A federal investigation into two workers’ fatal burns at an Oregon, Ohio, refinery’s crude unit found its operator, BP Products North America Inc., violated the U.S. Department of Labor’s process safety procedures for highly hazardous materials and failed to adequately train the workers.

On the day of the incident in September 2022, as the workers attempted to correct rising liquid levels in the fuel gas mix drum, a flammable vapor cloud formed, ignited and then triggered an explosion, causing the deadly burns.

Inspectors with the department’s Occupational Safety and Health Administration identified the training deficiencies and failure by BP Products North America to meet OSHA’s process safety management procedures. They also determined naphtha, a flammable liquid hydrocarbon mixture, was released when flow control valves were opened in an attempt to regulate an overfill occurring in upstream process equipment. The opened valve allowed the flammable liquid to enter the refinery’s fuel gas system.

OSHA cited BP Products for failing to implement shutdown procedures for the equipment when requested by the operators responding to the naphtha release and for not clearly defining conditions for emergency shutdown of the crude tower. OSHA proposed $156,250 in penalties, an amount set by federal statutes, and cited the company for 10 serious violations and one other-than-serious violation of process safety management procedures.