BP Texas City Explosion

00:55:42
https://www.youtube.com/watch?v=ti9YfdXqbjs

Résumé

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.

A retenir

  • 💥 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.

Chronologie

  • 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.

Afficher plus

Carte mentale

Mind Map

Questions fréquemment posées

  • 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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Sous-titres
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Défilement automatique:
  • 00:00:28
    at 1:20 p.m. on March 23rd 2005 a
  • 00:00:32
    massive explosion and fire erupted at
  • 00:00:35
    the BP refinery in Texas City Texas the
  • 00:00:39
    explosion killed 15 workers and injured
  • 00:00:41
    180 others many of them seriously the
  • 00:00:45
    blast occurred at the isomerisation or
  • 00:00:47
    Ison unit which produces materials to
  • 00:00:50
    boost the octane rating of gasoline the
  • 00:00:53
    explosion shattered windows in homes and
  • 00:00:55
    businesses up to three-quarters of a
  • 00:00:56
    mile away from the 1200 acre refinery as
  • 00:01:00
    thick black smoke billowed from the
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    plant authorities instructed some 43,000
  • 00:01:05
    Texas City residents to stay indoors the
  • 00:01:08
    accident cost BP billions of dollars in
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    victim's compensation property damage
  • 00:01:13
    and lost production this investigation
  • 00:01:16
    was the largest and most comprehensive
  • 00:01:18
    investigation in the history of the
  • 00:01:20
    Chemical Safety Board CSB Supervisory
  • 00:01:23
    investigator Don Holmstrom led a
  • 00:01:25
    two-year investigation to determine the
  • 00:01:27
    root causes of the accident we
  • 00:01:29
    interviewed over 370 witnesses we looked
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    at thousands of documents literally
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    millions of pages of documents and we
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    examined the plant inspected over 40
  • 00:01:41
    pieces of instrumentation and equipment
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    the investigation team examined a wide
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    range of safety systems practices and
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    standards and looked at human factors
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    such as fatigue and communication
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    between operators the board's report was
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    released at a public meeting in Texas
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    City on March 20th 2007 then CSB
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    chairman carolyn merritt presided many
  • 00:02:07
    of you here tonight had family members
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    or co-workers who were victims of this
  • 00:02:12
    explosion to all of you i express my
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    deepest condolences and sincere wishes
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    that society never allows another
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    accident like this to occur the tragedy
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    at BP was the worst industrial accident
  • 00:02:28
    in the United States in nearly 15 years
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    the CSB concluded that it was the result
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    of organizational and safety
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    deficiencies at all levels of the
  • 00:02:36
    company we found that BP management had
  • 00:02:39
    for many years overlooked warning signs
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    of a
  • 00:02:42
    possible catastrophic accident there's
  • 00:02:44
    an old saying that who think safety is
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    expensive trial accident accidents cost
  • 00:02:50
    a lot of money and they're not only in
  • 00:02:53
    damage to plant and in claims for injury
  • 00:02:56
    but also in the loss of the company's
  • 00:02:58
    reputation the reason why the Texas City
  • 00:03:03
    accident has such an impact is because
  • 00:03:05
    when people look at it they can see that
  • 00:03:07
    they are all in the same boat that they
  • 00:03:09
    the problems which led to that accident
  • 00:03:12
    are likely to be present at other sites
  • 00:03:16
    around the world my fear is as some of
  • 00:03:19
    the end some of the other refineries
  • 00:03:20
    within the United States will feel that
  • 00:03:23
    couldn't happen to me and the ones that
  • 00:03:26
    feel that that couldn't happen at their
  • 00:03:28
    side is the ones that are set up to have
  • 00:03:30
    it happen there the following CSB
  • 00:03:35
    computer animation depicts the sequence
  • 00:03:37
    of events over an 11 hour period leading
  • 00:03:41
    to the explosion at the BP Texas City
  • 00:03:43
    refinery on March 23rd 2005 several
  • 00:03:49
    units at the Texas City refinery had
  • 00:03:51
    been shut down for lengthy maintenance
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    projects which required nearly a
  • 00:03:54
    thousand contractors to be on site along
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    with BP employees BP had positioned a
  • 00:04:01
    number of portable trailers close to
  • 00:04:03
    process units for the use of contractors
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    and other maintenance workers over a
  • 00:04:08
    period of months BP had located ten
  • 00:04:11
    trailers for workers servicing the ultra
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    cracker unit including a double-wide
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    wood-frame trailer that contained 11
  • 00:04:18
    offices and was regularly used for
  • 00:04:21
    meetings though these trailers were
  • 00:04:25
    located near the isomerisation unit the
  • 00:04:28
    occupants were not warned the I saw muna
  • 00:04:30
    twas about to start up a potentially
  • 00:04:33
    hazardous operation at 2:15 a.m. on
  • 00:04:38
    March 23rd overnight operators began
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    introducing flammable liquid
  • 00:04:43
    hydrocarbons known as raffinate into a
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    170-foot tall raffinate splitter tower
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    used to distill and separate gasoline
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    components near the base of the tower
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    there was a
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    single instrument that measured how much
  • 00:04:56
    liquid was inside heat transmitted this
  • 00:05:00
    information to a central control room
  • 00:05:02
    located away from the I sama unit but
  • 00:05:05
    this level indicator was not designed to
  • 00:05:07
    measure liquid above the 9 foot mark
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    during normal operation the tower was
  • 00:05:12
    only supposed to contain about six and a
  • 00:05:13
    half feet of liquid but during startups
  • 00:05:16
    operators routinely deviated from
  • 00:05:18
    written procedures and filled the tower
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    above the 9 foot mark
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    concerned that if the liquid levels
  • 00:05:23
    fluctuated too low it would cause costly
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    damage to the furnace at 3:09 a.m. as
  • 00:05:29
    the liquid neared the 8 foot mark a high
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    level alarm activated and sounded in the
  • 00:05:35
    control room but a second high level
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    alarm slightly further up the tower
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    failed to go off by 3:30 a.m. the level
  • 00:05:45
    indicator showed that liquid had filled
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    the bottom 9 feet of the tower and the
  • 00:05:50
    feed was stopped the CSB later estimated
  • 00:05:54
    that the liquid was in fact at a height
