BP Texas City Explosion
Resumen
TLDRThe BP Texas City refinery explosion on March 23, 2005, was one of the most devastating industrial accidents in the United States, causing 15 fatalities and injuring 180 people. The accident exposed critical safety violations and systemic failures within BP's safety culture and process management. The Chemical Safety Board (CSB) conducted a thorough investigation revealing chronic safety deficiencies, ignored warnings, and relentless cost-cutting that compromised safety standards. BP management had repeatedly undervalued safety protocols and inadequately maintained safety systems. Human error, inadequate training, and failed safety equipment further exacerbated the situation. The tragedy led to significant financial repercussions for BP and urged industry-wide calls for reforms in safety oversight. The CSB's recommendations stress the importance of robust process safety management, better safety indicators, and organizational learning to prevent future disasters.
Para llevar
- 💥 The BP Texas City explosion was one of the worst industrial accidents in recent US history.
- 📉 BP's focus on cost-cutting severely impacted safety standards.
- 🚫 Multiple safety warnings were ignored, leading to the catastrophic accident.
- 👥 Organizational culture at BP overlooked process safety for personal safety targets.
- 🔧 Major deficiencies were found in safety systems, maintenance, and training.
- 📊 Effective process safety indicators are crucial for preventing future incidents.
- 🛑 CSB stressed the significance of understanding safety deficiencies and making systemic changes.
- 🚨 Human error, exacerbated by inadequate training and failed safety equipment, played a major role in the explosion.
- 🗣️ A safety culture where issues can be openly discussed without fear of reprisal is essential.
- 🏗️ BP committed to fixing the highlighted issues and adopting industry-leading safety practices after the accident.
Cronología
- 00:00:00 - 00:05:00
A catastrophic explosion at BP's Texas City refinery on March 23, 2005, resulted in 15 deaths and 180 injuries. The explosion's epicenter was the Ison unit, highlighting systemic safety failures within BP. The Chemical Safety Board (CSB) undertook an extensive investigation, uncovering overlooked warning signs and shortcomings in safety management. BP's management had long ignored potential hazards, prioritizing cost savings over comprehensive safety investment, thus allowing risks to accumulate.
- 00:05:00 - 00:10:00
BP's cost-cutting measures played a significant role in safety oversights, fueling a culture that disregarded warning signs and prioritized production. Despite numerous reports and internal audits indicating deteriorating safety conditions and infrastructure, BP's focus remained on maintaining profit margins. Leadership turnover and organizational neglect further compounded the refinery's systemic vulnerabilities, creating a disconnect between safety concerns and executive actions.
- 00:10:00 - 00:15:00
The explosion at BP was a culmination of human errors and systemic safety failures. Overfilled towers and failed alarms pointed to both procedural and equipment inadequacies. Human factors such as employee fatigue, communication breakdown, and inadequate training exacerbated the incident. A culture of acceptance towards deviating from safety procedures without rectification highlighted a systemic failure to enforce and comply with safety protocols.
- 00:15:00 - 00:20:00
The organizational structure and safety culture at BP contributed significantly to the disaster. A focus on personal injury rates overshadowed process safety indicators, resulting in critical safety lapses. BP's decentralized structure led to misalignment in safety protocols, impairing the organization's ability to effectively manage hazards. Consequently, mergers and budget decisions further stripped the organization of essential safety oversight capabilities.
- 00:20:00 - 00:25:00
BP failed to learn from previous incidents due to a poor safety culture and ineffective corporate infrastructure. Lessons from significant accidents, like those at other facilities, were ignored. Financial and production pressures overshadowed safety concerns, and events that should have served as warnings were dismissed due to organizational and management governance issues. This oversight resulted in continued vulnerabilities leading up to the Texas City explosion.
- 00:25:00 - 00:30:00
BP negligently maintained outdated equipment, like the blowdown drums at Texas City, despite prior warnings and potential danger. Their refusal to upgrade to safer systems such as flares exacerbated the incident's impact, as did placement of trailers near hazardous areas. Equipment compliance and adaptation to modern safety standards were repeatedly compromised by financial considerations and lack of urgent response to known safety risks.
- 00:30:00 - 00:35:00
The CSB concluded that BP's focus on cost-saving over safety investments precipitated the catastrophic event. Numerous internal warnings about safety deficiencies and equipment conditions were disregarded, influenced by a culture that emphasized budget compliance over safety enhancements. Noncompliance with safety protocols and inadequate maintenance led to systemic failings that critically impaired operational safety at Texas City.
- 00:35:00 - 00:40:00
The chemical industry, including BP, has long been challenged by accidents stemming from insufficient safety protocols and failure to implement recommendations post-incident. At Texas City, there were significant lapses in implementing and updating effective safety measures, a trend noted across BP's operations. BP's practices highlighted the need for greater industry-wide reform and adherence to stringent safety standards to prevent similar disasters.
- 00:40:00 - 00:45:00
Human error, influenced by inadequate training, fatigue, and lack of communication, played a critical role in the explosion. Organizational practices failed to provide the tools and oversight necessary to prevent deviations from safety. Communication lapses, such as unclear and incomplete shift briefings, contributed to confusion, while a lack of appropriate supervision and training compounded operational errors during crucial startup procedures.
- 00:45:00 - 00:55:42
Post-accident, BP worked with the CSB to address its failings, moving to update safety standards and infrastructure. This included relocating trailers, removing outdated blowdown drums, and investing in safety upgrades. The BP tragedy emphasized lessons on industrial safety, focusing on identifying and fixing underlying safety issues, refining safety culture, and ensuring adherence to and improvement of industry standards.
Mapa mental
Preguntas frecuentes
When did the BP Texas City explosion occur?
The explosion happened on March 23, 2005.
How many workers were killed and injured in the explosion?
15 workers were killed and 180 others were injured.
What was the primary cause of the explosion at the BP refinery?
The explosion was due to organizational and safety deficiencies at BP, including ignoring warning signs and inadequate safety systems.
What facility was involved in the BP explosion?
The explosion occurred at the isomerisation unit at BP's Texas City refinery.
What were the financial repercussions for BP following the explosion?
BP paid billions in victim compensation, property damage, and lost production costs.
What safety oversight existed prior to the explosion?
There were multiple unaddressed safety warnings, cost-cutting measures without safety assessments, and a culture of inadequate process safety management.
How did BP respond after the accident?
BP relocated trailers, eliminated blowdown drums, invested billions to upgrade refineries, and accepted recommendations to improve process safety management.
What was the result of the Chemical Safety Board's investigation?
The investigation found BP had a history of safety warnings being ignored, inadequate investment in safety, and a culture of focusing more on personal than process safety.
What recommendation did the CSB make to improve future safety standards at refineries?
The CSB recommended implementing effective process safety indicators and improving management systems to prevent similar tragedies.
