A sobering read this morning as I finished a detailed final draft investigative report into the fire at the Martinez refinery in California, USA (February 2025).
The findings were damning — pointing to multiple root causes, including:
❌ Flawed work processes and procedures
❌ Gaps in training and competency (human factors)
❌ Inadequate supervision and oversight
Most troubling was that contractor personnel mistakenly loosened bolts on a live flange containing hydrocarbons resulting in loss of process containment and fire. That single act could have resulted in catastrophic consequences — loss of life, severe injury, and widespread environmental harm.
This wasn’t just a near miss. It was a loud reminder that, even in 2025, loss of primary containment continues to occur at hazardous process sites due to preventable failures in basic systems of work – and its a global industry concern. Let’s not pretend this is unique to the USA. Similar accidents occur across the UK, and often for the same reasons.
It’s time to sharpen worksite protocols, prioritise field-level competency and strengthen supervisory accountability.
If you’re working to address systemic gaps or improve training frameworks, I’d love to connect; chrism@zulujointintegrity.co.uk +44 (0)1656 523273