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    of 13 feet but operators could not know
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    the actual level because the indicator
  • 00:06:01
    only measured up to 9 feet the lead
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    operator had been overseeing the startup
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    from a satellite control room within the
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    ice arm unit at 5 a.m. he briefly
  • 00:06:14
    updated the night board operator in the
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    central control room about the startup
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    activities the lead operator then left
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    the refinery early an hour before the
  • 00:06:24
    end of the shift a new board operator
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    arrived in the control room around 6
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    a.m. to start his thirtieth day in a row
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    working a 12-hour shift
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    he spoke briefly with the departing
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    nightshift operator and then read the
  • 00:06:38
    logbook to prepare for the startup but
  • 00:06:43
    the log book did not clearly indicate
  • 00:06:45
    how much liquid was already in the tower
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    and equipment and it left no
  • 00:06:49
    instructions on routing of the liquid
  • 00:06:51
    feed and products when the startup
  • 00:06:53
    resumed instead the control board
  • 00:06:55
    operator only found a one-line logbook
  • 00:06:58
    entry that said I some brought in some
  • 00:07:01
    RAF 2 unit 2 pack raffle
  • 00:07:04
    at 7:15 a.m. the day shift supervisor
  • 00:07:08
    arrived because he was more than an hour
  • 00:07:10
    late he received no formal briefing from
  • 00:07:13
    personnel on the night shift about
  • 00:07:15
    conditions in the ice armed unit at 951
  • 00:07:18
    a.m. operators resumed the start up they
  • 00:07:21
    began recirculating the liquid feed and
  • 00:07:23
    adding more liquid to the already
  • 00:07:25
    overfilled tower as new feed was added
  • 00:07:28
    startup procedures called for regulating
  • 00:07:31
    the liquid level in the tower using the
  • 00:07:33
    automatic level control valve but the
  • 00:07:37
    board operator and others had received
  • 00:07:39
    conflicting instructions on routing the
  • 00:07:41
    product as a result this critical valve
  • 00:07:44
    was left closed for several hours
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    blocking the flow of liquid from the
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    tower a few minutes later operators lit
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    burners on the furnace to begin heating
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    up the feed part of the normal startup
  • 00:07:59
    process while the startup was underway
  • 00:08:02
    the day supervisor left the refinery on
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    short notice just before 11:00 a.m. to
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    attend to a family medical emergency
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    contrary to bp's own procedures no
  • 00:08:13
    experienced supervisor was assigned to
  • 00:08:16
    replace him this left a single control
  • 00:08:19
    board operator now without a qualified
  • 00:08:21
    supervisor to run three refinery units
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    including the Ison unit which needed
  • 00:08:26
    close attention the refinery had
  • 00:08:29
    eliminated a second board operator
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    position following corporate budget cuts
  • 00:08:33
    in 1999 after BP acquired amico as the
  • 00:08:38
    startup continued the towers steadily
  • 00:08:40
    filled with liquid reaching a height of
  • 00:08:42
    98 feet shortly before noon more than 15
  • 00:08:46
    times the normal level but the
  • 00:08:50
    improperly calibrated level indicator
  • 00:08:52
    told operators in the control room that
  • 00:08:55
    the liquid was at 8.4 feet and gradually
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    falling furthermore the control panel
  • 00:09:01
    was not configured to clearly warn
  • 00:09:03
    operators of the growing danger it did
  • 00:09:05
    not display flows into and out of the
  • 00:09:07
    tower on the same screen nor did it
  • 00:09:10
    calculate the total liquid in the tower
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    meanwhile the maintenance contractors
  • 00:09:16
    who were not involved in the operation
  • 00:09:17
    of the I sound unit left their work
  • 00:09:19
    trailers to attend a company lunch
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    celebrating a month without a lost time
  • 00:09:24
    injury at 12:41 p.m. an alarm activated
  • 00:09:29
    as the rising liquid compressed the
  • 00:09:30
    gases remaining in the top of the tower
  • 00:09:33
    unable to understand the source of the
  • 00:09:35
    high-pressure operators opened a manual
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    chain valve to vent gases to the units
  • 00:09:40
    emergency relief system a 1950s era
  • 00:09:43
    blowdown drum that vented vapor directly
  • 00:09:46
    into the atmosphere operators also
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    turned off to burners in the furnace to
  • 00:09:51
    lower the temperature inside the tower
  • 00:09:52
    believing this would reduce the pressure
  • 00:09:55
    nobody knew the tower was dangerously
  • 00:09:58
    full the operators did become concerned
  • 00:10:02
    about the lack of flow out of the tower
  • 00:10:04
    and began opening the valve to send
  • 00:10:06
    liquid from the bottom of the tower to
  • 00:10:08
    storage tanks but this liquid was very
  • 00:10:10
    hot as it flowed through the heat
  • 00:10:12
    exchanger it suddenly raised the
  • 00:10:14
    temperature of the liquid entering high
  • 00:10:16
    up the tower by 141 degrees Fahrenheit
  • 00:10:19
    it was now about 1 p.m.
  • 00:10:23
    contract workers unaware of the startup
  • 00:10:25
    and the looming danger returned from
  • 00:10:28
    lunch and began a meeting in the
  • 00:10:30
    double-wide trailer in the corner room
  • 00:10:32
    closest to the blowdown drum over the
  • 00:10:36
    next few minutes the hot feed entering
  • 00:10:39
    the tower caused the liquid inside to
  • 00:10:41
    start to boil and swell liquid filled
  • 00:10:44
    the tower completely and began spilling
  • 00:10:46
    into the overhead vapor line exerting
  • 00:10:49
    great pressure on the emergency relief
  • 00:10:51
    valves 150 feet below at 1:14 p.m. the
  • 00:10:56
    three emergency valves opened sending
  • 00:10:58
    nearly 52,000 gallons of flammable
  • 00:11:01
    liquid to the blowdown drum at the other
  • 00:11:03
    end of the I psalm unit liquid rose
  • 00:11:05
    inside the blowdown drum and overflowed
  • 00:11:08
    into a processed sewer setting off
  • 00:11:11
    alarms in the control room but the high
  • 00:11:13
    level alarm on the blowdown drum failed
  • 00:11:15
    to go off none of the operators knew of
  • 00:11:19
    the catastrophe unfolding in the I psalm
  • 00:11:22
    unit
  • 00:11:23
    as flammable hydrocarbons overfilled the
  • 00:11:26
    blowdown drum operators nearby saw a
  • 00:11:28
    geyser of liquid and vapor erupt from
  • 00:11:31
    the top of the stack the equivalent of
  • 00:11:33
    nearly a tanker truck full of hot
  • 00:11:35
    gasoline fell to the ground and began
  • 00:11:38
    forming a huge flammable vapor cloud
  • 00:11:42
    this scene based on CSV computer
  • 00:11:45
    modeling shows how the vapor cloud
  • 00:11:47
    expanded in just 90 seconds engulfing
  • 00:11:51
    the unit and the nearby trailer is full
  • 00:11:52
    of workers about 25 feet from the base
  • 00:11:57
    of the blowdown drum two workers were
  • 00:11:59
    parked in a pickup truck with the engine
  • 00:12:01
    idling as flammable vapor entered the
  • 00:12:03
    air intake the diesel engine began to
  • 00:12:05
    race the two workers fled unable to shut
  • 00:12:09
    off the engine
  • 00:12:10
