirements; 
 
e. Require mechanisms for the regulator, the refinery, and workers and their representatives to play an 
equal and essential role in the direction of preventing major incidents. Require an expanded role for 
workers in management of process safety by establishing the rights and responsibilities of workers and 
their representatives on health and safety-related matters, and the election of safety representatives and 
establishment of safety committees (with equal representation between management and labor) to serve 
health and safety-related functions. The elected representatives should have a legally recognized role that 
goes beyond consultation in activities such as the development of the comprehensive process hazard 
analysis, implementation of corrective actions generated from hierarchy of control analyses, management 
of change, incident investigation, audits, and the identification, prevention, and control of all process 
hazards. The regulation should provide workers and their representatives with the authority to stop work 
that is perceived to be unsafe until the employer resolves the matter or the regulator intervenes. 
Workforce participation practices should be documented by the refinery to the regulator; 
 
f. Require reporting of information to the public to the greatest extent feasible, such as a summary of the 
comprehensive process hazard analysis (PHA) which should include a list of inherently safer systems 
implemented; safeguards implemented for remaining hazards; standards utilized to reduce risks to As 
Low As Reasonably Practicable (ALARP) or similar; and process safety indicators that demonstrate the 
effectiveness of the safeguards and management systems; 
 
g. Implement an approach or system that determines when new or improved industry standards and 
practices are needed and initiate programs and other activities, such as an advisory committee or forum, to 
prompt the timely development and implementation of such standards and practices; and 
 
h. Ensure that a means of sustained funding is established to support an independent, well-funded, well-
staffed, technically competent regulator. 
 
2012-03-I-CA-R22 
 
Implement a compensation system to ensure the regulator has the ability to attract and retain a sufficient 
number of employees with the necessary skills and experience to ensure regulator technical competency 
at all levels of process safety regulatory oversight and policy development in California. A market 
analysis and benchmarking review should be periodically conducted to ensure the compensation system 
remains competitive with California petroleum refineries. 
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2012-03-I-CA-R23 
Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the 
state of California to develop and implement a system that collects, tracks, and analyzes process safety 
leading and lagging indicators from refineries and contractors to promote continuous safety 
improvements. At a minimum, this program shall: 
a. Require the use of leading and lagging process safety indicators to actively monitor the 
effectiveness of process safety management systems and safeguards for major accident 
prevention. Include leading and lagging indicators that are measureable, actionable, and 
standardized. Require that the reported data be used for continuous process safety improvement 
and accident prevention; 
b. Analyze data to identify trends and poor performers and publish annual reports with the data at 
facility and corporate levels; 
c. Require companies to publicly report required indicators annually at facility and corporate 
levels; 
d. Use process safety indicators (1) to drive continuous improvement for major accident 
prevention by using the data to identify industry and facility safety trends and deficiencies and (2) 
to determine appropriate allocation of regulator resources and inspections; and 
e. Be periodically updated to incorporate new learning from world-wide industry improvements 
in order to drive continuous major accident safety improvements in California. 
 
Mayor and City Council, 
City of Richmond, California 
 
2012-03-I-CA-R24 
 
Implement or cause to be implemented a compensation system to ensure the regulator has the ability to 
attract and retain a sufficient number of employees with the necessary skills and experience to ensure 
regulator technical competency at all levels of process safety regulatory oversight and policy development 
in Richmond, California. A market analysis and benchmarking review should be periodically conducted 
to ensure the compensation system remains competitive with California petroleum refineries. 
 
 
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Board of Supervisors 
Contra Costa County, California 
 
2012-03-I-CA-R25 
 
Implement a compensation system to ensure the regulator has the ability to attract and retain a sufficient 
number of employees with the necessary skills and experience to ensure regulator technical competency 
at all levels of process safety regulatory oversight and policy development in Contra Costa County, 
California. A market analysis and benchmarking review should be periodically conducted to ensure the 
compensation system remains competitive with California petroleum refineries. 
 
 
 
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http://www.hse.gov.uk/offshore/aposc190306.pdf (accessed August 6, 2013). 
 
HSE. Assessing compliance with the law in individual cases and the use of good practice; May 2003. 
http://www.hse.gov.uk/risk/theory/alarp2.htm (accessed June 12, 2013). 
 
HSE. Developing process safety indicators: A step-by-step guide for chemical and major hazard 
industries; 2006. http://www.hse.gov.uk/pubns/books/hsg254.htm (accessed May 28, 2013). 
 
HSE. Planning to do business in the UK offshore oil and gas industry? What you should know about 
health and safety; October 2011. http://www.hse.gov.uk/offshore/guidance/entrants.pdf (accessed June 5, 
2013). 
 
HSE. Play your part! How offshore workers can help improve health and safety; 2013. 
http://www.hse.gov.uk/pubns/indg421.pdf (accessed June 17, 2013). 
 
Oil & Gas UK. Piper Alpha: Lessons Learnt; 2008. 
Process Safety Leadership Group. Safety and environmental standards for fuel storage sites; London, 
2009. http://www.hse.gov.uk/comah/buncefield/fuel-storage-sites.pdf (accessed August 1, 2013). 
 
Process Safety Leadership Group. Safety and environmental standards for fuel storage sites; London, 
2009. http://www.hse.gov.uk/comah/buncefield/fuel-storage-sites.pdf (accessed August 1, 2013). 
 
TAF Powell, SPE, UK Health & Safety Executive. US Voluntary Semp Initiative: Holy Grail or 
Poisoned Chalice? Proceedings of the Offshore Technology Conference, Houston, Texas, May 8-9, 
1996. 
 
The Competent Authority. Buncefield: Why did it happen? The underlying causes of the explosion and 
fire at the Buncefield oil storage depot, Hemel Hempstead, Hertfordshire on 11 December 2005; 
February 2011. http://www.hse.gov.uk/comah/buncefield/buncefield-report.pdf (accessed May 21, 
2013). 
 
