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Page 1: BP Texas Explosion

BP Texas City Refinery Fire & Explosion

March 23, 2005

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The USA's third-largest refinery, with a processing capacity of 470,000 barrels per day of oil

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The explosion on Wednesday 23-03-2005, afternoon at the BP (Research) plant in Texas City, Texas, outside Houston, killed more than 14 people.

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The Isomerization Process

• BP Isomerization unit:– Isomerization process increases the Octane rating of

Gasoline by which straight chain HCs are converted to branched chain HCs;

– Raffinate splitter tower separates light & heavy gasoline components;

– Raffinate: the portion of the original liquid that remains after the other components have been dissolved by a solvent

– Raffanate consists of BTX, Hexane & Cycloheptane and are highly flammable

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Source courtesy: CSB Video animation

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What happened?• Raffinate splitter tower was overfilled with liquid

due to errors in instrumentation & flaws in start-up procedures;

• The tower was over heated, pressurized and pressure relief operated;

• HC flowed into the BD drum & stack;• HC overflowed through top of BD stack forming

a pool below; and• The vapour cloud formed resulted in a VCE.

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The animated sequence of events

CSB Animation Video6m15s

You can get this great video and animation from CSB ‘free of charge’ if you write to them

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Raffinate Splitter Blowdown Drum and ISOM Unit after explosion

BP Texas City ExplosionBefore and After

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The devastating power of explosions!! It can virtually level anything. Only blast walls can mitigate the effects. Source courtesy: Internet

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Firefighers and rescue personnel search the rubble for victims following an explosion at the BP-Amoco plant in Texas City.

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BP Texas City ExplosionBP Fatal Accident Investigation

• Loss of Containment• Raffinate splitter start-up

procedure and applicaton of knowledge and skills

• Control of work and trailer siting

• Desgn and engineering of the blowdown stack

The report identified four critical areas:

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BP Texas City ExplosionBaker Report

The report identified numerous failings in equipment, risk management, staff management, working culture at the site, maintenance & inspection & general health & safety assessments.

• BP management had not distinguished between “occupational safety” & “process safety”

• Their metrics, incentives, and management systems focused on measuring & managing occupational safety & confused improving trends in occupational safety statistics for a general improvement in all types of safety.

• An employee survey showed that managers & white collar workers had a rosier view of process safety culture than blue collar operators and maintenance techs.

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BP Texas City ExplosionUS Chemical Safety Board Report

• The effectiveness of the safety management system at BP Texas refinery

• The effectiveness of BP North America’s corporate safety oversight of it’s refining facilities

• A corporate safety culture that may have tolerated serious longstanding deviations from good safety practice

An interim report cited serious concerns about:

• Cost cutting and a ‘cheque book’ mentality

• Failure of all levels of BP management including the board

The final report headlines two major issues:

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What went wrong?

• BP Management over-looked warning signs of a possible catastrophic accident;

• BP Management had a typical ‘Cheque-Book mentality’;

• Antiquated equipment design;

• Siting of occupied trailers near ISOM unit; and

• Human errors.

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Source courtesy: CSB Video animation

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Source courtesy: CSB Video animation

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Fines & Warnings ignored!!

• The Occupational Safety and Health Administration fined the refinery nearly $110,000 after two employees were burned to death by superheated water in September 2004.

• Another explosion forced the evacuation of the plant for several hours last March. Afterward, OSHA fined the refinery $63,000 for 14 safety violations, including problems with its emergency shutdown system and employee training.

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Key Lessons Learnt…

• Learn from organization memory;• If no accident has occurred till today, that

does not mean that no accident is going to happen!

• Monitor process safety performance using appropriate indicators;

• Invest sufficient resources to correct problems; and

• Maintain an open & trusting safety culture.

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Key lessons learnt

• Ensure that non-essential personnel & work trailers are located away from hazardous process areas;

• Ensure equipment & procedures are maintained up to date; and

• Carefully manage organizational changes and budget decisions to ensure safety is not compromised.

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