    moments later witnesses saw the truck
  • 00:12:13
    backfire and ignite the vapor cloud
  • 00:12:16
    powerful explosions swept through the
  • 00:12:19
    area computer modeling shows how the
  • 00:12:22
    blast pressure wave accelerated through
  • 00:12:24
    the ison unit causing heavy destruction
  • 00:12:27
    and igniting fires throughout the area
  • 00:12:30
    the workers inside the trailers were
  • 00:12:32
    right in the path of the explosions the
  • 00:12:35
    fires continued to burn for hours 12 of
  • 00:12:42
    the 20 occupants of the double-wide
  • 00:12:44
    trailer were killed along with three
  • 00:12:46
    workers in a trailer nearby dozens of
  • 00:12:49
    others suffered serious burns fractures
  • 00:12:52
    and other chromatic injuries the wood
  • 00:12:54
    and metal frame trailers were blown
  • 00:12:56
    apart by the blasts firefighters
  • 00:12:59
    struggled to rescue the injured and
  • 00:13:00
    recover the victims 50 large chemical
  • 00:13:03
    storage tanks were damaged and the ison
  • 00:13:06
    unit remained shut down for more than
  • 00:13:08
    two years
  • 00:13:15
    during the early stages of our
  • 00:13:17
    investigation our team had noted there
  • 00:13:21
    were multiple safety system deficiencies
  • 00:13:23
    at the Texas City plant
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    we also found there was a history of
  • 00:13:27
    fatalities of the plant prior to the
  • 00:13:30
    March 2005 accident 23 people died in
  • 00:13:33
    accidents over a 30-year period at the
  • 00:13:36
    Texas City refinery beginning when it
  • 00:13:39
    was owned by amico and continuing after
  • 00:13:41
    BP acquired the refinery in 1999 the CSB
  • 00:13:47
    wanted to know what the connection was
  • 00:13:48
    between this history of fatal incidents
  • 00:13:51
    and the organizational and cultural
  • 00:13:55
    factors BP corporation's lack of focus
  • 00:13:59
    on preventing major accidents allowed
  • 00:14:01
    budget cuts to be made without assessing
  • 00:14:03
    the impact on process safety the CSB
  • 00:14:06
    found that cost cutting production
  • 00:14:08
    pressures and failure to invest
  • 00:14:11
    significantly impacted the process
  • 00:14:14
    safety performance at the Texas City
  • 00:14:16
    refinery and left the refinery
  • 00:14:18
    vulnerable to catastrophe after the
  • 00:14:21
    merger with amico BP ordered a 25%
  • 00:14:24
    reduction in fixed costs at all the true
  • 00:14:27
    fineries this impacted important process
  • 00:14:31
    safety systems such as staffing training
  • 00:14:35
    and mechanical integrity
  • 00:14:42
    the effects of the budget cuts became
  • 00:14:44
    apparent in a number of internal BP
  • 00:14:47
    documents made public following the
  • 00:14:49
    accident
  • 00:14:52
    in one the refinery manager was quoted
  • 00:14:54
    as having observed in 2002 that the
  • 00:14:58
    infrastructure at Texas City was in
  • 00:15:00
    complete decline he ordered a study of
  • 00:15:02
    the refinery safety and mechanical
  • 00:15:04
    integrity a study which was shown to BP
  • 00:15:06
    executives in London that study warned
  • 00:15:09
    of serious concerns about the potential
  • 00:15:12
    for a major site incident following more
  • 00:15:14
    than 80 hydrocarbon releases in the
  • 00:15:17
    previous two years the study also
  • 00:15:19
    concluded that its own findings were
  • 00:15:21
    urgent and far-reaching a follow-up BP
  • 00:15:25
    study in 2002 found the refineries
  • 00:15:28
    integrity and reliability issues were
  • 00:15:31
    clearly linked to the reduction in
  • 00:15:32
    maintenance spend over the last decade
  • 00:15:34
    in 2003 a maintenance assessment stated
  • 00:15:38
    that cost-cutting measures have
  • 00:15:39
    intervened with the group's work to get
  • 00:15:41
    things right
  • 00:15:43
    usually reliability improvements are cut
  • 00:15:46
    and later that year a company audit
  • 00:15:50
    found the current condition of the
  • 00:15:51
    infrastructure and assets is poor at
  • 00:15:53
    Texas City and that maintenance spending
  • 00:15:56
    was limited by a checkbook mentality
  • 00:15:59
    only the money on hand would be spent
  • 00:16:02
    rather than increasing the budget in
  • 00:16:05
    March 2004 BP auditors in London
  • 00:16:08
    concluded that 35 business units around
  • 00:16:10
    the world including the Texas City
  • 00:16:13
    refinery suffered from a host of common
  • 00:16:15
    safety problems including widespread
  • 00:16:18
    tolerance of non-compliance with basic
  • 00:16:21
    HSE or health safety and environmental
  • 00:16:23
    rules poor implementation of safety
  • 00:16:26
    management systems and lack of
  • 00:16:29
    leadership competence and understanding
  • 00:16:32
    there were a number of reports that were
  • 00:16:34
    coming up to as high as the board level
  • 00:16:38
    that indicated serious problems
  • 00:16:40
    throughout the BP system during 2004 the
  • 00:16:45
    Texas City refinery had three major
  • 00:16:47
    accidents in addition to this process
  • 00:16:50
    unit fire that caused 30 million dollars
  • 00:16:52
    in damage to other accidents in 2004
  • 00:16:55
    resulted in three fatalities yet this
  • 00:16:58
    same year the refinery had its lowest
  • 00:17:00
    ever recorded injury rate a statistic
  • 00:17:03
    that does not include fatalities the CSB
  • 00:17:08
    found that maintenance spending
  • 00:17:10
    increased between 2003 and 2004 but most
  • 00:17:14
    of the increases were for responding to
  • 00:17:16
    serious accidents and complying with
  • 00:17:18
    environmental requirements not for
  • 00:17:21
    preventive maintenance late in 2004 the
  • 00:17:25
    Texas City refinery manager made a
  • 00:17:27
    presentation to supervisors titled
  • 00:17:30
    safety reality reviewing fatalities at
  • 00:17:33
    the plant over the past 30 years
  • 00:17:39
    one of the slides was entitled Texas
  • 00:17:42
    City is not a safe place to work
  • 00:17:44
    BP did its own safety culture survey
  • 00:17:47
    that was done just prior to the accident
  • 00:17:50
    that survey indicated there was an
  • 00:17:53
    exceptional degree of fear among
  • 00:17:54
    employees of a major catastrophe among
  • 00:17:59
    the findings of the survey the pressure
  • 00:18:01
    for production time pressure and
  • 00:18:03
    understaffing are the major causes of
  • 00:18:05
    accidents at Texas City critical events
  • 00:18:08
    like failures or breakdowns are
  • 00:18:10
    generally not attended to production and
  • 00:18:14
    budget compliance gets recognized and
  • 00:18:16
    rewarded above anything else sociology
  • 00:18:20
    professor dr. Andrew Hopkins has written
  • 00:18:22
    extensively on the causes of industrial
  • 00:18:24
    disasters my feeling is that the
  • 00:18:28
    solution to this problem of cost-cutting
  • 00:18:30
    by senior people is to hold them
  • 00:18:33
    responsible for the safety implications
  • 00:18:36
    of those cost cuts so that when they
  • 00:18:38
    order a cost cut they should personally
  • 00:18:41
    be able to certify that these things
  • 00:18:43
    will not have adverse safety
  • 00:18:45
    consequences the safety culture survey
  • 00:18:47
    also pointed to the exceptionally high
  • 00:18:49
    executive turnover at the refinery six
  • 00:18:52
    different business unit leaders or bu
  • 00:18:54
    ELLs in seven years prior to the
  • 00:18:57
    accident the authors of the survey
  • 00:18:59
    report concluded we have never seen an
  • 00:19:02
    organization with such a history of
  • 00:19:03
    leadership changes over such a short
  • 00:19:05
    period of time many managers are in and
  • 00:19:09
    out within a space of two years and what
  • 00:19:12
    they are assessed on the basis of is the
  • 00:19:14
    the profit they making on an annual
  • 00:19:16
    basis now omi as a manager am I going to
  • 00:19:20
    spend a large amount of money to deal
  • 00:19:23
    with some remote risk that is very
  • 00:19:26
    unlikely to generate a major axon during
  • 00:19:28
    my year or two on on my watch here the
  • 00:19:32
    survey of texas city employees also
  • 00:19:35
    found concern about safety and equipment
  • 00:19:37
    checks potentially left undone there was
  • 00:19:40
    a check the Box mentality which
  • 00:19:42
    indicated that personnel would go
  • 00:19:44
    through the motions with various