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Wilson, Michael P. Refinery Safety in California: Labor, Community and Fire Agency Views; Summary 
Report for Office of Governor Jerry Brown, Interagency Task Force on Refinery Safety; March 27, 2013, 
Revised June 4, 2013. Citing Zimgast, Erst. (June 6, 2006). Selective U/W in Oil-Petro Segment: Loss 
Burden in Different Regions, USA vs. Rest of the World, History of Selective U/W, Cause of Losses. 
Technical report-DRAFT-EXTRACT. Risk Engineering Services, Swiss Re. 
http://www.lohp.org/projects/refinery_safety.html (accessed July 8, 2013). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Appendix A: Significant Petroleum Refinery Incidents in 2012 
1. 
Tank failure at the ExxonMobil refinery in Beaumont, Texas on 11 January 
2. 
Vessel pressure excursion at the Flint Hills refinery in St. Paul, Minnesota on 22 January 
3. 
Hydrogen Sulfide release from mechanical integrity failure at the Northern Tier Energy 
refinery in St. Paul, Minnesota on 26 January 
4. 
Sulfuric acid release from a mechanical integrity failure at the ConocoPhillips refinery in 
Wood River, Illinois on 27 January 
5. 
Hydrogen Sulfide release from mechanical integrity failure at the Marathon refinery in 
Garyville, Louisiana on 31 January 
6. 
Hydrocarbon and hydrogen fluoride release from a mechanical integrity failure at the Flint 
Hills refinery in Corpus Christi, Texas on 31 January 
7. 
Sulfur dioxide and hydrogen sulfide release following a vessel pressure excursion at the 
Alon refinery in Big Spring, Texas on 1 February 
8. 
Hydrocarbon release from a vessel pressure excursion at the ConocoPhillips refinery in 
Belle Chasse, Louisiana on 1 February 
9. 
Benzene release from a mechanical integrity failure at the Husky refinery in Lima, Ohio on 
16 February 
10. 
Fire at the Tesoro refinery in Salt Lake City, Utah on 17 February 
11. 
Fire at the BP refinery in Cherry Point, Washington on 17 February 
12. 
Tank failure at the Shell refinery in Deer Park, Texas on 22 February 
13. 
Tank failure at the Paulsboro refinery in Paulsboro, New Jersey on 23 February 
14. 
Fire at the Citgo refinery in Corpus Christi, Texas on 24 February 
15. 
Hydrogen Sulfide release from a mechanical integrity failure at the Flint Hills refinery in 
Rosemount, Minnesota on 28 February 
16. 
Vessel pressure excursion at the Motiva refinery in St. Charles, Louisiana on 28 February 
17. 
Benzene release from a mechanical integrity failure at the Chalmette refinery in Chalmette, 
Louisiana on 28 February 
18. 
Crude oil release from a mechanical integrity failure at the Flint Hills refinery in North 
Pole, Alaska on 4 March 
19. 
Hydrogen fluoride release from a mechanical integrity failure at the Citgo refinery in 
Corpus Christi, Texas on 6 March 
20. 
1 worker was fatally injured and 2 other workers were burned at the Valero refinery in 
Memphis, Tennessee on 6 March 
21. 
Fire during a hot work activity at the Tesoro refinery in Martinez, California on 7 March 
22. 
Benzene release from a mechanical integrity failure at the Chevron refinery in Pascagoula, 
Mississippi on 8 March 
23. 
Heavy oil release from a mechanical integrity failure at the Chevron refinery in Pascagoula, 
Mississippi on 13 March 
24. 
Benzene release from a mechanical integrity failure at the Marathon refinery in Texas City, 
Texas on 14 March 
25. 
Fire at the PBF Energy refinery in Delaware City, Delaware on 16 March 
26. 
Hydrocarbon release from a mechanical integrity failure at the Chevron refinery in 
Pascagoula, Mississippi on 19 March 
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27. 
Hydrocarbon release from a mechanical integrity failure at the Tesoro refinery in 
Anacortes, Washington on 23 March 
28. 
Hydrocarbon release from a mechanical integrity failure at the ExxonMobil refinery in 
Baytown, Texas on 24 March 
29. 
Fire at the ExxonMobil refinery in Billings, Montana on 25 March 
30. 
Hydrogen fluoride release from a mechanical integrity failure at the BP refinery in Texas 
City, Texas on 27 March 
31. 
Hydrocarbon release from a mechanical integrity failure at the Total refinery in Port 
Arthur, Texas on 11 April 
32. 
Fire at the ConocoPhillips refinery in Rodeo, California on 13 April 
33. 
Hydrocarbon release from a mechanical integrity failure at the Flint Hills refinery in 
Corpus Christi, Texas on 16 April 
34. 
Crane fell over and damaged utility piping at the Citgo refinery in Lemont, Illinois on 17 
April 
35. 
Hydrocarbon release from a mechanical integrity failure at the Flint Hills refinery in 
Corpus Christi, Texas on 19 April 
36. 
Fire at BP refinery in Texas City, Texas on 20 April 
37. 
Hydrocarbon release from a mechanical integrity failure at the ConocoPhillips refinery in 
Sweeny, Texas on 24 April 
38. 
Fire at the Sunoco refinery in Philadelphia, Pennsylvania on 8 May 
39. 
4 workers injured in fire at the Sinclair refinery in Sinclair, Wyoming on 8 May 
40. 
Hydrocarbon release from a mechanical integrity failure at the LyondellBasell refinery in 
Houston, Texas on 8 May 
41. 
Fire at the Sunoco refinery in Philadelphia, Pennsylvania on 9 May 
42. 
Fire at the Motiva refinery in Port Arthur, Texas on 12 May 
43. 
Hydrogen sulfide release from a mechanical integrity failure at the CVR Energy refinery in 
Wynnewood, Oklahoma on 11 May 
44. 
Hydrogen fluoride release from a mechanical integrity failure at the Citgo refinery in 
Corpus Christi, Texas on 15 May 
45. 
Hydrogen sulfide release from a mechanical integrity failure at the Shell refinery in Deer 
Park, Texas on 17 May 
46. 
Benzene and hydrogen sulfide release from a mechanical integrity failure at the Flint Hills 
refinery in Corpus Christi, Texas on 21 May 
47. 
Fire at the Montana Refining Company refinery in Great Falls, Montana on 24 May 
48. 
Hydrocarbon release from a mechanical integrity failure at the Valero refinery in Memphis, 
Tennessee on 25 May 
49. 
2 workers injured from a fire at the Sinclair refinery in Sinclair, Wyoming on 28 May 
50. 
Propylene release from overpressure event at the PBF Energy refinery in Delaware City, 
Delaware on 29 May 
51. 
Hydrocarbon release from a mechanical integrity failure at the Valery refinery in Houston, 
Texas on 31 May 
52. 
Hydrogen and hydrocarbon release due to loss of containment event at the Shell refinery in 
Deer Park, Texas on 7 June 
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53. 
Hydrogen sulfide and hydrocarbon release due to flare failure at the Motiva refinery in 
Norco, Louisiana on 7 June 
54. 
Fire at the Motiva refinery in Port Arthur, Texas on 9 June 
55. 
Hydrocarbon release due to a mechanical integrity failure at the BP refinery in Texas City, 
Texas on 9 June 
56. 
Fire at the ExxonMobil refinery in Torrance, California on 11 June 
57. 
Fire at the Total refinery in Port Arthur, Texas on 13 June 
58. 
Hydrogen sulfide release from a tank failure at the ConocoPhillips refinery in Rodeo, 
California on 15 June 
59. 
Hydrocarbon release at the Shell refinery in Deer Park, Texas on 20 June 
60. 
Fire at the BP refinery in Whiting, Indiana on 21 June 
61. 
Hydrocarbon release due to a mechanical integrity failure at the Valero refinery in Corpus 
Christi, Texas on 23 June 
62. 
