Skip to content

CSB Safety Bulletin Focuses on Companies’ Inadequate Procedures During Non-Routine Maintenance

The U.S. Chemical Safety Board (“CSB”) recently issued a safety bulletin1 explaining that companies — and refineries in particular — need to be more systematic when preparing equipment for maintenance operations, to prevent injuries and hazardous conditions.

The safety bulletin was issued in the aftermath of a November 2015 accident at the Delaware City Refining Company (“DCRC”), where employees had been draining and isolating a piece of piping to prepare it for replacement. One employee — who had been relying on informal, handwritten instructions — did not realize that a valve had leaked flammable materials into a vessel. When the employee attempted to drain the vessel, the flammable materials contacted an igniter and caused a flash fire. The employee suffered second- and third-degree burns and spent three days in the hospital.

The CSB found that, at the time of this accident, DCRC had no formalized process, general procedure, or job aid for ensuring equipment was properly isolated, de-inventoried, or decontaminated prior to maintenance work.

The CSB further noted that this was not a unique problem: 37% of the incidents the CSB investigated had occurred during maintenance activities, ultimately resulting in 86 fatalities and 410 injuries. According to the CSB, incidents like these are often caused by improper preparation of equipment, rather than the actual maintenance itself. Non-routine maintenance can elevate the risk associated with preparing equipment even further.

Companies should develop standard operating procedures to ensure that equipment preparation is carefully planned and that hazards are identified and mitigated prior to beginning work. OSHA’s Process Safety Management (“PSM”) standard requires employers to develop and implement such safe work practices to control hazards during operations.2 OSHA interprets this requirement broadly, and we have seen a greater emphasis from OSHA on this in recent PSM audits. Without proper procedures in place, these activities can expose employees to hazardous conditions such as fires, explosions, and toxic gases.


1 The CSB safety bulletin is available at:

2 29 C.F.R. § 1910.119(f)(4).

This information is provided by Vinson & Elkins LLP for educational and informational purposes only and is not intended, nor should it be construed, as legal advice.