Accident Lesson Card · Real investigation (tap external link for official report)
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CSB Investigation Report No. CSB-BPHUSKY-TOLEDO-2022 2022 Fire Fire Explosion Explosion
CSB BP-Husky Toledo 炼厂 2022 石脑油溢流至燃料气系统闪火（2 死，2024 终报）
BP-Husky Toledo Refinery, Oregon, Ohio, USA (现已转 Ohio Refining Company / Cenovus)
Related equipment type → flare system (flare system)
2Fatalities
0Injuries
OverflowMechanism code REL
⌗Failure Mode · ISO 14224 Mapping
Damage mechanism (recorded in KB)
OverflowREL
Internal damage-mechanism code (not ISO 14224)
ISO 14224:2016 functional failure code
OTH · Other
Mapped to ISO OTH — Other.
1What Happened

石脑油加氢单元工艺扰动致塔器溢流，石脑油经气相旁路灌满本只承装燃料气(气相)的压力容器并溢出至下游炉/锅炉燃料气管线；安全阀(SIS/IPL)未能阻止溢流，操作人员将液体排至地面产生蒸气云点燃，2 名操作工死亡

2Root Cause

PHA 虽识别溢流风险但 SIS/紧急泄压阀等独立保护层未能阻止液体溢流进入燃料气系统；异常工况管理(报警洪泛 3712 条/12h)失效；未有效运用停工程序

3Reliability Lessons (from investigation root cause)
  • The 'Root Cause' above is the core lesson of this accident; not split further.
4Associated Failure Mechanisms (Keywords)
火炬 燃料气系统 溢流 安全阀 SIS 放空 石脑油 flare fuel gas overflow relief vapor cloud
About the Failure-Mode Code (click to expand)

The mechanism code REL shown on this card is the KB's internal damage-mechanism abbreviation (not an ISO 14224 code); it describes how the equipment failed. The 'ISO 14224 Mapping' block above maps it to the correct ISO functional failure code (which describes what the equipment failed to do) — these are two distinct dimensions in ISO 14224. The mechanism follows the narrative in the card body.

5Evidence Source (transparent)
Authority：U.S. Chemical Safety and Hazard Investigation Board (CSB)
Official Report：www.csb.gov ↗
Data Verification：verified_url_csb_2026-08-08 (CSB BP-Husky Toledo 2022 最终调查报告页)
↗Related Failure Modes · Traceability
高温氧化 MECH-OXIDATION湿硫化氢损伤 MECH-WET-H2S安全仪表拒动 MECH-SIS-FAIL-TO-ACT蠕变与应力破裂 MECH-CREEP酸性水腐蚀 MECH-SOUR-WATER高温硫化氢/氢腐蚀 MECH-HT-H2S结垢/堵塞 MECH-FOULING热疲劳 MECH-THERMAL-FATIGUE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大气腐蚀 MECH-ATMOS机械疲劳 MECH-MECH-FATIGUE球化（软化） MECH-SPHEROIDIZATION
Report No. CSB-BPHUSKY-TOLEDO-2022 · 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.