Benzene release due to a mechanical integrity failure at the ExxonMobil refinery in Baton 
Rouge, Louisiana on 25 June 
63. 
Benzene release due to a mechanical integrity failure at the ExxonMobil refinery in 
Baytown, Texas on 28 June 
64. 
Propane release due to a mechanical integrity failure at the Valero refinery in McKee, 
Texas on 28 June 
65. 
Sulfuric acid release due to a mechanical integrity failure at the Chevron refinery in El 
Segundo, California on 2 July 
66. 
Hydrocarbon release due to a mechanical integrity failure at the Phillips 66 refinery in 
Westlake, Louisiana on 14 July 
67. 
Fire at the Citgo refinery in Corpus Christi, Texas on 16 July 
68. 
Fire at the Valero refinery in Meraux, Louisiana on 22 July 
69. 
Sulfuric acid release due to a mechanical integrity failure at the Sunoco Point Breeze 
refinery in Philadelphia, Pennsylvania on 22 July 
70. 
Fire at the BP refinery in Whiting, Indiana on 23 July 
71. 
Hydrocarbon and hydrogen fluoride release due to a mechanical integrity failure at the Flint 
Hills refinery in Corpus Christi, Texas on 24 July 
72. 
Fire at the HollyFrontier refinery in Tulsa, Oklahoma on 2 August 
73. 
8,614 lbs of hydrogen sulfide were released to the atmosphere due to a mechanical integrity 
failure on a compressor suction line at the Chevron refinery in Richmond, California on 2 
August. 
74. 
Hydrogen sulfide release from an overpressure event at the Valero refinery in Texas City, 
Texas on 5 August 
75. 
Fire at the Sinclair refinery in Sinclair, Wyoming on 5 August 
76. 
Fire at the Chevron refinery in Richmond, California on 6 August 
77. 
Fire at the Shell refinery in Martinez, California on 13 August 
78. 
Hydrogen sulfide release from a mechanical integrity failure at the Shell refinery in 
Martinez, California on 14 August 
79. 
2 workers injured from a fire at the BP refinery in Whiting, Indiana on 14 August 
80. 
Hydrogen sulfide release due to a mechanical integrity failure at the Phillips 66 refinery in 
Wood River, Illinois on 22 August 
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81. 
Fire at the Sinclair refinery in Sinclair, Wyoming on 24 August 
82. 
Hydrocarbon release due to a mechanical integrity failure at the LyondellBasell refinery in 
Houston, Texas on 25 August 
83. 
Hydrocarbon release due to a mechanical integrity failure at the Flint Hills refinery in 
Corpus Christi, Texas on 26 August 
84. 
Hydrogen sulfide and propylene release due to a mechanical integrity failure at the 
ExxonMobil refinery in Beaumont, Texas on 29 August 
85. 
Fire at the Phillips 66 refinery in Rodeo, California on 29 August 
86. 
A high pressure excursion in a vessel resulted in a hydrocarbon release with offsite 
consequences at the Holly refinery in Woods Cross, Utah on 30 August 
87. 
Worker injured following a fire at the Marathon refinery in Detroit, Michigan on 5 
September 
88. 
Chemical release with offsite consequences at the Marathon refinery in Detroit, Michigan 
on 8 September 
89. 
Sulfuric acid release due to a mechanical integrity failure at the Tesoro refinery in 
Martinez, California on 10 September 
90. 
Carbon monoxide and hydrogen sulfide release due to a mechanical integrity failure at the 
ExxonMobil refinery in Baytown, Texas on 11 September 
91. 
Hydrogen sulfide release due to a mechanical integrity failure at the Marathon refinery in 
Garyville, Louisiana on 11 September 
92. 
Hydrocarbon release due to a mechanical integrity failure at the Chevron refinery in 
Pascagoula, Mississippi on 14 September 
93. 
Unspecified leak at the Tesoro refinery in Martinez, California on 15 September 
94. 
Hydrocarbon release due to a mechanical integrity failure at the PBF Energy refinery in 
Delaware City, Delaware on 21 September 
95. 
Hydrogen sulfide release due to a mechanical integrity failure at the Motiva refinery in 
Norco, Louisiana on 24 September 
96. 
2 workers killed from an explosion at the CVR Energy refinery in Wynnewood, Oklahoma 
on 28 September 
97. 
Fire at the Motiva refinery in Convent, Louisiana on 1 October 
98. 
Hydrogen fluoride release at the Placid refinery in Port Allen, Louisiana on 1 October 
99. 
Hydrogen sulfide release from a high pressure excursion at the Valero refinery in Port 
Arthur, Texas on 1 October 
100. 
Fire at the ExxonMobil refinery in Baytown, Texas on 3 October 
101. 
Vapor cloud release at the Hess refinery in Port Reading, New Jersey on 3 October 
102. 
Hydrocarbon release due to a mechanical integrity failure at the Phillips 66 refinery in 
Rodeo, California on 8 October 
103. 
Fire at the Citgo refinery in Corpus Christi, Texas on 9 October 
104. 
Vapor cloud release with offsite impact from the Kern Oil refinery in Bakersfield, 
California on 17 October 
105. 
Hydrocarbon and hydrogen sulfide release from a pressure excursion at the ExxonMobil 
refinery in Joliet, Illinois on 19 October 
106. 
Hydrocarbon release due to a mechanical integrity failure at the Citgo refinery in Sulfur, 
Louisiana on 22 October 
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107. 
Hydrogen sulfide release at the Chalmette refinery in Chalmette, Louisiana on 23 October 
108. 
Fire at the Tesoro refinery in Martinez, California on 21 October 
109. 
Fire at the BP refinery in Texas City, Texas on 30 October 
110. 
Fire at the Valero refinery in Port Arthur, Texas on 3 November 
111. 
Benzene release due to a mechanical integrity failure at the Shell refinery in Deer Park, 
Texas on 8 November 
112. 
Vapor release at the Tesoro refinery in Martinez, California on 8 November 
113. 
Hydrogen sulfide release due to a mechanical integrity failure or a high pressure excursion 
at the Shell refinery in Martinez, California on 24 November 
114. 
Hydrogen sulfide and hydrocarbon release at the Northern Tier Energy refinery in St. Paul 
Park, Minnesota on 27 November 
115. 
Benzene release due to a mechanical integrity failure at the ExxonMobil refinery in Baton 
Rouge, Louisiana on 1 December 
116. 
Hydrogen fluoride release that killed one worker, injured 2 other workers and 7 emergency 
responders at the Valero refinery in Memphis, Tennessee on 3 December 
117. 
Hydrocarbon release due to a mechanical integrity failure at the Flint Hills refinery in 
Corpus Christi, Texas on 5 December 
118. 
Hydrogen sulfide release at the Phillips 66 refinery in Wood River, Illinois on 8 December 
119. 
Fire at the Motiva refinery in Port Arthur, Texas on 11 December 
120. 
Benzene release due to a mechanical integrity failure at the Alon refinery in Big Spring, 
Texas on 11 December 
121. 
Hydrocarbon release due to a mechanical integrity failure at the Shell refinery in Deer Park, 
Texas on 11 December 
122. 
Hydrocarbon release at the Shell refinery in Anacortes, Washington on 12 December 
123. 
Hydrogen sulfide release due to a pressure excursion at the PBF Energy refinery in 
Paulsboro, New Jersey on 14 December 
124. 
Hydrocarbon and hydrogen sulfide release due to a mechanical integrity failure at the 
Marathon refinery in Garyville, Louisiana on 15 December 
125. 
Fire at the Motiva refinery in Port Arthur, Texas on 17 December 
Note -Incidents of hydrocarbon leaks into a cooling tower or releases to a flare system are not included in 
the above list. 
 