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- 00:00:28at 1:20 p.m. on March 23rd 2005 a
- 00:00:32massive explosion and fire erupted at
- 00:00:35the BP refinery in Texas City Texas the
- 00:00:39explosion killed 15 workers and injured
- 00:00:41180 others many of them seriously the
- 00:00:45blast occurred at the isomerisation or
- 00:00:47Ison unit which produces materials to
- 00:00:50boost the octane rating of gasoline the
- 00:00:53explosion shattered windows in homes and
- 00:00:55businesses up to three-quarters of a
- 00:00:56mile away from the 1200 acre refinery as
- 00:01:00thick black smoke billowed from the
- 00:01:02plant authorities instructed some 43,000
- 00:01:05Texas City residents to stay indoors the
- 00:01:08accident cost BP billions of dollars in
- 00:01:11victim's compensation property damage
- 00:01:13and lost production this investigation
- 00:01:16was the largest and most comprehensive
- 00:01:18investigation in the history of the
- 00:01:20Chemical Safety Board CSB Supervisory
- 00:01:23investigator Don Holmstrom led a
- 00:01:25two-year investigation to determine the
- 00:01:27root causes of the accident we
- 00:01:29interviewed over 370 witnesses we looked
- 00:01:32at thousands of documents literally
- 00:01:34millions of pages of documents and we
- 00:01:37examined the plant inspected over 40
- 00:01:41pieces of instrumentation and equipment
- 00:01:43the investigation team examined a wide
- 00:01:46range of safety systems practices and
- 00:01:48standards and looked at human factors
- 00:01:52such as fatigue and communication
- 00:01:54between operators the board's report was
- 00:01:59released at a public meeting in Texas
- 00:02:00City on March 20th 2007 then CSB
- 00:02:04chairman carolyn merritt presided many
- 00:02:07of you here tonight had family members
- 00:02:10or co-workers who were victims of this
- 00:02:12explosion to all of you i express my
- 00:02:16deepest condolences and sincere wishes
- 00:02:20that society never allows another
- 00:02:22accident like this to occur the tragedy
- 00:02:26at BP was the worst industrial accident
- 00:02:28in the United States in nearly 15 years
- 00:02:30the CSB concluded that it was the result
- 00:02:33of organizational and safety
- 00:02:35deficiencies at all levels of the
- 00:02:36company we found that BP management had
- 00:02:39for many years overlooked warning signs
- 00:02:41of a
- 00:02:42possible catastrophic accident there's
- 00:02:44an old saying that who think safety is
- 00:02:47expensive trial accident accidents cost
- 00:02:50a lot of money and they're not only in
- 00:02:53damage to plant and in claims for injury
- 00:02:56but also in the loss of the company's
- 00:02:58reputation the reason why the Texas City
- 00:03:03accident has such an impact is because
- 00:03:05when people look at it they can see that
- 00:03:07they are all in the same boat that they
- 00:03:09the problems which led to that accident
- 00:03:12are likely to be present at other sites
- 00:03:16around the world my fear is as some of
- 00:03:19the end some of the other refineries
- 00:03:20within the United States will feel that
- 00:03:23couldn't happen to me and the ones that
- 00:03:26feel that that couldn't happen at their
- 00:03:28side is the ones that are set up to have
- 00:03:30it happen there the following CSB
- 00:03:35computer animation depicts the sequence
- 00:03:37of events over an 11 hour period leading
- 00:03:41to the explosion at the BP Texas City
- 00:03:43refinery on March 23rd 2005 several
- 00:03:49units at the Texas City refinery had
- 00:03:51been shut down for lengthy maintenance
- 00:03:52projects which required nearly a
- 00:03:54thousand contractors to be on site along
- 00:03:57with BP employees BP had positioned a
- 00:04:01number of portable trailers close to
- 00:04:03process units for the use of contractors
- 00:04:06and other maintenance workers over a
- 00:04:08period of months BP had located ten
- 00:04:11trailers for workers servicing the ultra
- 00:04:14cracker unit including a double-wide
- 00:04:16wood-frame trailer that contained 11
- 00:04:18offices and was regularly used for
- 00:04:21meetings though these trailers were
- 00:04:25located near the isomerisation unit the
- 00:04:28occupants were not warned the I saw muna
- 00:04:30twas about to start up a potentially
- 00:04:33hazardous operation at 2:15 a.m. on
- 00:04:38March 23rd overnight operators began
- 00:04:41introducing flammable liquid
- 00:04:43hydrocarbons known as raffinate into a
- 00:04:46170-foot tall raffinate splitter tower
- 00:04:48used to distill and separate gasoline
- 00:04:51components near the base of the tower
- 00:04:54there was a
- 00:04:54single instrument that measured how much
- 00:04:56liquid was inside heat transmitted this
- 00:05:00information to a central control room
- 00:05:02located away from the I sama unit but
- 00:05:05this level indicator was not designed to
- 00:05:07measure liquid above the 9 foot mark
- 00:05:09during normal operation the tower was
- 00:05:12only supposed to contain about six and a
- 00:05:13half feet of liquid but during startups
- 00:05:16operators routinely deviated from
- 00:05:18written procedures and filled the tower
- 00:05:20above the 9 foot mark
- 00:05:22concerned that if the liquid levels
- 00:05:23fluctuated too low it would cause costly
- 00:05:26damage to the furnace at 3:09 a.m. as
- 00:05:29the liquid neared the 8 foot mark a high
- 00:05:32level alarm activated and sounded in the
- 00:05:35control room but a second high level
- 00:05:37alarm slightly further up the tower
- 00:05:39failed to go off by 3:30 a.m. the level
- 00:05:45indicator showed that liquid had filled
- 00:05:47the bottom 9 feet of the tower and the
- 00:05:50feed was stopped the CSB later estimated
- 00:05:54that the liquid was in fact at a height
- 00:05:56of 13 feet but operators could not know
- 00:05:59the actual level because the indicator
- 00:06:01only measured up to 9 feet the lead
- 00:06:06operator had been overseeing the startup
- 00:06:07from a satellite control room within the
- 00:06:09ice arm unit at 5 a.m. he briefly
- 00:06:14updated the night board operator in the
- 00:06:16central control room about the startup
- 00:06:18activities the lead operator then left
- 00:06:21the refinery early an hour before the
- 00:06:24end of the shift a new board operator
- 00:06:26arrived in the control room around 6
- 00:06:29a.m. to start his thirtieth day in a row
- 00:06:32working a 12-hour shift
- 00:06:34he spoke briefly with the departing
- 00:06:36nightshift operator and then read the
- 00:06:38logbook to prepare for the startup but
- 00:06:43the log book did not clearly indicate
- 00:06:45how much liquid was already in the tower
- 00:06:47and equipment and it left no
- 00:06:49instructions on routing of the liquid
- 00:06:51feed and products when the startup
- 00:06:53resumed instead the control board
- 00:06:55operator only found a one-line logbook
- 00:06:58entry that said I some brought in some
- 00:07:01RAF 2 unit 2 pack raffle
- 00:07:04at 7:15 a.m. the day shift supervisor
- 00:07:08arrived because he was more than an hour
- 00:07:10late he received no formal briefing from
- 00:07:13personnel on the night shift about
- 00:07:15conditions in the ice armed unit at 951
- 00:07:18a.m. operators resumed the start up they
- 00:07:21began recirculating the liquid feed and
- 00:07:23adding more liquid to the already
- 00:07:25overfilled tower as new feed was added
- 00:07:28startup procedures called for regulating
- 00:07:31the liquid level in the tower using the
- 00:07:33automatic level control valve but the
- 00:07:37board operator and others had received
- 00:07:39conflicting instructions on routing the
- 00:07:41product as a result this critical valve
- 00:07:44was left closed for several hours
- 00:07:46blocking the flow of liquid from the
- 00:07:48tower a few minutes later operators lit
- 00:07:55burners on the furnace to begin heating
- 00:07:57up the feed part of the normal startup
- 00:07:59process while the startup was underway
- 00:08:02the day supervisor left the refinery on
- 00:08:05short notice just before 11:00 a.m. to
- 00:08:08attend to a family medical emergency
- 00:08:10contrary to bp's own procedures no
- 00:08:13experienced supervisor was assigned to
- 00:08:16replace him this left a single control
- 00:08:19board operator now without a qualified
- 00:08:21supervisor to run three refinery units
- 00:08:24including the Ison unit which needed
- 00:08:26close attention the refinery had
- 00:08:29eliminated a second board operator
- 00:08:31position following corporate budget cuts
- 00:08:33in 1999 after BP acquired amico as the
- 00:08:38startup continued the towers steadily
- 00:08:40filled with liquid reaching a height of
- 00:08:4298 feet shortly before noon more than 15
- 00:08:46times the normal level but the
- 00:08:50improperly calibrated level indicator
- 00:08:52told operators in the control room that
- 00:08:55the liquid was at 8.4 feet and gradually
- 00:08:58falling furthermore the control panel
- 00:09:01was not configured to clearly warn
- 00:09:03operators of the growing danger it did
- 00:09:05not display flows into and out of the
- 00:09:07tower on the same screen nor did it
- 00:09:10calculate the total liquid in the tower
- 00:09:13meanwhile the maintenance contractors
- 00:09:16who were not involved in the operation
- 00:09:17of the I sound unit left their work
- 00:09:19trailers to attend a company lunch
- 00:09:21celebrating a month without a lost time
- 00:09:24injury at 12:41 p.m. an alarm activated
- 00:09:29as the rising liquid compressed the
- 00:09:30gases remaining in the top of the tower
- 00:09:33unable to understand the source of the
- 00:09:35high-pressure operators opened a manual
- 00:09:38chain valve to vent gases to the units
- 00:09:40emergency relief system a 1950s era
- 00:09:43blowdown drum that vented vapor directly
- 00:09:46into the atmosphere operators also
- 00:09:48turned off to burners in the furnace to
- 00:09:51lower the temperature inside the tower
- 00:09:52believing this would reduce the pressure
- 00:09:55nobody knew the tower was dangerously
- 00:09:58full the operators did become concerned
- 00:10:02about the lack of flow out of the tower
- 00:10:04and began opening the valve to send
- 00:10:06liquid from the bottom of the tower to
- 00:10:08storage tanks but this liquid was very
- 00:10:10hot as it flowed through the heat
- 00:10:12exchanger it suddenly raised the
- 00:10:14temperature of the liquid entering high
- 00:10:16up the tower by 141 degrees Fahrenheit
- 00:10:19it was now about 1 p.m.
