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CSB Investigation Report No. 2022-01-I-OH 2022 Safety Safety
BP-Husky Toledo Fuel Gas Mix Drum Overflow -> Boiler/Heater Fire
BP-Husky Toledo Refinery, Oregon, Ohio
Related equipment → Boiler (boiler)Related equipment → Fired heater (fired_heater)
2Fatalities
0Injuries
FireMechanism code OTH
⌗Failure Mode · ISO 14224 Mapping
Damage mechanism (recorded in KB)
FireOTH
ISO functional code (as recorded)
ISO 14224:2016 functional failure code
OTH · Other
ISO OTH — Other.
1What Happened

Fuel Gas Mix Drum high-level overflow -> naphtha entered boilers/heaters via vapor line -> fire

2Root Cause

Missing Fuel Gas Mix Drum high-level/overflow safeguards + alarm flood + inadequate abnormal-situation management (ASM)

3Reliability Lessons (from investigation root cause)
  • Missing Fuel Gas Mix Drum high-level/overflow safeguards
  • alarm flood
  • inadequate abnormal-situation management (ASM)
4Associated Failure Mechanisms (Keywords)
boiler heater fuel gas mix drum overflow high level leak tube drum
About the Failure-Mode Code (click to expand)

The recorded code OTH is an ISO 14224:2016 functional failure code (describes what the equipment failed to do). The damage mechanism (how it failed) is shown in the Mapping block above. The two are distinct dimensions in ISO 14224.

5Evidence Source (transparent)
Authority：U.S. Chemical Safety and Hazard Investigation Board (CSB)
Official Report：www.csb.gov ↗
Data Verification：verified_url_csb_report_2026-07-20
↗Related Failure Modes · Traceability
Steam Drum Internal Corrosion fmSteam Separator Failure -> Wet-steam Carryover fm_2Relief Valve Set-pressure Drift fm_3Valve Seat Leak fm_4Furnace Tube Rupture tube_ruptureInternal Fouling -> Overheating fm_5Superheater Tube Rupture fm_6High-temperature Oxidation / Creep fm_7Dew-point Corrosion Perforation fm_8Burner-tip Coking / Blockage fm_9Ignition Failure / Flameout fm_10Cavitation fm_11Mechanical Seal Leak fm_12Insufficient Deaeration -> Oxygen Corrosion fm_13Creep/Bulging creep_bulgingCarburization carburizationFurnace Tube Oxidation / Spalling oxidation_spallingInternal Coking internal_cokingHot Spot hot_spotBend Thinning bend_thinningWeld Crack weld_crackHigh-temp Failure high_temp_failureOxidation oxidationDew Point Corrosion dew_point_corrosionFin Loss/Fouling fin_loss_foulingErosion erosionBurner Tip Plugging burner_tip_pluggingFlame Impingement flame_impingementIgnition Failure / Flameout ignition_failurePilot Outage pilot_outageTC Failure tc_failureStack Corrosion stack_corrosionLining Loss lining_lossDamper Sticking damper_stickingActuator Failure actuator_failureFan Imbalance fan_imbalanceBearing Failure bearing_failureLens Fouling lens_foulingElectronics Failure electronics_failureValve Seat Leakage seat_leakageActuator Failure actuator_failure_2Refractory Spalling refractory_spallingRefractory Lining Thinning -> Shell Over-temperature (Hot Spot) hot_spot_on_shell结垢/堵塞 MECH-FOULING保温层下腐蚀 MECH-CUI热疲劳 MECH-THERMAL-FATIGUE湿硫化氢损伤 MECH-WET-H2S蠕变与应力破裂 MECH-CREEP酸性水腐蚀 MECH-SOUR-WATER锅炉水/凝结水腐蚀 MECH-BWC高温硫化氢/氢腐蚀 MECH-HT-H2S高温氧化 MECH-OXIDATION硫化腐蚀 MECH-SULFIDATION冲蚀/冲刷腐蚀 MECH-EROSION硫氢化铵腐蚀 MECH-ABS均匀/局部减薄（通用减薄） MECH-THINNING烟气露点腐蚀 MECH-DEWPOINT大气腐蚀 MECH-ATMOS
Report No. 2022-01-I-OH · Data from CSB public investigation conclusions, compiled by Reliability AI, for reliability demonstration purposes only. This case is derived from public incident investigation reports for learning purposes only. AIM does not endorse or guarantee its accuracy.