 
 
 
 
 
 
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Appendix B: Regulatory Comparison Table 
OSHA PSM Standard 
California PSM Standard 
The Safety Case Regulatory 
Regime 
Scope 
Covered processes excluding 
oil and gas well drilling and 
servicing 
Covered processes 
excluding oil and gas well 
drilling and servicing 
Applies to offshore and onshore 
oil and gas operations 
Specific PSM/ 
Major Accident Focus 
Yes 
Yes 
Yes 
ALARP or Equivalent 
No 
No 
Yes 
Adaptability to New or 
Revised Codes, 
Standards, Technology, 
Hazard Information, 
Lessons Learned, etc. 
Limited to RAGAGEP –only 
addresses equipment and 
mechanical integrity (2 of 14 
elements); RAGAGEP not 
defined in the standard or a 
referenced list, only a handful 
of standards referenced as 
RAGAGEP in OSHA 
interpretation letters 
Limited to RAGAGEP –
only addresses equipment 
and mechanical integrity; 
RAGAGEP not defined in 
the standard or a referenced 
list, only a handful of 
standards referenced as 
RAGAGEP in OSHA 
interpretation letters 
Yes via safety case and 
supporting framework 
legislation 
PSM Indicators Req. 
No 
No 
Yes for Companies 
Competent Regulator 
50% or more 
Engineers/PSM 
OSHA-some progress but no 
Cal/OSHA – some progress 
but no 
Yes 
Sufficient Funding for 
Competent Regulatory 
staff 
OSHA-No 
California is increasing 
funding to support 
additional staff on 
Cal/OSHA PSM team 
Yes 
Hazard Analysis 
Required – “shall identify, 
evaluate, and control the 
hazards involved in the 
process.” 
Required – “appropriate to 
the complexity of the 
process for identifying, 
evaluating, and controlling 
hazards involved in the 
process.” 
Is a specific aspect of SC and 
supporting framework 
regulation and is required for 
all onshore and offshore 
facilities. To meet legislative 
goal-setting requirements, a 
structured risk assessment 
including HA as appropriate is 
required from all “employers.” 
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OSHA PSM Standard 
California PSM Standard 
The Safety Case Regulatory 
Regime 
Incident Investigation 
Requires a report but activity-
based; requires including 
“any recommendations 
resulting from the 
investigations” (what if there 
are none?); system required 
to “resolve the incident 
report findings and 
recommendation; no explicit 
requirement to prevent a 
similar occurrence or 
controlling hazards. 
Requires a report including 
“any recommendations 
resulting from the 
investigation.” System 
required to “establish a 
system to promptly address 
and resolve the report 
findings and 
recommendations 
and…implement the report 
recommendations in a 
timely manner, or take 
action to prevent a 
reoccurrence.” 
Investigation of incidents 
required to demonstrate legal 
compliance with framework 
legislation. ‘Reasonably 
practicable’ requirement would 
require remedial action and 
cross company learning from 
incident investigations. HSE 
can require SC duty holder 
compliance with investigation 
report recommendations (e.g. 
Buncefield Report-“determine 
SIL level requirements for 
overfill protection”) 
Management of Change 
Activity-based; the employer 
“shall establish and 
implement written procedures 
to manage changes;” “the 
procedures shall assure the 
following considerations are 
addressed…impact of change 
on safety and health;” no 
formal hazard analysis 
required; no requirement that 
the identified safety impacts 
or hazards be controlled. 
Activity-based: the 
employer “shall establish 
and implement written 
procedures to manage 
changes…;” “the 
procedures shall assure that 
the following are addressed 
prior to any 
change…technical basis for 
proposed change; impact of 
change on safety and 
health;” no formal hazard 
analysis required; no 
requirement that the 
identified safety impacts or 
hazards be controlled. 
Description of MOC 
procedures and demonstrations 
of their effectiveness in 
managing major accident 
hazard risk are a key 
requirement of the safety case. 
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OSHA PSM Standard 
California PSM Standard 
The Safety Case Regulatory 
Regime 
Workforce 
Participation 
“Employers shall develop a 
written plan of action 
regarding the implementation 
of the employee 
participation;” Employers 
shall consult with employees 
and their representatives on 
the conduct and development 
of PHAs and the other 
elements of PSM in this 
standard.” 
“Employer shall develop a 
written plan of action to 
ensure employee 
participation in process 
safety management;” 
includes employer 
consultation with 
employees and their 
representatives on the 
conduct and development 
of the elements of process 
safety management 
required by this section; 
and providing employees 
and their representatives 
with access to all 
information required to be 
developed by this 
section…” 
Provides for the election of 
protected safety representative 
positions and safety 
committees. 
Inherent Safety 
No 
No 
Yes 
 
 
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Appendix C: Frequently Asked Questions (FAQs) Regarding the 
Safety Case Regulatory Approach 
1. Is it true that the safety case regulatory approach leads to self-regulation by industry? 
 
Critics of the safety case regulatory approach have noted that this type of regulatory regime is likely to 
result in mere industry self-regulation.456 Critics have also noted that this is at least partly due to the fact 
that there is no will in the US to ensure that regulators have the tools, resources, and competence to 
effectively regulate workplaces. The CSB and those with experience in developing and implementing the 
safety case regulatory regime have repeatedly stated that the purpose of the safety case regulatory 
approach is to ensure that all hazards have been identified, evaluated, and controlled so that risks are 
reduced to as low as reasonably practicable, or ALARP. In simple terms, the safety case report is a series 
of claims as to how an installation is being safety operated. The real strength of the safety case regulatory 
regime is testing the validity of those claims through strategic intervention by competent, well-funded 
regulators. Advanced performance-based regulatory regimes in the United Kingdom (UK) and Norway, 
for example,457 incorporate a list of regulator-accepted standards and good practices that provide 
companies with the minimum performance that is expected. Companies must demonstrate that they meet 
or exceed those standards. Therefore, companies are aware of minimum performance expectations they 
must meet as they work to reduce risks to ALARP. If a competent regulator is not in place, then the 
safety case report equates to nothing more than a lifeless document sitting on a shelf, and the criticism of 
self-regulation becomes valid. 
 
It is also important to point out that in a letter from the USW Local 5 to the CSB dated November 22, 
2013, it was stated that “[t]he current system is truly a self regulated system, with the industry setting the 
rules, changing the rules, and monitoring themselves.” Individuals are noting that the current system in 
place has actually led to self-regulation despite the intent of the PSM standard and RMP program to be 
performance-based. 
 
Critics have also argued that there is a lack of transparency with the safety case regime. However, under 
the existing PSM standard, none of the PSM elements are made public by the company or the regulator, 
including the process hazard analyses and management of change documents. To improve transparency, 
many safety case regimes collect and report indicator data, and companies are required make safety case 
report summaries publicly available. These are high level documents that are published online and 
summarize safety assessments, hazardous materials, hazards and control measures, potential major 
incidents, emergency response, and safety management systems. 
 
Rather than accepting the inevitability of catastrophic events, we should act to prevent them from 
happening. As discussed in this report, there is a movement in California to improve oversight of 
456 See e.g. Rena Steinzor. Lessons from the North Sea: Should “Safety Cases” Come to America? Vol. 38: 417; 
2011; p 439. Available at http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1735537 (accessed September 4, 
2013). 
457 Norway requires many similar aspects of a safety case regime offshore but there are differences in 
implementation and style and content of the regulations. The UK implements a safety case regime both onshore and 
offshore. 
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petroleum refineries. There has also been increased dialogue in the US in recent years surrounding the 
regulation of the oil and gas industry and how to make improvements. As such, the support exists to not 
only shift the current activity-based regulatory structure to a more goal-based safety case regulatory 
regime, but to also ensure that competent, well-funded regulators are in place to implement and enforce 
such a regime. 
 
2. How does the safety case regulatory regime in the US allow for changes to be made without requiring 
rulemaking under the Administrative Procedure Act? 
 
The Administrative Procedure Act, or APA, was passed in 1947, and lays out the basic framework under 
which federal rulemaking is conducted. It defines “rule” as “the whole or a part of an agency statement of 
general or particular applicability and future effect designed to implement, interpret, or prescribe law or 
policy or describing the organization, procedure, or practice requirements of an agency…”458 
“Rulemaking” is defined as the “agency process for formulating, amending, or repealing a rule.”459 
Federal agencies often impact their specific area of jurisdiction by publishing rules promulgated through 
notice and comment rulemaking, or informal rulemaking, under the APA. Unfortunately, as this report 
discusses at length, the rulemaking process in the US is cumbersome and some federal agencies, such as 
OSHA and the EPA, are subject to additional requirements and more stringent review standards that go 
above and beyond those contained in the APA. To avoid these additional burdens, many agencies provide 
further guidance to regulated parties through more informal means, such as answering questions and 
issuing policy statements, guidance, or opinion letters. Another way to lessen the burden on regulating 
agencies and their regulated entities is to adopt performance or goal-based regulations rather than 
prescriptive regulations. Performance-based standards state the objective or outcome to be achieved, such 
as risk reduction, without describing the specific means of obtaining that objective. This provides the 
regulated entities with the freedom and flexibility to work to achieve a stated goal, such as reducing risks 
to as low as reasonably practicable, or ALARP, through their chosen and preferred means.460 
Performance-based standards also provide flexibility to the regulator; for example, in a safety case 
regulatory regime, should the regulator determine through assessment of the safety case report and/or 
inspection that the facility has not reduced risks to ALARP with regard to a specific hazard, he or she may 
require that the facility take additional steps to further reduce risk without needing to propose and adopt a 
new rule or regulation to address it. The regulator must accept the safety case report in order for the 
facility to operate. 
 