  • 00:19:45
    policies and procedures but the work
  • 00:19:48
    would not be conducted for example the
  • 00:19:51
    tower high level alarm had
  • 00:19:53
    reported as not functioning several
  • 00:19:54
    times in the two years prior to the
  • 00:19:56
    accident
  • 00:19:58
    but maintenance work orders for this
  • 00:20:00
    alarm were closed
  • 00:20:01
    although the repairs were never actually
  • 00:20:03
    made work orders could be closed out as
  • 00:20:07
    completed even though the work hadn't
  • 00:20:09
    been performed this is important because
  • 00:20:12
    we found that on the day of the incident
  • 00:20:15
    during the ice on startup there were a
  • 00:20:17
    number of instruments and equipment that
  • 00:20:20
    we're not functioning properly on
  • 00:20:22
    February 20th 2005 a company's safety
  • 00:20:26
    manager wrote I truly believe we are on
  • 00:20:29
    the verge of something bigger happening
  • 00:20:31
    then three weeks later a BP business
  • 00:20:34
    plan recognized a number of key safety
  • 00:20:36
    risks including that TCS or Texas City
  • 00:20:40
    site kills someone in the next 12 to 18
  • 00:20:44
    months
  • 00:20:45
    eight days later those fears were
  • 00:20:48
    realized
  • 00:20:50
    here were these warnings these audits
  • 00:20:52
    were we were sounding very clear
  • 00:20:55
    warnings so why weren't they attended to
  • 00:20:58
    I think my feeling is that Texas City
  • 00:21:02
    was virtually paralyzed by the
  • 00:21:05
    cost-cutting which had occurred at that
  • 00:21:07
    side and they was simply unable to
  • 00:21:10
    respond to those warnings there needs to
  • 00:21:13
    be somebody on the board of directors
  • 00:21:15
    who can interpret those who ports and be
  • 00:21:16
    in position to drive change effectively
  • 00:21:19
    the CS B's final report recommended that
  • 00:21:23
    BP appoints an additional non-executive
  • 00:21:25
    member of the Board of Directors
  • 00:21:27
    with specific expertise in refinery
  • 00:21:29
    operations and Process Safety so the
  • 00:21:37
    problem that takes a city was that they
  • 00:21:39
    were essentially blind to this issue of
  • 00:21:42
    Process Safety they were focusing on
  • 00:21:45
    personal safety the CSB concluded that
  • 00:21:49
    over a period of years BP managers
  • 00:21:51
    focused on lowering rates for personal
  • 00:21:53
    injuries such as slips trips and falls
  • 00:21:56
    while often disregarding key process
  • 00:21:59
    safety indicators we as members of the
  • 00:22:02
    traveling public intuitively understand
  • 00:22:05
    that the numbers of baggage handling
  • 00:22:07
    injuries really tells us nothing about
  • 00:22:09
    the likelihood of a major accident an
  • 00:22:11
    aircraft crash and no airline in its
  • 00:22:13
    right mind is going to try and convince
  • 00:22:15
    the traveling public of our safe it is
  • 00:22:17
    by telling you about its workforce
  • 00:22:19
    injury statistics dr. Trevor clutch is
  • 00:22:22
    an internationally recognized chemical
  • 00:22:24
    process safety expert plus their safety
  • 00:22:27
    deals with the fires and explosions and
  • 00:22:30
    toxic releases and things like that and
  • 00:22:32
    you can have a very good accident rate
  • 00:22:36
    for what we call hardhats accidents but
  • 00:22:40
    not for processed ones there are a whole
  • 00:22:43
    series of incidents occurring at BP in
  • 00:22:45
    the years part of the accident gas
  • 00:22:47
    releases other kinds of releases fires
  • 00:22:51
    all of which were telling you that
  • 00:22:54
    process safety was not well-managed do
  • 00:22:56
    you need to measure Process Safety
  • 00:22:59
    performance with the appropriate
  • 00:23:00
    indicators both leading and lagging
  • 00:23:03
    indicators lagging indicators measure
  • 00:23:05
    events that have already occurred such
  • 00:23:08
    as fires explosions and equipment
  • 00:23:10
    failures leading indicators are designed
  • 00:23:13
    to predict the likelihood of an accident
  • 00:23:15
    before it occurs for example the
  • 00:23:18
    percentage of equipment inspections that
  • 00:23:20
    are overdue
  • 00:23:20
    the opening of a safety release pressure
  • 00:23:23
    relief valve is itself an indicator that
  • 00:23:26
    things are not as they should be so we
  • 00:23:29
    should count those and try and reduce
  • 00:23:31
    the number of occurrences of those sorts
  • 00:23:33
    of events but the investigation found
  • 00:23:35
    that BP did not effectively use leading
  • 00:23:37
    and lagging indicators to measure and
  • 00:23:40
    drive process safety performance for
  • 00:23:42
    example bp's pay plan rewarded managers
  • 00:23:45
    primarily for controlling costs the only
  • 00:23:48
    safety metric used to calculate bonuses
  • 00:23:50
    was the personal injury rate process
  • 00:23:52
    safety was not considered a CSB final
  • 00:23:55
    report recommended that the United
  • 00:23:57
    Steelworkers union and the American
  • 00:23:59
    Petroleum Institute create a new
  • 00:24:01
    standard for process safety indicators
  • 00:24:03
    for the petrochemical industry the board
  • 00:24:05
    also called on BP to use leading and
  • 00:24:08
    lagging indicators to strengthen
  • 00:24:09
    refinery safety performance
  • 00:24:15
    Oxford accent managers often say I
  • 00:24:18
    didn't know this was happening or not
  • 00:24:21
    happening the case maybe if I know and I
  • 00:24:24
    just stopped it now this is bad
  • 00:24:26
    management is the manager's job to know
  • 00:24:28
    what is going on and he can do that by
  • 00:24:31
    going round and by keeping his eyes open
  • 00:24:34
    and and reading the accident reports in
  • 00:24:37
    detail the CSB investigation noted that
  • 00:24:41
    BP ignored numerous warnings of the
  • 00:24:43
    potential for a catastrophic accident a
  • 00:24:45
    result of not having an effective
  • 00:24:47
    reporting and learning culture Glenn
  • 00:24:50
    Irwin is a safety official with the
  • 00:24:52
    United Steelworkers and was a member of
  • 00:24:54
    the independent panel that examined BP
  • 00:24:56
    safety culture I believe it's very
  • 00:24:59
    important that we do have an open and a
  • 00:25:01
    trusting environment to where people can
  • 00:25:03
    raise concerns and they can tell
  • 00:25:05
    management if they see a condition or
  • 00:25:07
    they or something that is out of the
  • 00:25:09
    ordinary
  • 00:25:10
    bp's own internal audits however
  • 00:25:13
    indicated a trusting environment was
  • 00:25:15
    lacking in 2005 the texas city
  • 00:25:18
    maintenance manager said in an e-mail
  • 00:25:20
    that the refinery has a ways to go to
  • 00:25:22
    becoming a learning culture and away
  • 00:25:24
    from a punitive culture it was a
  • 00:25:28
    long-standing problem in 2000 the BP
  • 00:25:31
    refinery in Grangemouth scotland had
  • 00:25:33
    three serious incidents including a
  • 00:25:36
    large process unit fire an investigation
  • 00:25:38
    by the British Health and Safety
  • 00:25:39
    Executive highlighted problems at the
  • 00:25:41
    Grangemouth refinery that would show up
  • 00:25:43
    again five years later in Texas City
  • 00:25:46
    there was need for corporate and board
  • 00:25:49
    oversight over process safety management
  • 00:25:52
    there was a need to develop leading and
  • 00:25:55
    lagging indicators for process safety
  • 00:25:56
    and there needed to be an emphasis on
  • 00:25:59
    process safety in order to prevent major
  • 00:26:01
    accidents but the CSB he found little
  • 00:26:04
    awareness in Texas City of the lessons
  • 00:26:06
    BP executives promised would be learned
  • 00:26:08
    worldwide after Grangemouth as British
  • 00:26:11
    regulators concluded
  • 00:26:12
    bp's decentralized management structure
  • 00:26:15
    impaired learning from previous
  • 00:26:17
    incidents and the reason why BP failed
  • 00:26:20
    to learn these lessons from other events
  • 00:26:21
    the reason why they seemed to have this
  • 00:26:24
    what I would call learning disability
  • 00:26:26
    lies in
  • 00:26:28
    the way in which the organization was
  • 00:26:30
    designed it lies in the bonus systems of
  • 00:26:33
    payment it lies in the decentralized
  • 00:26:36
    structure of the organization it lies in
  • 00:26:38
    the the organizational location of
