FLINT HILLS RESOURCES, LC

Incident Narrative

SUPPLEMENTAL INCLUDES PART G TO INCLUDE A NEW SUB-CASE FROM ROOT CAUSE INVESTIGATION, AND PART H UPDATED TO INCLUDE THE INVESTIGATION FINDINGS. ON JANUARY 6, 2024, FLINT HILLS RESOURCES OPERATIONS PERSONNEL NOTICED AN ODOR WHILE PERFORMING NIGHTLY ROUNDS AND SHORTLY THEREAFTER, HEARD FLOWING LIQUID. AT THAT TIME, THEY NOTIFIED THE PIPELINE CONTROL CENTER TO SHUT DOWN ALL INBOUND AND OUTBOUND PIPELINES. AT 21:23, PERSONNEL VISUALLY CONFIRMED PRODUCT BEING RELEASED FROM THE ROOF DRAIN ON TANK 28075. FLINT HILLS RESOURCES MADE NOTIFICATION TO TEXAS RAILROAD COMMISSION OFFICE OF PIPELINE SAFETY AT 22:15. REFINERY TERMINAL FIRE COMPANY WAS NOTIFIED AND ARRIVED ONSITE AT 22:00. FOAM WAS APPLIED TO THE AREA TO SUPPRESS VAPORS. ONCE AIR MONITORING READINGS INDICATED IT WAS SAFE FOR PERSONNEL TO ENTER THE AREA, THE MANUAL ROOF DRAIN VALVE WAS CLOSED AT 23:48. AFTER THE ROOF DRAIN WAS ISOLATED, FLINT HILLS RESOURCES BEGAN CLEAN-UP OF FREE LIQUID, FOLLOWED BY SOIL RECOVERY. FREE PRODUCT RECOVERY FROM THE TANK CONTAINMENT AREA WAS COMPLETE JANUARY 12. TANK DEGASSING FOR TANK INSPECTION WAS COMPLETE JANUARY 19. FHR'S INVESTIGATION REVEALED THAT THE ROOT CAUSE WAS THAT THE ROLLING LADDER TRACK WAS NOT DESIGNED TO ACCOMMODATE THE TANK'S LOW LEG SETTINGS, WHICH AT THE TIME OF THE INCIDENT WAS AT THE TANK'S LOWEST LEG SETTING SINCE THE TANK WAS LAST OUT OF SERVICE (2016/2017). THE TANK INSPECTION REPORT STATED THAT AN EXTENSION TO THE ROLLING LADDER TRACK WAS ADDED TO THE END OF THE TRACK AND A NEW STOP ANGLE IRON STOP WAS INSTALLED. HOWEVER, BASED ON THE EVENTS THAT OCCURRED ON JANUARY 6TH AND FIELD OBSERVATIONS MADE BY THE INVESTIGATION TEAM, THAT MODIFICATION TO EXTEND THE TRACK WAS NOT INSTALLED. AT LOW LEVEL, THE LADDER HAD DISENGAGED FROM THE LADDER RUNWAY. WHEN A PIPELINE RECEIPT WAS INITIATED INTO THE TANK, THE ROOF STARTED RISING AND THE LADDER DID NOT REENGAGE PROPERLY WITH THE RUNWAY. UPON FILLING THE TANK, THE BUOYANT FORCES OF THE CRUDE OIL UNDERNEATH, PUT THE LADDER UNDER STRESS AND THEN ALLOWED THE WHEELS TO SHEER FROM THE AXLE CAUSING THE LADDER TO ""JOLT"" FORWARD AND PUNCTURE THE ROOF. AS THE PRODUCT LEVEL CONTINUED TO RISE, PRODUCT FLOWED UP THROUGH THE PUNCTURE AND TO THE ROOF DRAIN. THE DRAIN HAD BEEN OPENED PRIOR TO THE TANK RECEIPT TO ACCOMMODATE RAINFALL DURING THE DAYS LEADING UP TO THE EVENT. THIS ALLOWED PRODUCT TO FLOW INTO THE TANK'S SECONDARY CONTAINMENT DIKE WHERE IT WAS FULLY CONTAINED.