The Regulatory Flexibility Act was passed in 1980 during the Carter Administration. It requires agencies 
to prepare and make available for public comment regulatory flexibility analyses of proposed rulemaking, 
and also encourages agencies to consider alternatives to rulemaking, including “the use of performance 
rather than design standards…”461 Executive Order 13272 then directed federal agencies to establish 
procedures and policies to comply with the Act.462 Federal agencies have been encouraged to adopt 
458 5 U.S.C. §551(4) (2011). 
459 5 U.S.C. §551(5) (2011). 
460 Such as reliance upon qualitative assessments, quantitative assessments, semi-quantitative risk assessments, and 
good practice guidance. 
461 5 U.S.C. §603(3) (2010). 
462 Exec. Order No. 13272, 67 Fed. Reg. 159 (August 13, 2002). http://www.gpo.gov/fdsys/pkg/FR-2002-08-
16/pdf/02-21056.pdf (accessed September 24, 2013). 
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performance-based standards in the US for decades. Recognizing the inefficient process of federal 
rulemaking in the US, President Clinton signed Executive Order 12866 in September of 1993, which, 
among other things, directed federal agencies to “identify and assess alternative forms of 
regulation…[and] specify performance objectives, rather than specifying the behavior or manner of 
compliance that regulated entities must adopt.”463 Executive Order 13563, entitled Improving Regulation 
and Regulatory Review, supplemented and reaffirmed Executive Order 12866 by ordering agencies to 
“identify and consider regulatory approaches that reduce burdens and maintain flexibility and freedom of 
choice for the public.”464 Its stated goal was to “protect public health, welfare, safety, and our 
environment while promoting economic growth, innovation, competitiveness, and job creation.”465 Its 
seven guiding principles are as follows: 
• 
Increase predictability and reduce uncertainty; 
• 
Use and rely on best available science; 
• 
Ensure public participation and open exchange of ideas; 
• 
Use the most innovative and least burdensome tools; 
• 
Consider cost benefit analysis (quantitative and qualitative); 
• 
Ensure regulations are publicly available, consistent, written in plain language and easy to 
understand; and 
• 
Measure results and seek to improve actual results.466 
 
The safety case regime aims to satisfy all of these principles. 
 
California has adopted its own version of the APA, known as the California Administrative Procedure 
Act (CAPA) (California Government Code §11340 et seq.).467 Among its many requirements for 
California state agencies that adopt regulations, CAPA directs them to consider the substitution of 
performance standards for prescriptive standards.468 CAPA defines “performance standard” as “a 
regulation that describes an objective with the criteria stated for achieving the objective.”469 
 
Federal agencies that are engaged in and responsible for regulating high hazards, such as NASA and the 
Nuclear Regulatory Commission (NRC), have adopted goal or performance-based standards that require 
risks to be reduced to “as safe as reasonably practicable” (ASARP) and “as low as reasonably 
achievable,” (ALARA), respectively. The OSHA Process Safety Management (PSM) standard also 
contains performance-based elements to some extent; for example, it provides regulated entities with 
flexibility in how to perform a process hazard analysis (PHA). However, it contains no risk reduction 
goals such as ALARP. This has resulted in an activity-based regulatory scheme that emphasizes 
completing activities, such as a PHA or a Management of Change (MOC) analysis, rather than actual risk 
reduction. Without a risk reduction goal such as ALARP in place, the PSM standard will not have the 
463 Exec. Order No. 12866, 48 Fed. Reg. 190 (September 30, 1993). http://www.archives.gov/federal-
register/executive-orders/pdf/12866.pdf (accessed September 24, 2013). 
464 Exec. Order No. 13563, 76 Fed. Reg. 14 (January 21, 2011). http://www.gpo.gov/fdsys/pkg/FR-2011-01-
21/pdf/2011-1385.pdf (accessed September 24, 2013). 
465 Ibid. 
466 Ibid. 
467 Available at http://www.oal.ca.gov/administrative_procedure_act.htm (accessed September 18, 2013). 
468 California Government Code, §11340.1(a) (1995). 
469 California Government Code, §11342.570 (1995). 
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ability to successfully drive continuous improvement and adaptation of industry safety management 
advances. 
 
3. Can the safety case regulatory approach work in the US when workforce involvement is emphasized 
less than other regions and unionization rates are lower than other countries? 
 
A majority of the workforce in California petroleum refineries is unionized, as the unionization rate for 
the 14 petroleum refineries in California is actually 73 percent,470 which is significantly higher than the 
2012 rates for the US as a whole (11.1 percent), Australia (17.9 percent), the UK (25.8 percent), and 
Norway (54.7 percent).471 Despite a declining unionization rate in the UK, the region has developed 
strong onshore and offshore regulations that provide for the creation of protected safety representative 
positions and safety committees for unionized and non-unionized facilities. These positions are meant to 
create a healthier and safer workplace, and result in better decision-making regarding health and safety, 
increased productivity, higher workforce motivation, a stronger commitment to implementing decisions 
or actions (as employees have been actively involved in reaching these decisions), and greater 
cooperation and trust.472 The HSE has devoted extensive time and resources to ensuring employers are 
complying with these regulations and understand the importance and benefits of involving workers in 
health and safety-related matters. 
 
The UK also has a standard establishing the minimum level of training that elected safety representatives 
offshore should receive to enable them to fully perform their functions as defined in the Safety 
Representatives and Safety Committees Regulations – SI 1989/971. This training standard, entitled the 
OPITO Approved Standard, was developed by an industry workgroup facilitated by OPITO.473 In June 
2013, Det Norske Veritas (DNV)474 became accredited by OPITO to offer newly developed training 
courses to more than 2,000 elected safety representatives in the offshore industry. The training, which 
has been driven and supported by HSE, Oil and Gas UK, and the Offshore Industry Advisory 
Committee’s Workforce Involvement Group, consists of four separate Modules run over the course of 
eight days.475 The training covers topics such as Understanding and Identifying Major Accident Hazards 
and Investigating Incidents and Applying Root Cause Analysis. 
 
The CSB recognizes the HSE’s effort to improve workforce involvement through regulations, protected 
positions, and training, and has recommended in this report that California develop regulations and 
guidelines to establish similar protected safety positions to ensure effective workforce participation. The 
470 In September 2013, the USW provided the CSB with a list of California petroleum refinery locations as of 
October 2012 and the existing unionization representation at those refineries. Of the 15 petroleum refineries 
operating in California as of October 2012, 11 of those were unionized, with USW providing the union 
representation at all 11 facilities. 
471 For complete statistics on trade union density for countries around the world see 
http://stats.oecd.org/Index.aspx?QueryId=20167 (accessed September 5, 2013). 
472 HSE. Consulting employees on health and safety: A brief guide to the law. 2013; p 2. 
http://www.hse.gov.uk/pubns/indg232.pdf (accessed September 5, 2013). 
473 OPITO is an industry-owned non-profit that serves the needs of the oil and gas industry in the UK and around the 
world. See http://www.opito.com/ (accessed September 10, 2013). 
474 DNV is an independent foundation headquartered in Oslo, Norway, that provides services for managing risk 
around the world. For more information see http://www.dnv.com/ (accessed September 10, 2013). 
475 http://www.marinelink.com/news/launches-offshore355749.aspx (accessed September 10, 2013). 
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CSB believes the HSE model can also be effective in the US as these regulations require effective safety 
representation regardless of unionization rates. 
 