- 00:10:23contract workers unaware of the startup
- 00:10:25and the looming danger returned from
- 00:10:28lunch and began a meeting in the
- 00:10:30double-wide trailer in the corner room
- 00:10:32closest to the blowdown drum over the
- 00:10:36next few minutes the hot feed entering
- 00:10:39the tower caused the liquid inside to
- 00:10:41start to boil and swell liquid filled
- 00:10:44the tower completely and began spilling
- 00:10:46into the overhead vapor line exerting
- 00:10:49great pressure on the emergency relief
- 00:10:51valves 150 feet below at 1:14 p.m. the
- 00:10:56three emergency valves opened sending
- 00:10:58nearly 52,000 gallons of flammable
- 00:11:01liquid to the blowdown drum at the other
- 00:11:03end of the I psalm unit liquid rose
- 00:11:05inside the blowdown drum and overflowed
- 00:11:08into a processed sewer setting off
- 00:11:11alarms in the control room but the high
- 00:11:13level alarm on the blowdown drum failed
- 00:11:15to go off none of the operators knew of
- 00:11:19the catastrophe unfolding in the I psalm
- 00:11:22unit
- 00:11:23as flammable hydrocarbons overfilled the
- 00:11:26blowdown drum operators nearby saw a
- 00:11:28geyser of liquid and vapor erupt from
- 00:11:31the top of the stack the equivalent of
- 00:11:33nearly a tanker truck full of hot
- 00:11:35gasoline fell to the ground and began
- 00:11:38forming a huge flammable vapor cloud
- 00:11:42this scene based on CSV computer
- 00:11:45modeling shows how the vapor cloud
- 00:11:47expanded in just 90 seconds engulfing
- 00:11:51the unit and the nearby trailer is full
- 00:11:52of workers about 25 feet from the base
- 00:11:57of the blowdown drum two workers were
- 00:11:59parked in a pickup truck with the engine
- 00:12:01idling as flammable vapor entered the
- 00:12:03air intake the diesel engine began to
- 00:12:05race the two workers fled unable to shut
- 00:12:09off the engine
- 00:12:10moments later witnesses saw the truck
- 00:12:13backfire and ignite the vapor cloud
- 00:12:16powerful explosions swept through the
- 00:12:19area computer modeling shows how the
- 00:12:22blast pressure wave accelerated through
- 00:12:24the ison unit causing heavy destruction
- 00:12:27and igniting fires throughout the area
- 00:12:30the workers inside the trailers were
- 00:12:32right in the path of the explosions the
- 00:12:35fires continued to burn for hours 12 of
- 00:12:42the 20 occupants of the double-wide
- 00:12:44trailer were killed along with three
- 00:12:46workers in a trailer nearby dozens of
- 00:12:49others suffered serious burns fractures
- 00:12:52and other chromatic injuries the wood
- 00:12:54and metal frame trailers were blown
- 00:12:56apart by the blasts firefighters
- 00:12:59struggled to rescue the injured and
- 00:13:00recover the victims 50 large chemical
- 00:13:03storage tanks were damaged and the ison
- 00:13:06unit remained shut down for more than
- 00:13:08two years
- 00:13:15during the early stages of our
- 00:13:17investigation our team had noted there
- 00:13:21were multiple safety system deficiencies
- 00:13:23at the Texas City plant
- 00:13:25we also found there was a history of
- 00:13:27fatalities of the plant prior to the
- 00:13:30March 2005 accident 23 people died in
- 00:13:33accidents over a 30-year period at the
- 00:13:36Texas City refinery beginning when it
- 00:13:39was owned by amico and continuing after
- 00:13:41BP acquired the refinery in 1999 the CSB
- 00:13:47wanted to know what the connection was
- 00:13:48between this history of fatal incidents
- 00:13:51and the organizational and cultural
- 00:13:55factors BP corporation's lack of focus
- 00:13:59on preventing major accidents allowed
- 00:14:01budget cuts to be made without assessing
- 00:14:03the impact on process safety the CSB
- 00:14:06found that cost cutting production
- 00:14:08pressures and failure to invest
- 00:14:11significantly impacted the process
- 00:14:14safety performance at the Texas City
- 00:14:16refinery and left the refinery
- 00:14:18vulnerable to catastrophe after the
- 00:14:21merger with amico BP ordered a 25%
- 00:14:24reduction in fixed costs at all the true
- 00:14:27fineries this impacted important process
- 00:14:31safety systems such as staffing training
- 00:14:35and mechanical integrity
- 00:14:42the effects of the budget cuts became
- 00:14:44apparent in a number of internal BP
- 00:14:47documents made public following the
- 00:14:49accident
- 00:14:52in one the refinery manager was quoted
- 00:14:54as having observed in 2002 that the
- 00:14:58infrastructure at Texas City was in
- 00:15:00complete decline he ordered a study of
- 00:15:02the refinery safety and mechanical
- 00:15:04integrity a study which was shown to BP
- 00:15:06executives in London that study warned
- 00:15:09of serious concerns about the potential
- 00:15:12for a major site incident following more
- 00:15:14than 80 hydrocarbon releases in the
- 00:15:17previous two years the study also
- 00:15:19concluded that its own findings were
- 00:15:21urgent and far-reaching a follow-up BP
- 00:15:25study in 2002 found the refineries
- 00:15:28integrity and reliability issues were
- 00:15:31clearly linked to the reduction in
- 00:15:32maintenance spend over the last decade
- 00:15:34in 2003 a maintenance assessment stated
- 00:15:38that cost-cutting measures have
- 00:15:39intervened with the group's work to get
- 00:15:41things right
- 00:15:43usually reliability improvements are cut
- 00:15:46and later that year a company audit
- 00:15:50found the current condition of the
- 00:15:51infrastructure and assets is poor at
- 00:15:53Texas City and that maintenance spending
- 00:15:56was limited by a checkbook mentality
- 00:15:59only the money on hand would be spent
- 00:16:02rather than increasing the budget in
- 00:16:05March 2004 BP auditors in London
- 00:16:08concluded that 35 business units around
- 00:16:10the world including the Texas City
- 00:16:13refinery suffered from a host of common
- 00:16:15safety problems including widespread
- 00:16:18tolerance of non-compliance with basic
- 00:16:21HSE or health safety and environmental
- 00:16:23rules poor implementation of safety
- 00:16:26management systems and lack of
- 00:16:29leadership competence and understanding
- 00:16:32there were a number of reports that were
- 00:16:34coming up to as high as the board level
- 00:16:38that indicated serious problems
- 00:16:40throughout the BP system during 2004 the
- 00:16:45Texas City refinery had three major
- 00:16:47accidents in addition to this process
- 00:16:50unit fire that caused 30 million dollars
- 00:16:52in damage to other accidents in 2004
- 00:16:55resulted in three fatalities yet this
- 00:16:58same year the refinery had its lowest
- 00:17:00ever recorded injury rate a statistic
- 00:17:03that does not include fatalities the CSB
- 00:17:08found that maintenance spending
- 00:17:10increased between 2003 and 2004 but most
- 00:17:14of the increases were for responding to
- 00:17:16serious accidents and complying with
- 00:17:18environmental requirements not for
- 00:17:21preventive maintenance late in 2004 the
- 00:17:25Texas City refinery manager made a
- 00:17:27presentation to supervisors titled
- 00:17:30safety reality reviewing fatalities at
- 00:17:33the plant over the past 30 years
- 00:17:39one of the slides was entitled Texas
- 00:17:42City is not a safe place to work
- 00:17:44BP did its own safety culture survey
- 00:17:47that was done just prior to the accident
- 00:17:50that survey indicated there was an
- 00:17:53exceptional degree of fear among
- 00:17:54employees of a major catastrophe among
- 00:17:59the findings of the survey the pressure
- 00:18:01for production time pressure and
- 00:18:03understaffing are the major causes of
- 00:18:05accidents at Texas City critical events
- 00:18:08like failures or breakdowns are
- 00:18:10generally not attended to production and
- 00:18:14budget compliance gets recognized and
- 00:18:16rewarded above anything else sociology