  • 00:26:41
    Process Safety experts the CSB found
  • 00:26:44
    that following the 1999 merger with
  • 00:26:47
    amico BP dismantled a MCOs existing
  • 00:26:50
    centralized safety structure the
  • 00:26:52
    reorganization left a diminished Process
  • 00:26:55
    Safety function that no longer reported
  • 00:26:57
    to senior refinery leadership
  • 00:27:00
    so I think the lesson one of the lessons
  • 00:27:02
    coming out of that is that if an
  • 00:27:05
    organization judge is something
  • 00:27:06
    important
  • 00:27:07
    it will locate people at towards the top
  • 00:27:10
    of the apex in that organization people
  • 00:27:13
    with responsibility for that and the
  • 00:27:15
    fact that the pressor Safety Manager was
  • 00:27:17
    further down the line is yet another
  • 00:27:18
    indication of the lack of focus on
  • 00:27:21
    Process Safety a positive safety culture
  • 00:27:23
    would ensure that incidents are being
  • 00:27:27
    reported that they're being followed up
  • 00:27:30
    on that there's enough resources to
  • 00:27:32
    ensure adequate safety over the years at
  • 00:27:37
    Texas city many critical incidents were
  • 00:27:39
    not reported nor were the lessons acted
  • 00:27:42
    upon to prevent future catastrophic
  • 00:27:44
    events and it's also in human nature
  • 00:27:47
    there's a tendency to say oh gosh that
  • 00:27:50
    was a new one I'm glad that they didn't
  • 00:27:51
    catch fire let's forget about it and get
  • 00:27:54
    on with the job for example BP wasn't
  • 00:27:57
    investigating abnormal conditions that
  • 00:27:59
    were occurring repeatedly during
  • 00:28:00
    startups of the ice on unit the CSV
  • 00:28:03
    examine 19 previous startups in the five
  • 00:28:07
    years prior to the ice on incident and
  • 00:28:09
    found in the vast majority of these
  • 00:28:11
    startups the operators ran a high level
  • 00:28:13
    above the range of the level transmitter
  • 00:28:16
    the problem with running the level above
  • 00:28:19
    the reading is that you don't know how
  • 00:28:22
    high the level really is this can lead
  • 00:28:25
    to grossly over filling the tower but
  • 00:28:28
    even though high levels and pressures
  • 00:28:30
    could have led to a catastrophic
  • 00:28:31
    accident the previous startups were
  • 00:28:34
    never investigated as near misses and
  • 00:28:36
    procedural deviations became accepted as
  • 00:28:39
    normal the CSB investigation also found
  • 00:28:42
    eight serious releases of flammable
  • 00:28:44
    vapor from the ice on blowdown drum two
  • 00:28:47
    of which caught fire between 1994 and
  • 00:28:49
    2004 only three of the incidents were
  • 00:28:53
    ever investigated
  • 00:28:54
    well it's widely recognized now that you
  • 00:28:57
    should that you should investigate near
  • 00:29:00
    misses a really near accidents or a call
  • 00:29:02
    near misses as suddenly as you
  • 00:29:04
    investigate accidents so it's only a
  • 00:29:09
    matter of luck whether only a leak of
  • 00:29:11
    flammable
  • 00:29:12
    we do gas catches fire or not in our
  • 00:29:15
    final report the CSB recommended that
  • 00:29:18
    bp's Board of Directors establish a
  • 00:29:20
    system to encourage reporting of
  • 00:29:22
    incidents without fear of retaliation to
  • 00:29:25
    investigate and implement prompt
  • 00:29:27
    corrective actions and to communicate
  • 00:29:29
    lessons throughout the company the first
  • 00:29:37
    choice after an accident is to say how
  • 00:29:39
    can we improve the design so this can't
  • 00:29:41
    happen how can we remove the opportunity
  • 00:29:44
    for errors even as releases occurred
  • 00:29:47
    over many years in the I saw MuNet VP
  • 00:29:50
    continued using equipment based on
  • 00:29:52
    outdated designs the raffinate splitter
  • 00:29:55
    tower lacked modern design safeguards
  • 00:29:57
    such as redundant level indicators and
  • 00:29:59
    alarms a differential pressure indicator
  • 00:30:02
    and automatic interlocks to prevent
  • 00:30:04
    overfilling in a well-designed plant a
  • 00:30:07
    simple error at closing the road well
  • 00:30:09
    shouldn't result in an accident the
  • 00:30:11
    design of the emergency pressure relief
  • 00:30:13
    system was also outdated relief valves
  • 00:30:16
    vented hydrocarbons directly to the
  • 00:30:18
    atmosphere through an antiquated
  • 00:30:20
    blowdown drum which was first installed
  • 00:30:22
    in the 1950s the CSB report said the
  • 00:30:25
    hydrocarbons should have been routed to
  • 00:30:27
    an inherently safer disposal system such
  • 00:30:30
    as a flare to contain the hydrocarbon
  • 00:30:32
    liquid and burn off flammable vapor in
  • 00:30:35
    fact the investigation found that amico
  • 00:30:37
    zone safety standards later adopted by
  • 00:30:40
    BP stated that new blowdown stacks which
  • 00:30:43
    discharged directly to the atmosphere
  • 00:30:46
    are not permitted as facilities were
  • 00:30:49
    upgraded existing blowdown systems which
  • 00:30:51
    are still necessary should be replaced
  • 00:30:54
    several occasions prior to the incident
  • 00:30:57
    BP had seriously considered connecting a
  • 00:31:00
    flare to the ison unit in the early
  • 00:31:03
    1990s when amico owned the refinery
  • 00:31:05
    three proposals were made to replace
  • 00:31:08
    blowdown stacks at Texas City two more
  • 00:31:11
    proposals were made in 2002 after the
  • 00:31:14
    merger with BP however these decisions
  • 00:31:18
    were impacted by production pressures
  • 00:31:21
    and budget cuts and the flare was never
  • 00:31:24
    constructed
  • 00:31:24
    in 1992 OSHA conducted an inspection at
  • 00:31:28
    the Texas City refinery because there
  • 00:31:30
    had been released from a very similar
  • 00:31:32
    blowdown drum in a different process
  • 00:31:34
    unit OSHA cited the then amico refinery
  • 00:31:37
    for the unsafe blowdown system OSHA
  • 00:31:39
    determined that the design of the
  • 00:31:41
    blowdown drum was unsafe because it did
  • 00:31:43
    relieve the atmosphere it didn't relieve
  • 00:31:45
    to a safe place
  • 00:31:46
    but OSHA later withdrew the citation
  • 00:31:49
    after Amoco asserted the equipment
  • 00:31:51
    conformed to American Petroleum
  • 00:31:53
    Institute standards in October 2006 the
  • 00:31:56
    board issued a recommendation to the
  • 00:31:58
    American Petroleum Institute calling for
  • 00:32:01
    new guidelines that weren't against the
  • 00:32:02
    use of blowdown drums similar to those
  • 00:32:04
    found in Texas City we also recommended
  • 00:32:07
    that OSHA implement a national emphasis
  • 00:32:10
    program for all oil refineries focused
  • 00:32:13
    on the hazards of blowdown drums that
  • 00:32:15
    release to the atmosphere whenever
  • 00:32:17
    possible
  • 00:32:17
    companies should use inherently safer
  • 00:32:19
    systems such as flares instead of
  • 00:32:22
    blowdown drums
  • 00:32:27
    the presence of occupied trailers near
  • 00:32:30
    the blowdown stack added to the hazards
  • 00:32:32
    of venting flammable material to the
  • 00:32:34
    atmosphere prior to the incident and
  • 00:32:37
    prior to the start of the ison unit a
  • 00:32:39
    number of trailers occupy trailers have
  • 00:32:42
    been placed close to the I am unit these
  • 00:32:45
    these trailers were occupied by workers
  • 00:32:47
    who are not involved in the turnaround
  • 00:32:49
    activities in the ison unit the
  • 00:32:52
    investigation found this was a key
  • 00:32:54
    factor leading to the deaths of the
  • 00:32:56
    workers they were right on top of the
  • 00:32:58
    process in trailers too close to as
  • 00:33:02
    close as 120 feet from the blowdown
  • 00:33:04
    blowdown drum which is right at the edge
  • 00:33:06
    of the isomerization process CSB
  • 00:33:08
    investigator mark as niak well it is not
  • 00:33:11
    safe they have trailers that that close
  • 00:33:13
    to a blowdown drum or in the edge of an
  • 00:33:16
    active process in the immigrant
  • 00:33:17
    petroleum refinery during an explosion
  • 00:33:20
    in a refinery you're actually safer in
  • 00:33:22
    the open atmosphere than if you were
  • 00:33:23
    working inside of a trailer this is
  • 00:33:26
    because the explosion overpressure will
  • 00:33:29
    destroy the weak trailer construction
  • 00:33:31
    resulting in the formation of missiles