4. Has the safety case regulatory approach resulted in fewer major accidents? 
The CSB has identified a small number of independent studies conducted on the impact of the safety case 
regulatory approach on safety performance onshore and offshore. In 1999, a report commissioned by the 
HSE (“the Aberdeen Report”) which evaluated the impact of the offshore Safety Case Regulations on 
offshore safety was published.476 One of the purposes of the study was to review published safety data 
for trends in offshore accidents and incidents from 1990 until 1997.477 Upon this review, it was 
determined there had been a decrease in accidents since the implementation of the offshore safety case 
regulations in the UK, but cautioned it was difficult to distinguish the effect of the safety case regulations 
from other industry activities such as the level and type of exploration and production activity, oil prices, 
and industry-led initiatives.478 The Aberdeen Report also cautioned about the difficulties in analyzing 
offshore data that also hold true for the more current data presented in Figure 3. The total number of 
accidents and incidents recorded can be affected by industry attitudes toward reporting, changes in how 
and what data is reported, and the decrease or increase in offshore activity. As stated in the Aberdeen 
Report, “[d]espite these cautions, accident statistics play an important role in the analysis of the state of 
safety in any industry, since accidents represent the ‘bottom line’ in safety. It is therefore important to 
analyze the trends, but to also take the drawbacks into consideration.”479 As discussed in this report, the 
reporting and analyzing leading process safety indicators is important to gain a better understanding of 
how safety management systems are functioning, and thus a better idea of how well the various regimes 
are managing hazards and mitigating risk. 
Statistics from the seven years covered by the Aberdeen Report indicated an overall decrease in reported 
accident rates in the UK and Norwegian databases up until 1994. From 1994 to 1997, both the UK and 
Norway reported a slight increase in the number of reported accidents.480 Norway did report a drop in 
1997 from 1996. The decrease reported up until 1994 for the UK appeared to be independent of the 
offshore production activities as those levels had been on the increase during the same time period. 
Drilling in the UK decreased during the same time frame, making the cause for the decrease in reported 
drilling accidents unclear. 
More recent reviews of accident data indicate decreasing trends in accident statistics. The Presidential Oil 
Spill Commission noted the following in its report to the President on the Macondo disaster: 
 
[f]rom 2004 to 2009, fatalities in the offshore oil and gas industry were 
more than four times higher per person-hours worked in U.S. waters than 
in European waters, even though many of the same companies work in 
both venues. This striking statistical discrepancy reinforces the view that 
the problem is not an inherent trait of the business itself, but rather 
476 Evaluation of the Offshore Safety Legislative Regime—A study undertaken by AUPEC Ltd. For the Safety Policy 
Division, Health & Safety Executive, Ref: 8938/3714, June 1999. 
477 Ibid at Ch 7. 
478 Ibid at Ch 7, p 7-1. 
479 Ibid at Ch. 7, p 7-11. 
480 This was based on the number of accidents per million man hours for the two Continental Shelves (Ibid, Figure 
7.8) 
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depends on the differing cultures and regulatory systems under which 
members of the industry operate.481 
 
In September 2013, Det Norske Veritas (DNV)482 released a position paper discussing necessary 
improvements to reduce risk of major offshore accidents, and noted in the report that “there are no good 
globally accepted metrics for major accident hazards…”483 However, DNV was able to point to UK 
HSE’s Hydrocarbon Releases Database System (HCR)484 in the North Sea to provide an example of 
improving safety performance trends.485 The HRC contains detailed voluntary information of over 4,000 
hydrocarbon releases offshore from close to 300 installations since 1992. The HRC data, plotted in 
Figure 3, show the total number of releases to be on the decline. Classifying the severity of a release is 
based on agreed-upon criteria with the offshore industry.486 The UK has defined significant events to be 
those that, if ignited, have the potential to cause a major accident where multiple casualties could occur. 
The occurrence of any hydrocarbon release is undesirable because of the potential to escalate, and so 
reporting data from minor incidents has also been included in Figure 3 below. 
 
 
Figure 3. Hydrocarbon releases in the North Sea reported to UK HSE as dangerous occurrences under the 
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations.487 
481 National Commission on the BP Deepwater Horizon Oil Spill. Deep Water: The Gulf Oil Disaster and the 
Future of Offshore Drilling. Report to the President; January 2011; Ch 8, p 225. 
482 DNV is an independent foundation headquartered in Oslo, Norway, that provides services for managing risk 
around the world. For more information see http://www.dnv.com/ (accessed September 10, 2013). 
483 DNV. Enhancing offshore safety and environmental performance: Key levers to further reduce the risk of major 
offshore accidents. 2013; p 5. http://www.dnv.com/industry/oil_gas/services_solutions/offshore_safety.asp 
(accessed September 10, 2013). 
484 https://www.hse.gov.uk/hcr3/ (accessed January 13, 2014). 
485 In its position paper, DNV cited data from 1996, but UK HSE has noted that the criteria for severity classification 
was refined in 1999 so data since that date is presented here. 
486 Hydrocarbon Releases System Internet Help File, https://www.hse.gov.uk/hcr3/help/help_public.asp (accessed 
September 10, 2013). 
487 RIDDOR – Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 became effective 
offshore on April 1, 1996, http://www.hse.gov.uk/riddor/ (accessed September 10, 2013). 
0 
50 
100 
150 
200 
250 
Reported Releases 
Financial Year (April-March) 
2000/01 to 2012/13 
Minor 
Significant 
Major 
Total 
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It is important to note that major accidents are low-probability, high-consequence events, and as such they 
are difficult to measure. According to Dr. Andrew Hopkins, major accidents are more difficult to define 
than, say, a car accident, and they are rare, making it difficult to estimate the number of major accidents 
prevented.488 In addition, based on the data in existence, there is a continued need for improved data 
collection; key leading performance indicators development and implementation on a global scale would 
provide an improved glimpse into how safety is being managed for major accident prevention. 
 
A team of three independent safety experts was asked to conduct an independent evaluation of the 
operational effectiveness of the National Offshore Petroleum Safety Authority (NOPSA), which was 
established in January 2005 to regulate offshore health and safety in Australia (it was superseded by 
NOPSEMA in January 2012). The 2008 report released as a result of the evaluation noted that the team 
of experts received submissions identifying issues surrounding the safety case regime from twelve 
stakeholders, including the Australian Workers Union, the Maritime Union of Australia, and the 
International Association of Drilling Contractors. The report states that a majority of the submissions 
expressed that the safety case regime had “generally been a success…” and “had led to improvements and 
already brought forth better consistency in many areas….”489 The report noted that there was general 
stakeholder agreement “that the regulatory processes have been improved.”490 
 
As mentioned in Section 3.2.1.2 of the report, following the Macondo incident in April 2010, an 
independent review of the offshore safety case regime in the UK was conducted by a panel consisting of 
three independent appointees, including Professor Geoffrey Maitland at Imperial College London. A 
report was published discussing the review in December 2011, and it noted that, while not perfect, the 
offshore safety case regime was “robust and effective at identifying risks and appropriate measures for 
mitigation and response….”491 The report stated the following: 
 
From its analysis of the existing UK framework and the information it 
gleaned from its discussion with those directly involved in the sector 
from both an operational and regulatory perspective, the Review 
Panel was reassured that the UK regime already incorporates a 
number of positive, key features which were not present in the US at 
the time of the Macondo incident. At a high level, the Panel notes and 
commends in particular: 
 