- 00:18:20professor dr. Andrew Hopkins has written
- 00:18:22extensively on the causes of industrial
- 00:18:24disasters my feeling is that the
- 00:18:28solution to this problem of cost-cutting
- 00:18:30by senior people is to hold them
- 00:18:33responsible for the safety implications
- 00:18:36of those cost cuts so that when they
- 00:18:38order a cost cut they should personally
- 00:18:41be able to certify that these things
- 00:18:43will not have adverse safety
- 00:18:45consequences the safety culture survey
- 00:18:47also pointed to the exceptionally high
- 00:18:49executive turnover at the refinery six
- 00:18:52different business unit leaders or bu
- 00:18:54ELLs in seven years prior to the
- 00:18:57accident the authors of the survey
- 00:18:59report concluded we have never seen an
- 00:19:02organization with such a history of
- 00:19:03leadership changes over such a short
- 00:19:05period of time many managers are in and
- 00:19:09out within a space of two years and what
- 00:19:12they are assessed on the basis of is the
- 00:19:14the profit they making on an annual
- 00:19:16basis now omi as a manager am I going to
- 00:19:20spend a large amount of money to deal
- 00:19:23with some remote risk that is very
- 00:19:26unlikely to generate a major axon during
- 00:19:28my year or two on on my watch here the
- 00:19:32survey of texas city employees also
- 00:19:35found concern about safety and equipment
- 00:19:37checks potentially left undone there was
- 00:19:40a check the Box mentality which
- 00:19:42indicated that personnel would go
- 00:19:44through the motions with various
- 00:19:45policies and procedures but the work
- 00:19:48would not be conducted for example the
- 00:19:51tower high level alarm had
- 00:19:53reported as not functioning several
- 00:19:54times in the two years prior to the
- 00:19:56accident
- 00:19:58but maintenance work orders for this
- 00:20:00alarm were closed
- 00:20:01although the repairs were never actually
- 00:20:03made work orders could be closed out as
- 00:20:07completed even though the work hadn't
- 00:20:09been performed this is important because
- 00:20:12we found that on the day of the incident
- 00:20:15during the ice on startup there were a
- 00:20:17number of instruments and equipment that
- 00:20:20we're not functioning properly on
- 00:20:22February 20th 2005 a company's safety
- 00:20:26manager wrote I truly believe we are on
- 00:20:29the verge of something bigger happening
- 00:20:31then three weeks later a BP business
- 00:20:34plan recognized a number of key safety
- 00:20:36risks including that TCS or Texas City
- 00:20:40site kills someone in the next 12 to 18
- 00:20:44months
- 00:20:45eight days later those fears were
- 00:20:48realized
- 00:20:50here were these warnings these audits
- 00:20:52were we were sounding very clear
- 00:20:55warnings so why weren't they attended to
- 00:20:58I think my feeling is that Texas City
- 00:21:02was virtually paralyzed by the
- 00:21:05cost-cutting which had occurred at that
- 00:21:07side and they was simply unable to
- 00:21:10respond to those warnings there needs to
- 00:21:13be somebody on the board of directors
- 00:21:15who can interpret those who ports and be
- 00:21:16in position to drive change effectively
- 00:21:19the CS B's final report recommended that
- 00:21:23BP appoints an additional non-executive
- 00:21:25member of the Board of Directors
- 00:21:27with specific expertise in refinery
- 00:21:29operations and Process Safety so the
- 00:21:37problem that takes a city was that they
- 00:21:39were essentially blind to this issue of
- 00:21:42Process Safety they were focusing on
- 00:21:45personal safety the CSB concluded that
- 00:21:49over a period of years BP managers
- 00:21:51focused on lowering rates for personal
- 00:21:53injuries such as slips trips and falls
- 00:21:56while often disregarding key process
- 00:21:59safety indicators we as members of the
- 00:22:02traveling public intuitively understand
- 00:22:05that the numbers of baggage handling
- 00:22:07injuries really tells us nothing about
- 00:22:09the likelihood of a major accident an
- 00:22:11aircraft crash and no airline in its
- 00:22:13right mind is going to try and convince
- 00:22:15the traveling public of our safe it is
- 00:22:17by telling you about its workforce
- 00:22:19injury statistics dr. Trevor clutch is
- 00:22:22an internationally recognized chemical
- 00:22:24process safety expert plus their safety
- 00:22:27deals with the fires and explosions and
- 00:22:30toxic releases and things like that and
- 00:22:32you can have a very good accident rate
- 00:22:36for what we call hardhats accidents but
- 00:22:40not for processed ones there are a whole
- 00:22:43series of incidents occurring at BP in
- 00:22:45the years part of the accident gas
- 00:22:47releases other kinds of releases fires
- 00:22:51all of which were telling you that
- 00:22:54process safety was not well-managed do
- 00:22:56you need to measure Process Safety
- 00:22:59performance with the appropriate
- 00:23:00indicators both leading and lagging
- 00:23:03indicators lagging indicators measure
- 00:23:05events that have already occurred such
- 00:23:08as fires explosions and equipment
- 00:23:10failures leading indicators are designed
- 00:23:13to predict the likelihood of an accident
- 00:23:15before it occurs for example the
- 00:23:18percentage of equipment inspections that
- 00:23:20are overdue
- 00:23:20the opening of a safety release pressure
- 00:23:23relief valve is itself an indicator that
- 00:23:26things are not as they should be so we
- 00:23:29should count those and try and reduce
- 00:23:31the number of occurrences of those sorts
- 00:23:33of events but the investigation found
- 00:23:35that BP did not effectively use leading
- 00:23:37and lagging indicators to measure and
- 00:23:40drive process safety performance for
- 00:23:42example bp's pay plan rewarded managers
- 00:23:45primarily for controlling costs the only
- 00:23:48safety metric used to calculate bonuses
- 00:23:50was the personal injury rate process
- 00:23:52safety was not considered a CSB final
- 00:23:55report recommended that the United
- 00:23:57Steelworkers union and the American
- 00:23:59Petroleum Institute create a new
- 00:24:01standard for process safety indicators
- 00:24:03for the petrochemical industry the board
- 00:24:05also called on BP to use leading and
- 00:24:08lagging indicators to strengthen
- 00:24:09refinery safety performance
- 00:24:15Oxford accent managers often say I
- 00:24:18didn't know this was happening or not
- 00:24:21happening the case maybe if I know and I
- 00:24:24just stopped it now this is bad
- 00:24:26management is the manager's job to know
- 00:24:28what is going on and he can do that by
- 00:24:31going round and by keeping his eyes open
- 00:24:34and and reading the accident reports in
- 00:24:37detail the CSB investigation noted that
- 00:24:41BP ignored numerous warnings of the
- 00:24:43potential for a catastrophic accident a
- 00:24:45result of not having an effective
- 00:24:47reporting and learning culture Glenn
- 00:24:50Irwin is a safety official with the
- 00:24:52United Steelworkers and was a member of
- 00:24:54the independent panel that examined BP
- 00:24:56safety culture I believe it's very
- 00:24:59important that we do have an open and a
- 00:25:01trusting environment to where people can
- 00:25:03raise concerns and they can tell
- 00:25:05management if they see a condition or
- 00:25:07they or something that is out of the
- 00:25:09ordinary
- 00:25:10bp's own internal audits however
- 00:25:13indicated a trusting environment was
- 00:25:15lacking in 2005 the texas city
- 00:25:18maintenance manager said in an e-mail
- 00:25:20that the refinery has a ways to go to
- 00:25:22becoming a learning culture and away
- 00:25:24from a punitive culture it was a
- 00:25:28long-standing problem in 2000 the BP
- 00:25:31refinery in Grangemouth scotland had
- 00:25:33three serious incidents including a
- 00:25:36large process unit fire an investigation
