PA EPA RELEASES ACCIDENT INVESTIGATION REPORT ON TOSCO AVON REFINERY

•Lack of management and supervisory oversight to ensure that emergency procedures were followed;
•Management unawareness and tolerance of other safety hazards and risky operator practices;
•Poor consideration of human factors in the design and operation of the temperature monitoring and control system which did not allow operators to make critical decisions quickly;
•Operating with unreliable or malfunctioning equipment which created operating hazards and increased risk;
•Outdated and incomplete procedures, training materials and a process hazard analysis that did not reflect actual process and operating conditions.