On the 20th of September, 2022 at the BP Husky Toledo refinery in Ohio, a level transmitter change out from a month prior triggered a chain of events that would cost two operators their lives. We look at how poor Management of Change, high alarm rates and a resistance to stopping the job, let a plant upset turn into a disaster.With John Chidgey.Formal Report: U.S. Chemical Safety Board Issues Final Report into Fatal 2022 Fire at BP-Husky Refinery Fatal Naphtha Release and Fire at BP-Husky Toledo Refinery (PDF) CSB June 2023 Investigation Update (PDF) CSB Comments on the OSHA September 20, 2022, Federal Register Notice (PDF) News Releases and Articles: BP Faces $156K OSHA Fine in Refinery Explosion BP accused of serious violations after fatal blast at US refinery General Information: Naphtha What You Need to Know About California’s PSM Regulation for Refinery Safety OSHA Penalties Support Causality on PatreonEpisode Gold Producers: 'r', Steven Bridle and Kellen Frodelius-Fujimoto.Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring and Ian Gallagher.