- 00:25:38by the British Health and Safety
- 00:25:39Executive highlighted problems at the
- 00:25:41Grangemouth refinery that would show up
- 00:25:43again five years later in Texas City
- 00:25:46there was need for corporate and board
- 00:25:49oversight over process safety management
- 00:25:52there was a need to develop leading and
- 00:25:55lagging indicators for process safety
- 00:25:56and there needed to be an emphasis on
- 00:25:59process safety in order to prevent major
- 00:26:01accidents but the CSB he found little
- 00:26:04awareness in Texas City of the lessons
- 00:26:06BP executives promised would be learned
- 00:26:08worldwide after Grangemouth as British
- 00:26:11regulators concluded
- 00:26:12bp's decentralized management structure
- 00:26:15impaired learning from previous
- 00:26:17incidents and the reason why BP failed
- 00:26:20to learn these lessons from other events
- 00:26:21the reason why they seemed to have this
- 00:26:24what I would call learning disability
- 00:26:26lies in
- 00:26:28the way in which the organization was
- 00:26:30designed it lies in the bonus systems of
- 00:26:33payment it lies in the decentralized
- 00:26:36structure of the organization it lies in
- 00:26:38the the organizational location of
- 00:26:41Process Safety experts the CSB found
- 00:26:44that following the 1999 merger with
- 00:26:47amico BP dismantled a MCOs existing
- 00:26:50centralized safety structure the
- 00:26:52reorganization left a diminished Process
- 00:26:55Safety function that no longer reported
- 00:26:57to senior refinery leadership
- 00:27:00so I think the lesson one of the lessons
- 00:27:02coming out of that is that if an
- 00:27:05organization judge is something
- 00:27:06important
- 00:27:07it will locate people at towards the top
- 00:27:10of the apex in that organization people
- 00:27:13with responsibility for that and the
- 00:27:15fact that the pressor Safety Manager was
- 00:27:17further down the line is yet another
- 00:27:18indication of the lack of focus on
- 00:27:21Process Safety a positive safety culture
- 00:27:23would ensure that incidents are being
- 00:27:27reported that they're being followed up
- 00:27:30on that there's enough resources to
- 00:27:32ensure adequate safety over the years at
- 00:27:37Texas city many critical incidents were
- 00:27:39not reported nor were the lessons acted
- 00:27:42upon to prevent future catastrophic
- 00:27:44events and it's also in human nature
- 00:27:47there's a tendency to say oh gosh that
- 00:27:50was a new one I'm glad that they didn't
- 00:27:51catch fire let's forget about it and get
- 00:27:54on with the job for example BP wasn't
- 00:27:57investigating abnormal conditions that
- 00:27:59were occurring repeatedly during
- 00:28:00startups of the ice on unit the CSV
- 00:28:03examine 19 previous startups in the five
- 00:28:07years prior to the ice on incident and
- 00:28:09found in the vast majority of these
- 00:28:11startups the operators ran a high level
- 00:28:13above the range of the level transmitter
- 00:28:16the problem with running the level above
- 00:28:19the reading is that you don't know how
- 00:28:22high the level really is this can lead
- 00:28:25to grossly over filling the tower but
- 00:28:28even though high levels and pressures
- 00:28:30could have led to a catastrophic
- 00:28:31accident the previous startups were
- 00:28:34never investigated as near misses and
- 00:28:36procedural deviations became accepted as
- 00:28:39normal the CSB investigation also found
- 00:28:42eight serious releases of flammable
- 00:28:44vapor from the ice on blowdown drum two
- 00:28:47of which caught fire between 1994 and
- 00:28:492004 only three of the incidents were
- 00:28:53ever investigated
- 00:28:54well it's widely recognized now that you
- 00:28:57should that you should investigate near
- 00:29:00misses a really near accidents or a call
- 00:29:02near misses as suddenly as you
- 00:29:04investigate accidents so it's only a
- 00:29:09matter of luck whether only a leak of
- 00:29:11flammable
- 00:29:12we do gas catches fire or not in our
- 00:29:15final report the CSB recommended that
- 00:29:18bp's Board of Directors establish a
- 00:29:20system to encourage reporting of
- 00:29:22incidents without fear of retaliation to
- 00:29:25investigate and implement prompt
- 00:29:27corrective actions and to communicate
- 00:29:29lessons throughout the company the first
- 00:29:37choice after an accident is to say how
- 00:29:39can we improve the design so this can't
- 00:29:41happen how can we remove the opportunity
- 00:29:44for errors even as releases occurred
- 00:29:47over many years in the I saw MuNet VP
- 00:29:50continued using equipment based on
- 00:29:52outdated designs the raffinate splitter
- 00:29:55tower lacked modern design safeguards
- 00:29:57such as redundant level indicators and
- 00:29:59alarms a differential pressure indicator
- 00:30:02and automatic interlocks to prevent
- 00:30:04overfilling in a well-designed plant a
- 00:30:07simple error at closing the road well
- 00:30:09shouldn't result in an accident the
- 00:30:11design of the emergency pressure relief
- 00:30:13system was also outdated relief valves
- 00:30:16vented hydrocarbons directly to the
- 00:30:18atmosphere through an antiquated
- 00:30:20blowdown drum which was first installed
- 00:30:22in the 1950s the CSB report said the
- 00:30:25hydrocarbons should have been routed to
- 00:30:27an inherently safer disposal system such
- 00:30:30as a flare to contain the hydrocarbon
- 00:30:32liquid and burn off flammable vapor in
- 00:30:35fact the investigation found that amico
- 00:30:37zone safety standards later adopted by
- 00:30:40BP stated that new blowdown stacks which
- 00:30:43discharged directly to the atmosphere
- 00:30:46are not permitted as facilities were
- 00:30:49upgraded existing blowdown systems which
- 00:30:51are still necessary should be replaced
- 00:30:54several occasions prior to the incident
- 00:30:57BP had seriously considered connecting a
- 00:31:00flare to the ison unit in the early
- 00:31:031990s when amico owned the refinery
- 00:31:05three proposals were made to replace
- 00:31:08blowdown stacks at Texas City two more
- 00:31:11proposals were made in 2002 after the
- 00:31:14merger with BP however these decisions
- 00:31:18were impacted by production pressures
- 00:31:21and budget cuts and the flare was never
- 00:31:24constructed
- 00:31:24in 1992 OSHA conducted an inspection at
- 00:31:28the Texas City refinery because there
- 00:31:30had been released from a very similar
- 00:31:32blowdown drum in a different process
- 00:31:34unit OSHA cited the then amico refinery
- 00:31:37for the unsafe blowdown system OSHA
- 00:31:39determined that the design of the
- 00:31:41blowdown drum was unsafe because it did
- 00:31:43relieve the atmosphere it didn't relieve
- 00:31:45to a safe place
- 00:31:46but OSHA later withdrew the citation
- 00:31:49after Amoco asserted the equipment
- 00:31:51conformed to American Petroleum
- 00:31:53Institute standards in October 2006 the
- 00:31:56board issued a recommendation to the
- 00:31:58American Petroleum Institute calling for
- 00:32:01new guidelines that weren't against the
- 00:32:02use of blowdown drums similar to those
- 00:32:04found in Texas City we also recommended
- 00:32:07that OSHA implement a national emphasis
- 00:32:10program for all oil refineries focused
- 00:32:13on the hazards of blowdown drums that
- 00:32:15release to the atmosphere whenever
- 00:32:17possible
- 00:32:17companies should use inherently safer
- 00:32:19systems such as flares instead of
- 00:32:22blowdown drums
- 00:32:27the presence of occupied trailers near
- 00:32:30the blowdown stack added to the hazards
- 00:32:32of venting flammable material to the
- 00:32:34atmosphere prior to the incident and
- 00:32:37prior to the start of the ison unit a
- 00:32:39number of trailers occupy trailers have
- 00:32:42been placed close to the I am unit these
- 00:32:45these trailers were occupied by workers