  • 00:33:33
    and loss collapsing which which is
  • 00:33:35
    potentially fatal to the occupants the
  • 00:33:38
    CSB determined that industry siting
  • 00:33:40
    guidelines did not adequately protect
  • 00:33:42
    trailer occupants from the fire and
  • 00:33:44
    blast damage that can occur hundreds of
  • 00:33:46
    feet from an explosion like the one at
  • 00:33:48
    BP we found that these guidelines were
  • 00:33:50
    not safe enough prior to this accident
  • 00:33:53
    and resulted in placing people in harm's
  • 00:33:57
    way
  • 00:33:58
    in addition BP did not follow its own
  • 00:34:00
    management have changed procedures
  • 00:34:02
    before placing most of the trailers in a
  • 00:34:05
    dangerous location they did not assess
  • 00:34:07
    the blast hazards posted the trailer and
  • 00:34:11
    action items that were created during
  • 00:34:13
    the review were never followed up and
  • 00:34:15
    correct
  • 00:34:15
    ultimately the decision on where to
  • 00:34:18
    place the trailers was largely based on
  • 00:34:20
    convenience not safety and contrary to
  • 00:34:24
    BP startup procedures on the morning of
  • 00:34:26
    March 23rd managers did not remove
  • 00:34:28
    personnel from the nearby trailers or
  • 00:34:30
    even alert them that the potentially
  • 00:34:33
    hazardous startup was taking place the
  • 00:34:36
    explosion totally destroyed 13
  • 00:34:39
    and damaged 27 others some as far away
  • 00:34:42
    as a thousand feet people inside
  • 00:34:45
    trailers as far away as 479 feet were
  • 00:34:49
    injured in October 2005 the CSB issued
  • 00:34:53
    an urgent recommendation to the American
  • 00:34:55
    Petroleum Institute to revise industry
  • 00:34:57
    standards and establish minimum safe
  • 00:34:59
    distances for occupied trailers away
  • 00:35:02
    from hazardous process areas On June
  • 00:35:05
    21st 2007 the American Petroleum
  • 00:35:08
    Institute issued new industry guidelines
  • 00:35:10
    to minimize the presence of people and
  • 00:35:13
    occupied trailers in hazardous process
  • 00:35:15
    areas for a long time people were saying
  • 00:35:23
    that most accidents were due to human
  • 00:35:25
    error and this is true in a sense but
  • 00:35:29
    it's not very helpful it's a bit like
  • 00:35:32
    saying that falls are due to gravity
  • 00:35:34
    there were a number of human errors that
  • 00:35:36
    contributed to the overfilling of the
  • 00:35:38
    tower and the disaster that followed at
  • 00:35:40
    Texas City no one shows up to work
  • 00:35:43
    planning to make mistakes so we looked
  • 00:35:45
    at the conditions in the workplace that
  • 00:35:47
    would make air more likely you really
  • 00:35:50
    need to look at why the operators did
  • 00:35:52
    what they did
  • 00:35:52
    CSB human factors specialist Cheryl
  • 00:35:55
    Mackenzie there were a number of human
  • 00:35:57
    factors issues involved with this
  • 00:35:59
    incident including a fatigue of the
  • 00:36:02
    workers training that was insufficient
  • 00:36:05
    and procedural deviations that occur
  • 00:36:08
    during startup the CSB investigation
  • 00:36:11
    found that underlying conditions in the
  • 00:36:13
    ison unit encouraged operators to
  • 00:36:15
    consciously deviate from written
  • 00:36:17
    operating procedures why do they make
  • 00:36:19
    that judgment I think they did because
  • 00:36:22
    these procedures were some of them were
  • 00:36:25
    out of date some of them were in
  • 00:36:26
    applicable they were routinely not
  • 00:36:29
    following his procedures and nobody had
  • 00:36:31
    said otherwise nobody had said hang on
  • 00:36:34
    you must be following these procedures
  • 00:36:36
    the investigation found that operators
  • 00:36:39
    were concerned that if they let the
  • 00:36:40
    liquid level in the tower get too low
  • 00:36:42
    during startups it would damage the
  • 00:36:44
    furnace so they had adopted an informal
  • 00:36:47
    procedure of adding extra liquid to the
  • 00:36:49
    tower during startup to
  • 00:36:51
    do this they placed the level control
  • 00:36:53
    valve in manual not the automatic mode
  • 00:36:55
    required by procedures and left the
  • 00:36:58
    valve closed to raise the liquid above
  • 00:37:00
    the recommended six and a half foot
  • 00:37:02
    level so routine had this practice
  • 00:37:05
    become the CSB found that the towers
  • 00:37:07
    high level alarm had activated sixty
  • 00:37:10
    five times during the previous nineteen
  • 00:37:13
    startups the outdated operating
  • 00:37:15
    procedures for the unit did not
  • 00:37:17
    establish an a safe upper limit for the
  • 00:37:19
    liquid level in the tower
  • 00:37:20
    unknown to operators regularly
  • 00:37:23
    overfilling the tower had serious risks
  • 00:37:25
    the towers liquid level transmitter had
  • 00:37:28
    a limited range and should the liquid
  • 00:37:30
    rise above the maximum reading of nine
  • 00:37:32
    feet operators could not know if the
  • 00:37:35
    tower was dangerously over filling this
  • 00:37:38
    informal practice of running the level
  • 00:37:41
    in the raffinate splitter tower above
  • 00:37:43
    the range of the transmitter led to
  • 00:37:46
    running blind they weren't aware of the
  • 00:37:49
    dangers of over filling the column and
  • 00:37:51
    so they tended to err on the side of
  • 00:37:55
    what they saw as caution by over filling
  • 00:37:57
    the column so their their systematic
  • 00:38:01
    deviation from what they should have
  • 00:38:03
    been doing was actually well intentioned
  • 00:38:05
    it was with the interest as a company at
  • 00:38:07
    heart that they were they were violating
  • 00:38:10
    the startup procedures but on the day of
  • 00:38:13
    the accident the routine deviation over
  • 00:38:16
    filling the tower above the range of the
  • 00:38:18
    indicator coincided with a number of
  • 00:38:20
    instrument failures which impaired the
  • 00:38:22
    board operators decision-making this had
  • 00:38:25
    tragic results as the board operator
  • 00:38:28
    lost awareness of just how high the
  • 00:38:29
    level was the tower level indicator had
  • 00:38:33
    been calibrated for years based on 1975
  • 00:38:36
    data for a different liquid used in a
  • 00:38:39
    different process as a result of the
  • 00:38:41
    miss calibration the indicator showed
  • 00:38:44
    the level in the tower was declining
  • 00:38:45
    just prior to the explosion when it was
  • 00:38:48
    actually increasing
  • 00:38:51
    and a backup high-level alarm on the
  • 00:38:53
    tower failed to activate seeming to
  • 00:38:55
    confirm that the liquid level was
  • 00:38:57
    dropping a sight glass on the tower was
  • 00:38:59
    dirty and unreadable and could not be
  • 00:39:02
    used to visually check the liquid level
  • 00:39:04
    the investigation concluded that the
  • 00:39:07
    board operator truly had no functional
  • 00:39:09
    and accurate measure of the tower level
  • 00:39:11
    on March 23rd 2005 and when the liquid
  • 00:39:16
    finally did spill over into the blowdown
  • 00:39:18
    drum the high-level alarm there failed
  • 00:39:21
    to go off BP procedures required that
  • 00:39:25
    alarms and instruments and other
  • 00:39:28
    equipment be checked for their
  • 00:39:30
    functionality prior to startup the CSB
  • 00:39:33
    determined that these checks were
  • 00:39:35
    largely not performed a poorly designed
  • 00:39:38
    computer display in the control room
  • 00:39:40
    added to the difficulty of determining
  • 00:39:43
    if the splitter tower was overfilling
  • 00:39:45
    liquid flows into and out of the tower
  • 00:39:47
    were not shown on the same screen even
  • 00:39:50
    though the computer could have been
  • 00:39:51
    configured to do so
  • 00:39:53
    the investigation also found that
  • 00:39:56
    communication problems among BP
  • 00:39:58
    personnel during the morning of the
  • 00:39:59
    startup increased the likelihood of
  • 00:40:01
    errors operators received contradictory
  • 00:40:04
    instructions on where to send the
  • 00:40:05
    products from the tower and the day
  • 00:40:08
    shift operators never got clear
  • 00:40:09
    information from the nightshift about
  • 00:40:11
    how much liquid the tower already
  • 00:40:13
    contained
  • 00:40:15
    well then the board operator and the
  • 00:40:17
