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BP - Husky Oregon Chemical Release and Fire

The investigation concluded that an overwhelming "alarm flood" distracted operators during a process upset, leading them to mistakenly drain liquid naphtha from a pressurized vessel directly onto the ground, where it ignited and killed two brothers.

On 20 September 2022, a catastrophic fire occurred at the BP-Husky refinery in Oregon, Ohio. The incident was the deadliest at a BP-operated refinery since the 2005 Texas City disaster. The sequence of events began nearly 24 hours prior with a process upset in the Crude 1 unit, which caused liquid naphtha to overflow into systems designed only for vapour. By the evening of the 20th, the refinery's Fuel Gas Mix Drum had become dangerously overfilled with flammable liquid naphtha.


The Chemical Safety Board (CSB) investigation identified a "series of cascading failures." A primary factor was an extreme alarm flood: in the 12 hours leading up to the explosion, board operators were bombarded with 3,712 alarms. This data overload made it nearly impossible for the crew to identify the critical overfill situation. Believing the liquid in the drum was merely amine-water (a non-flammable byproduct), the two Morrissey brothers, an outside operator and a trainee, were instructed to drain the vessel as quickly as possible.


As they opened the valves, over 23,000 pounds (approx. 10,400 kg) of liquid naphtha was released directly onto the refinery floor. The volatile liquid rapidly vaporised, creating a massive cloud that was pushed by shifting winds toward an ignition source—a nearby crude oil furnace. The resulting flash fire engulfed the two workers.


The CSB was highly critical of the refinery's management of "Abnormal Situations." Despite the escalating crisis, management did not implement a controlled shutdown or use "Stop Work Authority" to pause operations. The inquiry also noted that a similar overflow event had occurred in 2019, but the refinery had failed to implement the necessary safeguards from that "near miss" to prevent a recurrence. By the time the final report was released in 2024, the refinery had been sold to Cenovus Energy (operating as Ohio Refining Company), and the CSB's recommendations focused on ensuring the new owners implemented engineered controls to prevent liquid overfill without relying solely on human intervention.

Key numbers at a glance

7

Recommendations

21

Months to complete

Cost in millions      (if known)

2

Deaths (direct)

Recommendations

Recommendation Category

Summary of Advice

Current Implementation Status

Overflow Prevention

Establish engineered controls (e.g., automated shut-offs) to prevent liquid overfill in mix drums.

Open - Acceptable Response (Cenovus/ORC is implementing new hardware).

Alarm Management

Revise the "Toledo Alarm Philosophy" to meet EEMUA 191 standards for alarm rates during upsets.

Closed - Acceptable Action (Refinery protocols updated 2025).

Stop Work Authority

Formalise and train employees on the authority to stop work during "abnormal situations."

Closed - Acceptable Action (New policy and training modules implemented).

Abnormal Situations

Update the Abnormal Situation Management (ASM) policy to include unplanned crude slate changes.

Closed - Acceptable Alternative (Procedures integrated into site safety manual).

Industry Standards

API to develop new guidance on preventing pressure vessel overflows in refineries.

Open - Awaiting Response (API reviewing technical publications as of 2026).


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