- 00:32:47who are not involved in the turnaround
- 00:32:49activities in the ison unit the
- 00:32:52investigation found this was a key
- 00:32:54factor leading to the deaths of the
- 00:32:56workers they were right on top of the
- 00:32:58process in trailers too close to as
- 00:33:02close as 120 feet from the blowdown
- 00:33:04blowdown drum which is right at the edge
- 00:33:06of the isomerization process CSB
- 00:33:08investigator mark as niak well it is not
- 00:33:11safe they have trailers that that close
- 00:33:13to a blowdown drum or in the edge of an
- 00:33:16active process in the immigrant
- 00:33:17petroleum refinery during an explosion
- 00:33:20in a refinery you're actually safer in
- 00:33:22the open atmosphere than if you were
- 00:33:23working inside of a trailer this is
- 00:33:26because the explosion overpressure will
- 00:33:29destroy the weak trailer construction
- 00:33:31resulting in the formation of missiles
- 00:33:33and loss collapsing which which is
- 00:33:35potentially fatal to the occupants the
- 00:33:38CSB determined that industry siting
- 00:33:40guidelines did not adequately protect
- 00:33:42trailer occupants from the fire and
- 00:33:44blast damage that can occur hundreds of
- 00:33:46feet from an explosion like the one at
- 00:33:48BP we found that these guidelines were
- 00:33:50not safe enough prior to this accident
- 00:33:53and resulted in placing people in harm's
- 00:33:57way
- 00:33:58in addition BP did not follow its own
- 00:34:00management have changed procedures
- 00:34:02before placing most of the trailers in a
- 00:34:05dangerous location they did not assess
- 00:34:07the blast hazards posted the trailer and
- 00:34:11action items that were created during
- 00:34:13the review were never followed up and
- 00:34:15correct
- 00:34:15ultimately the decision on where to
- 00:34:18place the trailers was largely based on
- 00:34:20convenience not safety and contrary to
- 00:34:24BP startup procedures on the morning of
- 00:34:26March 23rd managers did not remove
- 00:34:28personnel from the nearby trailers or
- 00:34:30even alert them that the potentially
- 00:34:33hazardous startup was taking place the
- 00:34:36explosion totally destroyed 13
- 00:34:39and damaged 27 others some as far away
- 00:34:42as a thousand feet people inside
- 00:34:45trailers as far away as 479 feet were
- 00:34:49injured in October 2005 the CSB issued
- 00:34:53an urgent recommendation to the American
- 00:34:55Petroleum Institute to revise industry
- 00:34:57standards and establish minimum safe
- 00:34:59distances for occupied trailers away
- 00:35:02from hazardous process areas On June
- 00:35:0521st 2007 the American Petroleum
- 00:35:08Institute issued new industry guidelines
- 00:35:10to minimize the presence of people and
- 00:35:13occupied trailers in hazardous process
- 00:35:15areas for a long time people were saying
- 00:35:23that most accidents were due to human
- 00:35:25error and this is true in a sense but
- 00:35:29it's not very helpful it's a bit like
- 00:35:32saying that falls are due to gravity
- 00:35:34there were a number of human errors that
- 00:35:36contributed to the overfilling of the
- 00:35:38tower and the disaster that followed at
- 00:35:40Texas City no one shows up to work
- 00:35:43planning to make mistakes so we looked
- 00:35:45at the conditions in the workplace that
- 00:35:47would make air more likely you really
- 00:35:50need to look at why the operators did
- 00:35:52what they did
- 00:35:52CSB human factors specialist Cheryl
- 00:35:55Mackenzie there were a number of human
- 00:35:57factors issues involved with this
- 00:35:59incident including a fatigue of the
- 00:36:02workers training that was insufficient
- 00:36:05and procedural deviations that occur
- 00:36:08during startup the CSB investigation
- 00:36:11found that underlying conditions in the
- 00:36:13ison unit encouraged operators to
- 00:36:15consciously deviate from written
- 00:36:17operating procedures why do they make
- 00:36:19that judgment I think they did because
- 00:36:22these procedures were some of them were
- 00:36:25out of date some of them were in
- 00:36:26applicable they were routinely not
- 00:36:29following his procedures and nobody had
- 00:36:31said otherwise nobody had said hang on
- 00:36:34you must be following these procedures
- 00:36:36the investigation found that operators
- 00:36:39were concerned that if they let the
- 00:36:40liquid level in the tower get too low
- 00:36:42during startups it would damage the
- 00:36:44furnace so they had adopted an informal
- 00:36:47procedure of adding extra liquid to the
- 00:36:49tower during startup to
- 00:36:51do this they placed the level control
- 00:36:53valve in manual not the automatic mode
- 00:36:55required by procedures and left the
- 00:36:58valve closed to raise the liquid above
- 00:37:00the recommended six and a half foot
- 00:37:02level so routine had this practice
- 00:37:05become the CSB found that the towers
- 00:37:07high level alarm had activated sixty
- 00:37:10five times during the previous nineteen
- 00:37:13startups the outdated operating
- 00:37:15procedures for the unit did not
- 00:37:17establish an a safe upper limit for the
- 00:37:19liquid level in the tower
- 00:37:20unknown to operators regularly
- 00:37:23overfilling the tower had serious risks
- 00:37:25the towers liquid level transmitter had
- 00:37:28a limited range and should the liquid
- 00:37:30rise above the maximum reading of nine
- 00:37:32feet operators could not know if the
- 00:37:35tower was dangerously over filling this
- 00:37:38informal practice of running the level
- 00:37:41in the raffinate splitter tower above
- 00:37:43the range of the transmitter led to
- 00:37:46running blind they weren't aware of the
- 00:37:49dangers of over filling the column and
- 00:37:51so they tended to err on the side of
- 00:37:55what they saw as caution by over filling
- 00:37:57the column so their their systematic
- 00:38:01deviation from what they should have
- 00:38:03been doing was actually well intentioned
- 00:38:05it was with the interest as a company at
- 00:38:07heart that they were they were violating
- 00:38:10the startup procedures but on the day of
- 00:38:13the accident the routine deviation over
- 00:38:16filling the tower above the range of the
- 00:38:18indicator coincided with a number of
- 00:38:20instrument failures which impaired the
- 00:38:22board operators decision-making this had
- 00:38:25tragic results as the board operator
- 00:38:28lost awareness of just how high the
- 00:38:29level was the tower level indicator had
- 00:38:33been calibrated for years based on 1975
- 00:38:36data for a different liquid used in a
- 00:38:39different process as a result of the
- 00:38:41miss calibration the indicator showed
- 00:38:44the level in the tower was declining
- 00:38:45just prior to the explosion when it was
- 00:38:48actually increasing
- 00:38:51and a backup high-level alarm on the
- 00:38:53tower failed to activate seeming to
- 00:38:55confirm that the liquid level was
- 00:38:57dropping a sight glass on the tower was
- 00:38:59dirty and unreadable and could not be
- 00:39:02used to visually check the liquid level
- 00:39:04the investigation concluded that the
- 00:39:07board operator truly had no functional
- 00:39:09and accurate measure of the tower level
- 00:39:11on March 23rd 2005 and when the liquid
- 00:39:16finally did spill over into the blowdown
- 00:39:18drum the high-level alarm there failed
- 00:39:21to go off BP procedures required that
- 00:39:25alarms and instruments and other
- 00:39:28equipment be checked for their
- 00:39:30functionality prior to startup the CSB
- 00:39:33determined that these checks were
- 00:39:35largely not performed a poorly designed
- 00:39:38computer display in the control room
- 00:39:40added to the difficulty of determining
- 00:39:43if the splitter tower was overfilling
- 00:39:45liquid flows into and out of the tower
- 00:39:47were not shown on the same screen even