• the UK’s “goal-setting” safety regime and its ability to foster 
innovation and continuous improvement in process integrity, 
 
488 Hopkins, Andrew. The Cost-Benefit Hurdle for Safety Case Regulation: A discussion paper prepared for the US 
Chemical Safety Board. Add Date, Page, and Link. 
489 Ognedal, Magne; Griffiths, Derek; and Lake, Bruce. Review of the National Offshore Petroleum Safety Authority 
Operational Activities. February-March 2008; p 14. 
490 Ibid at 28. 
491 Maitland, Geoffrey. Offshore Oil and Gas in the UK: an independent review of the regulatory regime. 
December 2011; p 4. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/48252/3875-
offshore-oil-gas-uk-ind-rev.pdf (accessed January 13, 2014). 
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• the strength of the mechanisms in place for independent, third party 
verification in the crucial areas of well design and integrity of safety 
critical equipment, 
 
• the rigour with which the potential environmental impacts of the 
industry are examined and of the controls and procedures in place to 
mitigate them, 
 
• the detailed and comprehensive emergency response framework 
which exists for managing the consequences of incidents should they 
occur, 
 
• the high regard in which the UK authorities, in the form of DECC, 
HSE and MCA, are held both by UK operators and international 
observers, 
 
• the fact that the events in the Gulf of Mexico have clearly acted as a 
catalyst for UK operators, working in concert with the regulators and 
other stakeholders, to redouble their efforts to improve safety and to 
strengthen response capabilities.492 
 
 
5. The UK HSE has published reports493 showing significant industry problems with maintenance of 
safety critical equipment, poor understanding of the potential impact of degrading plant and utility 
systems on safety critical elements, and lack of understanding of the role of asset integrity and the concept 
of barriers in major hazard risk control. Don’t these reports developed by the UK regulator demonstrate 
that the safety case is not effective and is not working? 
The CSB recognizes that there have been critiques of the safety case regime and its implementation. The 
CSB acknowledges that the safety case is not perfect and that no regulatory system will be perfect in its 
implementation. Some have noted the issue of aging equipment due to many issues, including the harsh 
conditions that exist in the North Sea. Regulators and commissions in the UK have found degradation of 
pipes, valves, and other equipment at many facilities due to company deferrals of maintenance, 
insufficient testing of safety-critical elements, and a continuing industry culture of responding to 
disasters, rather than anticipating worst-case scenarios. However, the safety case regime’s adaptive 
nature has been able to address these concerns. The HSE has recognized asset integrity management and 
the issue of ageing equipment as key issues to address in its inspection programs, and has developed 
internal processes and priorities for these areas. 
In 2010, the UK HSE initiated Key Programme 4 to address the issue of aging equipment offshore and the 
operation of installations beyond their design life.494 The same year, the HSE published a report intended 
492 Ibid at 3. 
493 The HSE published a report to communicate the results and conclusions of the Asset Integrity Key Programme 
carried out between 2004 and 2007 by the Health and Safety Executive’s Offshore Division. See 
http://www.hse.gov.uk/offshore/kp3.pdf (accessed August 28, 2013). 
494 The report is available at http://www.hse.gov.uk/offshore/ageing/kp4-interim-report.pdf (accessed November 1, 
2013). 
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to inform industry and aid in the prevention of major accidents entitled Managing Ageing Plant: A 
Summary Guide,495 which provides an overview of ageing plant mechanisms and their management and 
presents the findings of an analysis of loss of containment incidents to indicate the extent to which ageing 
plant equipment may be a factor. This type of programmatic proactive approach and information 
dissemination is lacking in the US both on and offshore. 
 
6. How have other countries implemented the safety case regime? What challenges do the countries face 
when transitioning to a safety case approach? 
 
From the international safety case community, the CSB has found that when transitioning to a safety case 
regime there are many obstacles that may hinder the transition, such as: 
 
• 
Major stakeholders not being committed to the process, unconvinced of the need; 
• 
Lack of understanding that the safety case regime is a “process” to be undertaken by the duty 
holder and the workforce to improve understanding of the hazards, risks, and their controls, and 
to put in place measures for continuous improvement, rather than just creation of a “document”; 
• 
Lack of sufficient funding by government and industry; and 
• 
Lack of the necessary legislative timetable. 
 
The transition to a safety case regime has significant challenges for both the duty holder and the regulator, 
including: 
 
• 
The safety case report could be treated as a check-the-box exercise; 
• 
Documented safety management system does not reflect reality; 
• 
Poor identification of hazards and risks; 
• 
Poor understanding of the performance of control systems; 
• 
Attempting to justify existing controls rather than to seek opportunity to improve; 
• 
Insufficient workforce involvement in the process; 
• 
The safety case process is under-resourced; 
• 
The safety case report is “inaccessible” so the report simply lives on the shelf; 
• 
The regulator does not use the safety case report to inform the inspection or audit; 
• 
Limited requirement for the reporting of accidents, dangerous occurrences and precursors 
resulting in lack of comprehensive performance data; and 
• 
The regulator is under-resourced, technically challenged, poorly trained, has poor systems and 
procedures, and is inconsistent. 
 
In implementing the safety case regime, there should be regard for the regulatory principles and 
frameworks which represent best practice. The underlying principles are: 
 
• 
The legislation and regulation should be fit for purpose, not simply superimposed on existing 
prescriptive regulation; 
495 See http://www.hse.gov.uk/research/rrpdf/rr823-summary-guide.pdf (accessed November, 1, 2013). 
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• 
Regulation should be effective and efficient; and 
• 
Industry should move away from a culture of compliance with detailed prescriptive regulation to 
one of involving the workforce in understanding the hazards. 
 
Some significant points worth noting from international experience in setting up the regulation are: 
 
• 
Staff should be recruited against detailed job descriptions and should cover the full range of 
technical, management and regulatory requirements; 
• 
Pay rates and terms and conditions should be sufficient to attract highly qualified staff; 
• 
A competency framework needs to be developed reflecting the required knowledge, skills, and 
experience required to undertake; 
• 
Appropriate training programs must be in place; 
• 
An electronic dedicated safety case assessment procedure which captures the detail of the process 
to be followed and records the background to the decision-making process will be needed. This 
helps ensure good quality, consistent, and transparent assessment and provides a database of 
information which is used for future validation/topic facility inspections. It also provides a 
comprehensive record of the process which can be used in the event of an appeal against an 
assessment decision; 
• 
An accident and dangerous occurrence data base will be needed to store knowledge and data to 
provide reference information and the capacity to analyze trends; and 
• 
An emergency reporting and response process is necessary to ensure all significant events are 
properly logged and dealt with. 
 
 
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Appendix D: CSB Staff May 2014 Response to the Board’s Motion 
to Postpone issued on January 15, 2014 
Background 
 
On January 15, 2014, the CSB held a public meeting in Richmond, California, to present the draft 
Chevron Regulatory Report for a vote by the Board. In the first CSB Chevron Report (the Chevron 
Interim Report), which was approved by the Board on April 19, 2013, the CSB staff committed to 
investigating additional issues which would be presented in a final report on the incident. These issues 
included the regulatory oversight of petroleum refineries in California. Due to deployments to West, 
Texas, and Geismar, Louisiana, the CSB Chevron investigation team produced a second interim draft 
report focused solely on the regulation of petroleum refineries. At the Richmond public meeting, the 
Board moved to postpone a vote on the draft regulatory report in order for the CSB investigation staff to 
address additional issues raised concerning regulatory oversight of petroleum refineries and the proposed 
safety case regime. The CSB staff was given 120 days from the date of the public meeting to respond to 
the motion. 
 
