OREGON, Ohio — In a final report, the U.S. Chemical Safety Board said "nearly everything that could go wrong did go wrong," in the 2022 explosion that killed two employees — brothers Ben and Max Morrissey — at the former BP-Husky oil refinery in Oregon.
The final report comes almost two years after the explosion and fire. Since then, BP Products was cited by the U.S. Department of Labor for safety violations. The refinery, which came under new ownership after the incident, partially reopened in April 2023.
The Morrissey brothers were mourned by the community after their loss and lauded for their heroic efforts that likely prevented a much worse outcome for the refinery and its employees.
The Morrissey family provided the following statement to WTOL 11 Tuesday night:
"I’m saddened that this work place incident could have been completely avoided if BP would have followed safety protocols and made sure their employees were coming into a safe work environment. We miss Ben and Max so much. My son is so curious about his daddy. And my daughter will never know who her daddy really was only from stories we share. We didn’t learn many new things from the final report. I tend to take a few steps forward then when another meeting comes up I take triple the amount of steps back but I can only speak for myself as how much relief I have knowing we don’t have to sit through another meeting.. The CSB has been very kind and informative through this process."
According to a press release issued Monday from CSB, the report described the Sept. 20, 2022, incident as a "series of cascading - and worsening - events" that occurred throughout the day.
This included "more than 3,700 alarms" going off in a period of 12 hours before the incident. CSB said BP's board operators were distracted and overwhelmed by the flood of alarms, which caused delays and errors in responding to the alarms.
CSB's full investigation report can be read below:
Additionally, the refinery never implemented a shutdown in time to prevent the explosion.
The report found the Morrissey brothers were killed when they were instructed to drain liquid naphtha from a pressurized container intended to only carry vapor. The opening of the vessel created a vapor cloud that ignited, resulting in the fire that killed both brothers.
The release also stated the report concluded the employees may have believed the liquid in the vessel was an amine-water solution, not naphtha.
Ultimately, the final report identified four "critical safety issues" that CSB said contributed to the explosion. These included liquid overflow prevention, which pertained to the overflow and release of naphtha; abnormal situation management, alarm flood and learning from incidents. The press release cited an incident relating to a non-catastrophic naphtha overflow in 2019 and described it as a "missed opportunity" to learn from the incident and improve refinery safety.
CSB said it made no recommendations to BP since the oil company no longer operates the Toledo Refinery.
In February 2023, Cenovus purchased the refinery and CSB issued seven total safety recommendations to the company, as well as to the American Petroleum Institute and the International Society of Automation.
CSB also recommended the Ohio Refining Company LLC develop a policy to provide employees with the authority to stop work they perceive to be unsafe, accompanied by appropriate training.
“Nearly everything that could go wrong did go wrong during this incident," CSB Chairperson Steve Owens said in a press release. "The tragic loss of life resulting from this fire underscores the importance of putting in place the tools that employees need to perform tasks safely, such as stop work authority, and having adequate policies, procedures, and safeguards in place to effectively manage highly stressful abnormal situations, including alarm floods.”
The Toledo Refinery explosion and fire was the largest fatal incident at a BP-operated petroleum refinery in the US since the 2005 explosion and fires at a refinery in Texas City, Texas in 2005, according to CSB.
Cenovus provided the following statement to WTOL 11 Tuesday night:
"At the time of the incident in September 2022, the refinery was operated by an affiliate of bp and we’d refer you to bp for any comment. In February 2023, Cenovus completed the acquisition of the Toledo refinery and assumed full ownership and operatorship. The safety of our people and the community remains our top priority. We took the actions necessary for a safe restart and operations, and we continue to make improvements, including implementing what we’ve learned. We are working cooperatively with regulatory agencies and are in the process of addressing all of OSHA’s recommendations and those identified by the Chemical Safety Board (CSB). Our thoughts continue to be with the Morrissey family."
WATCH MORE COVERAGE