- 00:39:50though the computer could have been
- 00:39:51configured to do so
- 00:39:53the investigation also found that
- 00:39:56communication problems among BP
- 00:39:58personnel during the morning of the
- 00:39:59startup increased the likelihood of
- 00:40:01errors operators received contradictory
- 00:40:04instructions on where to send the
- 00:40:05products from the tower and the day
- 00:40:08shift operators never got clear
- 00:40:09information from the nightshift about
- 00:40:11how much liquid the tower already
- 00:40:13contained
- 00:40:15well then the board operator and the
- 00:40:17other operators that came in during the
- 00:40:19day ship really didn't understand what
- 00:40:21it occurred the night before so they're
- 00:40:23starting up this unit without full
- 00:40:25knowledge of the state of the unit and
- 00:40:27they're making judgments and decisions
- 00:40:30based on incomplete information the
- 00:40:32investigation found that BP lacked
- 00:40:35adequate policies and a management
- 00:40:36emphasis on effective communications key
- 00:40:40instructions on sending the feed into
- 00:40:42the tower were given over the phone and
- 00:40:44radio instead of in writing operators
- 00:40:47later told investigators these verbal
- 00:40:49communications were rushed and vague
- 00:40:51written communications in the log book
- 00:40:53were brief and unclear nightshift
- 00:40:57operators did not conduct a crucial
- 00:40:59face-to-face meeting to brief day shift
- 00:41:01operators on the conditions in the unit
- 00:41:03therefore they didn't realize how much
- 00:41:07liquid was in the the tower and the
- 00:41:09equipment so they added more which led
- 00:41:11to the subsequent overfilling of the
- 00:41:13tower which later led to the release the
- 00:41:16opportunities for human error were
- 00:41:18multiplied by the lack of adequate
- 00:41:20supervision staffing and training at the
- 00:41:23refinery training had been downsized and
- 00:41:27that training was largely delivered
- 00:41:30through computerized means rather than
- 00:41:33face-to-face training BP did not train
- 00:41:37operators on the hazards of overfilling
- 00:41:39towers and training for abnormal
- 00:41:42situations was insufficient despite
- 00:41:45recommendations dating back five years
- 00:41:47simulators were not used to train board
- 00:41:50operators on making critical decisions
- 00:41:52as noted in an internal BP email about
- 00:41:56simulators three weeks after the
- 00:41:58accident big pushback has always been
- 00:42:01initial cost budget pressures also
- 00:42:04impacted control room staffing BP
- 00:42:07implemented a 25% cost reduction in 99
- 00:42:11during the same time period
- 00:42:13BP downsized the board operators in the
- 00:42:17I am unit from two to one later BP at an
- 00:42:22additional process unit to the
- 00:42:25responsibilities of the board operator
- 00:42:27in the ice on
- 00:42:28unit the result was that you had three
- 00:42:31complex refinery units under the
- 00:42:34supervision of one board operator
- 00:42:36according to BP zone assessment even
- 00:42:39under normal conditions monitoring and
- 00:42:42controlling these three units would
- 00:42:44require ten and a half hours of the
- 00:42:46board operators 12-hour shift
- 00:42:48but the startup of the ison unit would
- 00:42:50demand significantly more time and
- 00:42:52attention from the operator whose
- 00:42:54workload was already nearly full and
- 00:42:56when the startup began to encounter
- 00:42:58problems late that morning supervisory
- 00:43:01oversight of the board operator was
- 00:43:03absent
- 00:43:04bp's own policies required that a
- 00:43:07supervisor or technically trained person
- 00:43:10be present during start-up because it's
- 00:43:12an especially hazardous period a
- 00:43:14supervisor who showed up on March 23rd
- 00:43:17left due to a family emergency and there
- 00:43:20was no replacement finally investigators
- 00:43:23looked at the roll operator fatigue
- 00:43:25played as a human factor contributing to
- 00:43:28the accident fatigue can affect
- 00:43:30performance in many ways that can a
- 00:43:32cloud decision making it can delay
- 00:43:34responses to actions on a control board
- 00:43:37and it can lead an operator to miss out
- 00:43:42on what's going on overall in a unit
- 00:43:44fatigue can impair judgment it can lead
- 00:43:46an operator to fixate on one operational
- 00:43:49parameter such as the declining level
- 00:43:52and lose track of other factors such as
- 00:43:55liquid being added to the tower for
- 00:43:58three hours and no liquid being removed
- 00:44:00I Somme unit operators have been working
- 00:44:0312-hour shifts for at least 29 days
- 00:44:06prior to the accident in particular the
- 00:44:09board operator was likely suffering from
- 00:44:11fatigue including acute sleep loss and a
- 00:44:14cumulative sleep debt of more than 43
- 00:44:17hours we determined that BP had no
- 00:44:20fatigue prevention policy and in fact
- 00:44:23there was no fatigue for prevention
- 00:44:24policy in the industry as a whole
- 00:44:27companies and employees may believe they
- 00:44:29benefit from overtime schedules
- 00:44:31particularly during maintenance
- 00:44:32turnarounds but operator fatigue can
- 00:44:35have deadly consequences our final
- 00:44:38report recommended that the United
- 00:44:40Steelworkers and the American Patrol
- 00:44:42institute develop new guidance on
- 00:44:44preventing fatigue in the petrochemical
- 00:44:46industry including limits on hours and
- 00:44:48days at work
- 00:44:55OSHA's 1992 standard on process safety
- 00:44:58management or PSM requires thousands of
- 00:45:02oil and chemical facilities to implement
- 00:45:0414 management elements to prevent
- 00:45:06catastrophic releases the Environmental
- 00:45:09Protection Agency has similar
- 00:45:10requirements under its risk management
- 00:45:12program the CSB investigation revealed
- 00:45:16many long-standing deficiencies in the
- 00:45:19BP refineries compliance with federal
- 00:45:21process safety regulations preventive
- 00:45:24maintenance and testing procedures were
- 00:45:26inadequate for key alarms instruments
- 00:45:28and equipment required safety studies of
- 00:45:31pressure relief systems we're years
- 00:45:33overdue operating procedures were out of
- 00:45:36date and there were other flaws
- 00:45:38management of change reviews were not
- 00:45:40conducted for critical design equipment
- 00:45:43and procedural changes hazard analyses
- 00:45:45were poor overlooking serious fire and
- 00:45:48explosion risks audits revealed many
- 00:45:51process safety problems but they were
- 00:45:53never resolved OSHA's enforcement
- 00:45:56program for the PSM regulations requires
- 00:45:59planned comprehensive inspections of
- 00:46:01facilities with accident histories or
- 00:46:04other indications of catastrophic risks
- 00:46:06a 1992 OSHA directive stated the primary
- 00:46:10enforcement tool would be the program
- 00:46:12quality verification inspection or pqv a
- 00:46:16large complex audit involving highly
- 00:46:19trained OSHA inspectors and taking weeks
- 00:46:22or months to complete despite the fact
- 00:46:25that the BPU Texas City refinery had a
- 00:46:28long history of fatality incidents there
- 00:46:31was no program quality verification or
- 00:46:34intensive PSM inspection conducted at
- 00:46:37that refinery OSHA did conduct smaller
- 00:46:40unplanned inspections of the Texas City
- 00:46:42refinery in response to accidents and
- 00:46:44complaints but these inspections did not
- 00:46:47uncover major flaws in process safety
- 00:46:50management compliance in fact the CSB
- 00:46:53found that OSHA conducted only a handful
- 00:46:55of program quality verification pqv
- 00:46:58inspections at the thousands of
- 00:47:00regulated facilities across the country
- 00:47:04there's no set interval when OSHA comes
- 00:47:06in and inspects the plant in the United