I. 
 
1. 
Does Cal/OSHA have sufficient authority to require timely abatement of hazards associated 
with serious and willful violations? 
 
CSB Investigations Staff Response: 
 
Following the August 6th incident at the Chevron Richmond Refinery, Cal/OSHA cited Chevron for, 
among other things, failing to replace pipe clamps at the refinery, and ordered Chevron to replace those 
pipe clamps by a certain date. The CSB Chevron Interim Report states that Chevron has a history of 
frequently using leak repair clamps to externally stop process fluid leaks, and that following discovery of 
the leak on the 4-sidecut piping prior to the incident, “Chevron hoped to forestall a shutdown by installing 
a leak repair clamp.”496 The CSB determined that Chevron had more than 100 clamps on hydrocarbon 
and other piping components containing hazardous flammable process fluids at the Richmond refinery 
and that reliance on such clamps to mitigate leaks “identifies serious questions about its mechanical 
integrity program.”497 The interim report, which was approved by the Board on April 19, 2013, 
committed to evaluating the Chevron Richmond Refinery’s use of clamps and its mechanical integrity 
program as they relate to the refinery’s process safety culture in the final CSB report on the Chevron 
incident. 
 
A letter written by California Representative George Miller dated January 15, 2014 discussed Chevron’s 
use of clamps and expressed concern that some of the clamps have not been replaced, and will not be 
replaced until late 2014. The letter stated that under the California Labor Code, an employer is not 
obligated to correct a Cal/OSHA safety violation if they appeal. According to Representative Miller, 
496 CSB. Chevron Interim Report. April 19, 2013; p 62. 
497 Ibid. 
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Chevron appealed its Cal/OSHA citations on February 19, 2013. In the letter Rep. Miller requested that 
given these facts, the CSB investigators should assess the issue of timely abatement, and consider making 
recommendations to the Legislature and Governor on this matter. 
 
 
The CSB staff notes that while it has already committed to evaluating the use of clamps at the Chevron 
Richmond Refinery as it relates to mechanical integrity and process safety culture, we are not aware of a 
causal connection between the refinery’s use of the clamps to mitigate leaks and the August 6th incident. 
Regulatory bodies often cite companies for deficiencies following an incident that are not related to that 
incident. However, the CSB is directed under the Clean Air Act to “investigate (or cause to be 
investigated), determine and report to the public in writing the facts, conditions, and circumstances and 
the cause or probable cause” of an accidental release.498 (emphasis added). The CSB’s Board Order 
040, Procedure G: Causal Analysis, discusses requirements of formal analysis tools that identify the 
multiple causes of an incident, including technical, organizational, and societal causes. Thus, while the 
CSB staff committed to analyzing the issue of clamps at the refinery as it pertains to safety culture, the 
staff did not analyze the usage of clamps and abatement in its regulatory report, as it was not determined 
to be causal and was therefore not within the scope of the regulatory investigation. 
 
 
2. 
Should Contra Costa County Health Services have direct enforcement authority under the 
Industrial Safety Ordinance? 
 
The CSB staff looked into this matter, including interviewing key personnel, and determined that while 
having enforcement power is generally beneficial, a CSB recommendation on the issue is not warranted in 
this case, as Contra Costa County’s lack of enforcement authority under the ISO is not causal to the 
August 6th incident. According to Contra Costa County officials, the inspectors have never gone to the 
District Attorney to enforce the ISO. In addition, these officials have stated to the CSB that the Chevron 
Richmond Refinery has cooperated fully with past recommendations and has addressed any violations 
issued as a result of any audit conducted by Contra Costa County inspectors. While the CSB agrees that 
having enforcement power provides the regulator with another tool to ensure compliance with regulations, 
there is no causal connection to the August 6th incident and therefore no additional recommendation 
regarding this issue is warranted. 
 
3. 
Does Contra Costa County Health Services have sufficient resources to conduct 
comprehensive inspections and retain technically qualified personnel? 
 
The report discusses the lack of resources and funding within the Contra Costa Hazardous Materials 
Program, which has limited its ability to hire additional highly qualified staff to oversee the petroleum 
refineries in Contra Costa County. The engineers are part of a bargaining unit and their salaries are paid 
through the county’s general fund, which has experienced annual budget reductions in the millions. The 
CSB agrees that for a performance based regulatory approach to be effective it is essential to have a well 
funded, qualified regulator and has therefore added a recommendation to the City of Richmond and 
Contra Costa County. 
498 42 U.S.C. §7412 (r)(6)(C)(i) (1990). 
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4. 
Does Contra Costa County Health Services have sufficient authority to require facilities to 
undertake feasible risk reduction measures, such as best practices, which go beyond minimum 
regulatory requirements? 
 
The draft report discusses on page 89 that Contra Costa engineers conduct CalArp and ISO/RISO audits 
concurrently at each covered facility generally once every three years. The engineers are only able to 
audit against the regulatory requirements, and while they can issue “consider” action items to the facility 
recommending actions above and beyond regulatory requirements, they do this very infrequently. 
 
The Chevron Interim Report addressed ISO regulatory deficiencies, including the fact that there is no 
required implementation of inherent safety (unlike in the safety case). The Interim Report issues 
recommendations R3, R4 and R6 and R7, which request the City of Richmond and Contra Costa County 
to revise the ISO to require damage mechanism hazard reviews and the documented use of inherently 
safer systems analysis and the hierarchy of controls “to the greatest extent feasible” in establishing 
safeguards for identified process hazards. The recommendations note that the goal shall be to drive the 
risk of major accidents to As Low As Reasonably Practicable, or ALARP. 
 
The ISO is currently being revised to implement these recommendations, and should be finalized as early 
as June 2014. The revised regulatory language would require facilities to reduce risk to “the greatest 
extent feasible,” which is a concept that is very similar to ALARP. Contra Costa County will have the 
ability to issue guidance that elaborates on what will be required to achieve that standard. 
 
The CSB staff believes that these recommendations cover the issue raised in this question, and no 
additional recommendations are warranted. 
 
II. 
 
In the motion to postpone the Board made the following proposal to have additional questions addressed 
by an expert panel: 
 
The CSB staff shall convene a multidisciplinary expert panel (selected by the full Board), similar to 
the Baker Panel established after the BP Texas City incident, to provide the agency with an 
assessment of the following topics regarding regulating process safety in refineries in California: 
 
1. To address questions raised in the comments received by the CSB, the panel shall assess the 
available process safety performance data to evaluate the effectiveness of the safety case regulatory 
model for refineries. 
 
2. Assess the challenges of making safety case operational and effective with regard to the following 
topics: 
 
 
a. What is the role of transparency and community involvement under this regime? Are 
safety case reports made public? 
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b. How are workers empowered as part of the tripartite model? Have there been 
retaliatory actions taken against workers for their involvement, and what protective 
measures are in place? 
c. Are safety committees mandatory or optional in non-union workplaces? How are safety 
committee members selected, and under what authority? 
d. Is there a public data base of incident and near miss reporting? How are process safety 
performance indicators developed and used? Are these made public? 
e. How are standards for minimum levels of risk set (ALARP presumably goes beyond 
minimum levels)? 
f. What are the enforcement methods used by regulators under the safety case? 
g. What are the key transition issues that were addressed with facilities in operation at the 
time the safety case was adopted? 
 
In response to this Board motion the staff has developed a white paper with staff responses to the 
questions posed by the Board. Additionally, the CSB is planning a public hearing in the Spring of 2015 
to discuss various models, including safety case, for regulating high hazard facility safety. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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