    other operators that came in during the
  • 00:40:19
    day ship really didn't understand what
  • 00:40:21
    it occurred the night before so they're
  • 00:40:23
    starting up this unit without full
  • 00:40:25
    knowledge of the state of the unit and
  • 00:40:27
    they're making judgments and decisions
  • 00:40:30
    based on incomplete information the
  • 00:40:32
    investigation found that BP lacked
  • 00:40:35
    adequate policies and a management
  • 00:40:36
    emphasis on effective communications key
  • 00:40:40
    instructions on sending the feed into
  • 00:40:42
    the tower were given over the phone and
  • 00:40:44
    radio instead of in writing operators
  • 00:40:47
    later told investigators these verbal
  • 00:40:49
    communications were rushed and vague
  • 00:40:51
    written communications in the log book
  • 00:40:53
    were brief and unclear nightshift
  • 00:40:57
    operators did not conduct a crucial
  • 00:40:59
    face-to-face meeting to brief day shift
  • 00:41:01
    operators on the conditions in the unit
  • 00:41:03
    therefore they didn't realize how much
  • 00:41:07
    liquid was in the the tower and the
  • 00:41:09
    equipment so they added more which led
  • 00:41:11
    to the subsequent overfilling of the
  • 00:41:13
    tower which later led to the release the
  • 00:41:16
    opportunities for human error were
  • 00:41:18
    multiplied by the lack of adequate
  • 00:41:20
    supervision staffing and training at the
  • 00:41:23
    refinery training had been downsized and
  • 00:41:27
    that training was largely delivered
  • 00:41:30
    through computerized means rather than
  • 00:41:33
    face-to-face training BP did not train
  • 00:41:37
    operators on the hazards of overfilling
  • 00:41:39
    towers and training for abnormal
  • 00:41:42
    situations was insufficient despite
  • 00:41:45
    recommendations dating back five years
  • 00:41:47
    simulators were not used to train board
  • 00:41:50
    operators on making critical decisions
  • 00:41:52
    as noted in an internal BP email about
  • 00:41:56
    simulators three weeks after the
  • 00:41:58
    accident big pushback has always been
  • 00:42:01
    initial cost budget pressures also
  • 00:42:04
    impacted control room staffing BP
  • 00:42:07
    implemented a 25% cost reduction in 99
  • 00:42:11
    during the same time period
  • 00:42:13
    BP downsized the board operators in the
  • 00:42:17
    I am unit from two to one later BP at an
  • 00:42:22
    additional process unit to the
  • 00:42:25
    responsibilities of the board operator
  • 00:42:27
    in the ice on
  • 00:42:28
    unit the result was that you had three
  • 00:42:31
    complex refinery units under the
  • 00:42:34
    supervision of one board operator
  • 00:42:36
    according to BP zone assessment even
  • 00:42:39
    under normal conditions monitoring and
  • 00:42:42
    controlling these three units would
  • 00:42:44
    require ten and a half hours of the
  • 00:42:46
    board operators 12-hour shift
  • 00:42:48
    but the startup of the ison unit would
  • 00:42:50
    demand significantly more time and
  • 00:42:52
    attention from the operator whose
  • 00:42:54
    workload was already nearly full and
  • 00:42:56
    when the startup began to encounter
  • 00:42:58
    problems late that morning supervisory
  • 00:43:01
    oversight of the board operator was
  • 00:43:03
    absent
  • 00:43:04
    bp's own policies required that a
  • 00:43:07
    supervisor or technically trained person
  • 00:43:10
    be present during start-up because it's
  • 00:43:12
    an especially hazardous period a
  • 00:43:14
    supervisor who showed up on March 23rd
  • 00:43:17
    left due to a family emergency and there
  • 00:43:20
    was no replacement finally investigators
  • 00:43:23
    looked at the roll operator fatigue
  • 00:43:25
    played as a human factor contributing to
  • 00:43:28
    the accident fatigue can affect
  • 00:43:30
    performance in many ways that can a
  • 00:43:32
    cloud decision making it can delay
  • 00:43:34
    responses to actions on a control board
  • 00:43:37
    and it can lead an operator to miss out
  • 00:43:42
    on what's going on overall in a unit
  • 00:43:44
    fatigue can impair judgment it can lead
  • 00:43:46
    an operator to fixate on one operational
  • 00:43:49
    parameter such as the declining level
  • 00:43:52
    and lose track of other factors such as
  • 00:43:55
    liquid being added to the tower for
  • 00:43:58
    three hours and no liquid being removed
  • 00:44:00
    I Somme unit operators have been working
  • 00:44:03
    12-hour shifts for at least 29 days
  • 00:44:06
    prior to the accident in particular the
  • 00:44:09
    board operator was likely suffering from
  • 00:44:11
    fatigue including acute sleep loss and a
  • 00:44:14
    cumulative sleep debt of more than 43
  • 00:44:17
    hours we determined that BP had no
  • 00:44:20
    fatigue prevention policy and in fact
  • 00:44:23
    there was no fatigue for prevention
  • 00:44:24
    policy in the industry as a whole
  • 00:44:27
    companies and employees may believe they
  • 00:44:29
    benefit from overtime schedules
  • 00:44:31
    particularly during maintenance
  • 00:44:32
    turnarounds but operator fatigue can
  • 00:44:35
    have deadly consequences our final
  • 00:44:38
    report recommended that the United
  • 00:44:40
    Steelworkers and the American Patrol
  • 00:44:42
    institute develop new guidance on
  • 00:44:44
    preventing fatigue in the petrochemical
  • 00:44:46
    industry including limits on hours and
  • 00:44:48
    days at work
  • 00:44:55
    OSHA's 1992 standard on process safety
  • 00:44:58
    management or PSM requires thousands of
  • 00:45:02
    oil and chemical facilities to implement
  • 00:45:04
    14 management elements to prevent
  • 00:45:06
    catastrophic releases the Environmental
  • 00:45:09
    Protection Agency has similar
  • 00:45:10
    requirements under its risk management
  • 00:45:12
    program the CSB investigation revealed
  • 00:45:16
    many long-standing deficiencies in the
  • 00:45:19
    BP refineries compliance with federal
  • 00:45:21
    process safety regulations preventive
  • 00:45:24
    maintenance and testing procedures were
  • 00:45:26
    inadequate for key alarms instruments
  • 00:45:28
    and equipment required safety studies of
  • 00:45:31
    pressure relief systems we're years
  • 00:45:33
    overdue operating procedures were out of
  • 00:45:36
    date and there were other flaws
  • 00:45:38
    management of change reviews were not
  • 00:45:40
    conducted for critical design equipment
  • 00:45:43
    and procedural changes hazard analyses
  • 00:45:45
    were poor overlooking serious fire and
  • 00:45:48
    explosion risks audits revealed many
  • 00:45:51
    process safety problems but they were
  • 00:45:53
    never resolved OSHA's enforcement
  • 00:45:56
    program for the PSM regulations requires
  • 00:45:59
    planned comprehensive inspections of
  • 00:46:01
    facilities with accident histories or
  • 00:46:04
    other indications of catastrophic risks
  • 00:46:06
    a 1992 OSHA directive stated the primary
  • 00:46:10
    enforcement tool would be the program
  • 00:46:12
    quality verification inspection or pqv a
  • 00:46:16
    large complex audit involving highly
  • 00:46:19
    trained OSHA inspectors and taking weeks
  • 00:46:22
    or months to complete despite the fact
  • 00:46:25
    that the BPU Texas City refinery had a
  • 00:46:28
    long history of fatality incidents there
  • 00:46:31
    was no program quality verification or
  • 00:46:34
    intensive PSM inspection conducted at
  • 00:46:37
    that refinery OSHA did conduct smaller
  • 00:46:40
    unplanned inspections of the Texas City
  • 00:46:42
    refinery in response to accidents and
  • 00:46:44
    complaints but these inspections did not
  • 00:46:47
    uncover major flaws in process safety
  • 00:46:50
    management compliance in fact the CSB
  • 00:46:53
    found that OSHA conducted only a handful
  • 00:46:55
    of program quality verification pqv
  • 00:46:58
    inspections at the thousands of
  • 00:47:00
    regulated facilities across the country
  • 00:47:04
    there's no set interval when OSHA comes
  • 00:47:06
    in and inspects the plant in the United
  • 00:47:09
    States we found that inspections in the
  • 00:47:11
    US are largely driven by personal injury
  • 00:47:14
    statistics the CSB also found that prior
  • 00:47:18
    to March 2005 the EPA never audited the
  • 00:47:21
    Texas City refinery for compliance with
  • 00:47:23
    risk management requirements other
  • 00:47:26