- 00:47:09States we found that inspections in the
- 00:47:11US are largely driven by personal injury
- 00:47:14statistics the CSB also found that prior
- 00:47:18to March 2005 the EPA never audited the
- 00:47:21Texas City refinery for compliance with
- 00:47:23risk management requirements other
- 00:47:26jurisdictions inspect process plants
- 00:47:28more frequently in California's Contra
- 00:47:31Costa County a local process safety
- 00:47:33ordinance requires thorough inspections
- 00:47:35of 48 major oil and chemical plants
- 00:47:37every three years by a team of
- 00:47:40specialized engineers in the United
- 00:47:43Kingdom 105 specialists from the Health
- 00:47:46and Safety Executive inspect high hazard
- 00:47:48facilities every five years in addition
- 00:47:51all nine refineries in the UK are
- 00:47:53inspected annually if accepted process
- 00:47:56safety principles had been thoroughly
- 00:47:58implemented at the refinery
- 00:47:59thus accident likely would not have
- 00:48:02occurred the CSB recommended that OSHA
- 00:48:05takes steps to conduct more process
- 00:48:07safety inspections and strengthen
- 00:48:09enforcement of the PSM standard OSHA
- 00:48:12should identify those facilities at
- 00:48:14greatest risk see the comprehensive
- 00:48:16inspections are conducted at such
- 00:48:18facilities and to establish the capacity
- 00:48:21to conduct those inspections OSHA should
- 00:48:23create a group of highly trained PSM
- 00:48:25inspectors on June 12 2007 OSHA
- 00:48:30announced a new national emphasis
- 00:48:31program to inspect most US oil
- 00:48:34refineries for process safety compliance
- 00:48:43I participated in the panel because I
- 00:48:45lost a near and dear friend in this
- 00:48:47incident a personal friend of mine was
- 00:48:49killed in this incident and I thought it
- 00:48:52was very important that that the
- 00:48:55management systems be looked at with a
- 00:48:58fresh set of eyes early in the
- 00:49:00investigation of the Texas City accident
- 00:49:02the CSB observed what appeared to be a
- 00:49:05pattern of safety deficiencies we
- 00:49:07therefore issued an urgent
- 00:49:09recommendation the first ever by this
- 00:49:11agency that BP convene an independent
- 00:49:14panel of experts to study the safety
- 00:49:16culture of its five North American
- 00:49:18refineries in October 2005 BP
- 00:49:22established an 11 member panel that
- 00:49:24included leading industry labor and
- 00:49:26academic safety experts it was headed by
- 00:49:29former Secretary of State James a baker
- 00:49:31the third the panel found that BP did
- 00:49:35not ensure as a matter of best practices
- 00:49:38that its management implemented a
- 00:49:41comprehensive and effective process
- 00:49:43safety management system the report
- 00:49:47issued in 2007 concluded there were
- 00:49:50instances of a lack of operating
- 00:49:52discipline toleration of serious
- 00:49:54deviations from safe operating practices
- 00:49:56and apparent complacency toward serious
- 00:49:59process safety risks at each of BP's
- 00:50:02North American refineries the Baker
- 00:50:05panel also voiced concern that other
- 00:50:07companies share similar problems ladies
- 00:50:10and gentlemen we are under no illusion
- 00:50:12that such deficiencies are in fact
- 00:50:16limited to BP one of the things that I'd
- 00:50:19like to see personally after having
- 00:50:22served on the Baker panel is that we
- 00:50:24will never have another incident of this
- 00:50:27magnitude the number of people that were
- 00:50:29killed a number of lives that were
- 00:50:31changed so many good hard-working people
- 00:50:34go to work every day and too often some
- 00:50:37never return I think the work that we
- 00:50:41did in the Baker panel I believe that if
- 00:50:44this if our work is applied within our
- 00:50:46industry we will not see another BP
- 00:50:51explosion
- 00:50:52the baker panel report concluded that
- 00:50:55the restructuring following bp's merger
- 00:50:57with amico have resulted in a
- 00:50:59significant loss of people expertise and
- 00:51:01experience in the refining sector only
- 00:51:04much later did BP recognize the negative
- 00:51:07impact of these changes the CS B's final
- 00:51:10report said all hazardous chemical
- 00:51:13operations should be required to review
- 00:51:15the safety impact of major
- 00:51:16organizational changes the board
- 00:51:19recommended that OSHA amend its process
- 00:51:21safety management standard to require
- 00:51:23management of change reviews for mergers
- 00:51:26acquisitions personnel reductions budget
- 00:51:28cuts or other organizational changes
- 00:51:31that can impact Process Safety we also
- 00:51:34recommended that the Center for chemical
- 00:51:36process safety develop guidelines on how
- 00:51:39to perform organizational management of
- 00:51:41change reviews
- 00:51:48the major problem of the chemical
- 00:51:50industry and indeed with other
- 00:51:51industries is the way accidents are
- 00:51:54investigated reports are written
- 00:51:56circulating read filed away and then
- 00:51:59forgotten and then ten years later even
- 00:52:04in the same company the accident happens
- 00:52:06again there is a saying that
- 00:52:09organizations have no memory only people
- 00:52:12have memory once they leave the plant
- 00:52:14the accident occurred that is forgotten
- 00:52:16about and what companies must do in the
- 00:52:19petrochemical industry is realized that
- 00:52:21the fact that you've had 20 years
- 00:52:22without a catastrophic catastrophic
- 00:52:24event is no guarantee that there won't
- 00:52:27be one tomorrow you have to keep your
- 00:52:29eye on the ball constantly all oil and
- 00:52:31chemical businesses should seek to learn
- 00:52:33from the tragedy at BP the CSB believes
- 00:52:36there are key lessons to be drawn from
- 00:52:38our investigation the CSB said managers
- 00:52:42executives and boards of directors
- 00:52:43should do the following monitor process
- 00:52:46safety performance using appropriate
- 00:52:48indicators invest sufficient resources
- 00:52:51to correct problems maintain an open and
- 00:52:54trusting safety culture where near
- 00:52:56misses are reported and investigated
- 00:52:58ensure that non-essential personnel and
- 00:53:01work trailers are located a safe
- 00:53:03distance from hazardous process areas
- 00:53:06ensure equipment and procedures are
- 00:53:08maintained and up-to-date carefully
- 00:53:11manage organizational changes and budget
- 00:53:13decisions to ensure safety is not
- 00:53:15compromised analyze and correct the
- 00:53:18underlying causes of human errors
- 00:53:20including fatigue and miscommunication
- 00:53:23finally boards of directors must
- 00:53:25exercise their duty to ensure that the
- 00:53:28highest standards of safety are met the
- 00:53:34BP tragedy was years in the making but
- 00:53:37it was by no means inevitable we hope
- 00:53:40our investigation will provide all of
- 00:53:42industry with valuable lessons to assure
- 00:53:45such a tragedy will not be repeated for
- 00:53:48the CSB s final report key investigation
- 00:53:52documents the Baker panel report and
- 00:53:54other information please visit the
- 00:53:57Chemical Safety Board website at CSB dot
- 00:54:01b.p cooperated with the CSB
- 00:54:04investigation and provided documents and
- 00:54:06witnesses voluntarily after the Texas
- 00:54:09City accident
- 00:54:10BP acted to relocate trailers eliminate
- 00:54:13blowdown drums and invest billions of
- 00:54:16dollars to upgrade the condition of its
- 00:54:18US refineries in 2007 BP accepted the
- 00:54:22recommendations of the Baker panel
- 00:54:23including a call to become a recognized
- 00:54:26industry leader in process safety
- 00:54:28management
- BP explosion
- Texas City
- industrial accident
- safety failures
- process safety
- Chemical Safety Board
- CSB investigation
- organizational deficiencies
- cost-cutting
- safety culture