    jurisdictions inspect process plants
  • 00:47:28
    more frequently in California's Contra
  • 00:47:31
    Costa County a local process safety
  • 00:47:33
    ordinance requires thorough inspections
  • 00:47:35
    of 48 major oil and chemical plants
  • 00:47:37
    every three years by a team of
  • 00:47:40
    specialized engineers in the United
  • 00:47:43
    Kingdom 105 specialists from the Health
  • 00:47:46
    and Safety Executive inspect high hazard
  • 00:47:48
    facilities every five years in addition
  • 00:47:51
    all nine refineries in the UK are
  • 00:47:53
    inspected annually if accepted process
  • 00:47:56
    safety principles had been thoroughly
  • 00:47:58
    implemented at the refinery
  • 00:47:59
    thus accident likely would not have
  • 00:48:02
    occurred the CSB recommended that OSHA
  • 00:48:05
    takes steps to conduct more process
  • 00:48:07
    safety inspections and strengthen
  • 00:48:09
    enforcement of the PSM standard OSHA
  • 00:48:12
    should identify those facilities at
  • 00:48:14
    greatest risk see the comprehensive
  • 00:48:16
    inspections are conducted at such
  • 00:48:18
    facilities and to establish the capacity
  • 00:48:21
    to conduct those inspections OSHA should
  • 00:48:23
    create a group of highly trained PSM
  • 00:48:25
    inspectors on June 12 2007 OSHA
  • 00:48:30
    announced a new national emphasis
  • 00:48:31
    program to inspect most US oil
  • 00:48:34
    refineries for process safety compliance
  • 00:48:43
    I participated in the panel because I
  • 00:48:45
    lost a near and dear friend in this
  • 00:48:47
    incident a personal friend of mine was
  • 00:48:49
    killed in this incident and I thought it
  • 00:48:52
    was very important that that the
  • 00:48:55
    management systems be looked at with a
  • 00:48:58
    fresh set of eyes early in the
  • 00:49:00
    investigation of the Texas City accident
  • 00:49:02
    the CSB observed what appeared to be a
  • 00:49:05
    pattern of safety deficiencies we
  • 00:49:07
    therefore issued an urgent
  • 00:49:09
    recommendation the first ever by this
  • 00:49:11
    agency that BP convene an independent
  • 00:49:14
    panel of experts to study the safety
  • 00:49:16
    culture of its five North American
  • 00:49:18
    refineries in October 2005 BP
  • 00:49:22
    established an 11 member panel that
  • 00:49:24
    included leading industry labor and
  • 00:49:26
    academic safety experts it was headed by
  • 00:49:29
    former Secretary of State James a baker
  • 00:49:31
    the third the panel found that BP did
  • 00:49:35
    not ensure as a matter of best practices
  • 00:49:38
    that its management implemented a
  • 00:49:41
    comprehensive and effective process
  • 00:49:43
    safety management system the report
  • 00:49:47
    issued in 2007 concluded there were
  • 00:49:50
    instances of a lack of operating
  • 00:49:52
    discipline toleration of serious
  • 00:49:54
    deviations from safe operating practices
  • 00:49:56
    and apparent complacency toward serious
  • 00:49:59
    process safety risks at each of BP's
  • 00:50:02
    North American refineries the Baker
  • 00:50:05
    panel also voiced concern that other
  • 00:50:07
    companies share similar problems ladies
  • 00:50:10
    and gentlemen we are under no illusion
  • 00:50:12
    that such deficiencies are in fact
  • 00:50:16
    limited to BP one of the things that I'd
  • 00:50:19
    like to see personally after having
  • 00:50:22
    served on the Baker panel is that we
  • 00:50:24
    will never have another incident of this
  • 00:50:27
    magnitude the number of people that were
  • 00:50:29
    killed a number of lives that were
  • 00:50:31
    changed so many good hard-working people
  • 00:50:34
    go to work every day and too often some
  • 00:50:37
    never return I think the work that we
  • 00:50:41
    did in the Baker panel I believe that if
  • 00:50:44
    this if our work is applied within our
  • 00:50:46
    industry we will not see another BP
  • 00:50:51
    explosion
  • 00:50:52
    the baker panel report concluded that
  • 00:50:55
    the restructuring following bp's merger
  • 00:50:57
    with amico have resulted in a
  • 00:50:59
    significant loss of people expertise and
  • 00:51:01
    experience in the refining sector only
  • 00:51:04
    much later did BP recognize the negative
  • 00:51:07
    impact of these changes the CS B's final
  • 00:51:10
    report said all hazardous chemical
  • 00:51:13
    operations should be required to review
  • 00:51:15
    the safety impact of major
  • 00:51:16
    organizational changes the board
  • 00:51:19
    recommended that OSHA amend its process
  • 00:51:21
    safety management standard to require
  • 00:51:23
    management of change reviews for mergers
  • 00:51:26
    acquisitions personnel reductions budget
  • 00:51:28
    cuts or other organizational changes
  • 00:51:31
    that can impact Process Safety we also
  • 00:51:34
    recommended that the Center for chemical
  • 00:51:36
    process safety develop guidelines on how
  • 00:51:39
    to perform organizational management of
  • 00:51:41
    change reviews
  • 00:51:48
    the major problem of the chemical
  • 00:51:50
    industry and indeed with other
  • 00:51:51
    industries is the way accidents are
  • 00:51:54
    investigated reports are written
  • 00:51:56
    circulating read filed away and then
  • 00:51:59
    forgotten and then ten years later even
  • 00:52:04
    in the same company the accident happens
  • 00:52:06
    again there is a saying that
  • 00:52:09
    organizations have no memory only people
  • 00:52:12
    have memory once they leave the plant
  • 00:52:14
    the accident occurred that is forgotten
  • 00:52:16
    about and what companies must do in the
  • 00:52:19
    petrochemical industry is realized that
  • 00:52:21
    the fact that you've had 20 years
  • 00:52:22
    without a catastrophic catastrophic
  • 00:52:24
    event is no guarantee that there won't
  • 00:52:27
    be one tomorrow you have to keep your
  • 00:52:29
    eye on the ball constantly all oil and
  • 00:52:31
    chemical businesses should seek to learn
  • 00:52:33
    from the tragedy at BP the CSB believes
  • 00:52:36
    there are key lessons to be drawn from
  • 00:52:38
    our investigation the CSB said managers
  • 00:52:42
    executives and boards of directors
  • 00:52:43
    should do the following monitor process
  • 00:52:46
    safety performance using appropriate
  • 00:52:48
    indicators invest sufficient resources
  • 00:52:51
    to correct problems maintain an open and
  • 00:52:54
    trusting safety culture where near
  • 00:52:56
    misses are reported and investigated
  • 00:52:58
    ensure that non-essential personnel and
  • 00:53:01
    work trailers are located a safe
  • 00:53:03
    distance from hazardous process areas
  • 00:53:06
    ensure equipment and procedures are
  • 00:53:08
    maintained and up-to-date carefully
  • 00:53:11
    manage organizational changes and budget
  • 00:53:13
    decisions to ensure safety is not
  • 00:53:15
    compromised analyze and correct the
  • 00:53:18
    underlying causes of human errors
  • 00:53:20
    including fatigue and miscommunication
  • 00:53:23
    finally boards of directors must
  • 00:53:25
    exercise their duty to ensure that the
  • 00:53:28
    highest standards of safety are met the
  • 00:53:34
    BP tragedy was years in the making but
  • 00:53:37
    it was by no means inevitable we hope
  • 00:53:40
    our investigation will provide all of
  • 00:53:42
    industry with valuable lessons to assure
  • 00:53:45
    such a tragedy will not be repeated for
  • 00:53:48
    the CSB s final report key investigation
  • 00:53:52
    documents the Baker panel report and
  • 00:53:54
    other information please visit the
  • 00:53:57
    Chemical Safety Board website at CSB dot
  • 00:54:01
    b.p cooperated with the CSB
  • 00:54:04
    investigation and provided documents and
  • 00:54:06
    witnesses voluntarily after the Texas
  • 00:54:09
    City accident
  • 00:54:10
    BP acted to relocate trailers eliminate
  • 00:54:13
    blowdown drums and invest billions of
  • 00:54:16
    dollars to upgrade the condition of its
  • 00:54:18
    US refineries in 2007 BP accepted the
  • 00:54:22
    recommendations of the Baker panel
  • 00:54:23
    including a call to become a recognized
  • 00:54:26
    industry leader in process safety
  • 00:54:28
    management
Tags
  • BP explosion
  • Texas City
  • industrial accident
  • safety failures
  • process safety
  • Chemical Safety Board
  • CSB investigation
  • organizational deficiencies
  • cost-cutting
  • safety culture