texas city refinery explosion 2005 emily ackerman, yu-chieh cheng, roshni pillai, gustavo santos,...
TRANSCRIPT
Texas City Refinery Explosion 2005
Emily Ackerman, Yu-Chieh Cheng, Roshni Pillai, Gustavo Santos, Rishikesh Shetty
Outline
❏Overview of the accident❏Flow Diagram❏Operational Misbehavior❏Investigation report findings❏TELOS Survey ❏Reparations❏Ethical Implications
❏ Safety❏ Environment
❏Cultural Causes ❏Industry Lessons
Overview of the accident
❏BP took over the Texas City Refinery from Amoco in 1999
❏Produced 11 million gallons of gasoline a day
❏On March 23rd, 2005 a blast occurred during the startup of the isomerization unit which produces materials to boost the octane rating of gasoline
❏The explosion killed 15 workers and injured 180 others
❏Shattered windows of homes and businesses up to three quarters of a mile away from the 1,200 acre refinery
Flow Diagram of Isomerization Unit
Operational Misbehavior
❏The level transmitter (LT):
❏ Monitored only the bottom 9 ft section of the tower, with a Low Level Alarm (LAL) and a High Level Alarm (LAH), programmed to sound at 72% and 90%, respectively
❏ However, during the unit start-up, operators state that it was common practice to operate at higher liquid levels.
❏Wrong indication of temperature:
❏ The temperature ramp was more than 2x higher than it was supposed to be
❏Level control valve failure: ❏ When the level was found too high, the bottom pump was turned on in
order to drain the bottom of the tower. This increased the feed temperature
Investigation Report Findings
❏ The U.S. Chemical Safety and Hazard Investigation Board (CSB) was the primary investigator into the incident
❏ Key findings : Lax attitude of BP’s management towards process safety Production pressure controlled the safety culture Weak and dismantled HS&E department
❏ BP’s focus on cost cutting and headcount reduction, critically compromised a safe working environment
❏ Poor supervision of critical activities like startups and shutdowns highlight the incompetency of BP’s technical staff
❏ Unusually, OSHA (Occupational Safety and Health Administration) was criticized for weak inspection and implementation of regulations for such high hazard industries
TELOS Survey:❏In late 2004, Researchers from safety culture consultant the Telos
Group surveyed 1,080 employees, interviewing 112 including the leadership team and supervisors.
❏ Important findings :❏ Production pressures impact managers “where it appears as though
they must compromise safety”❏ ”Production and budget compliance gets recognized and rewarded
before anything else at Texas City”❏ “The pressure for production, time pressure, and understaffing are
the major causes of accidents at Texas City”❏ Many employees also reported “feeling blamed when they had gotten
hurt or they felt investigations were too quick to stop at operator error as the root cause” with a “culture of casual compliance”
Reparations
❏BP was fined $21 million for the incident for “egregious willful violations” of rules and regulations that governed the industry
❏ They also signed a settlement agreement with BP which emphasizes workers and their safety as BP’s primary goal
❏In a 2007 speech, BP's CEO said the company would spend $1.7 billion more on safety each year for the next four years
❏OSHA fined BP $87 million in 2009 (the largest fine in OSHA history) for failing to repair many of the safety problems that led to the blast.
❏ BP agreed to pay $50 million in 2010
Safety Ethics
❏Budget cuts reigned the refinery despite safety concerns ❏Training staff was cut, creating an unwelcoming atmosphere and
under qualified operators and engineers ❏ Downsized from ~30 people to 8 people within 10 years before the
accident❏BP did not replace the known out of date facilities
❏ Plans for flare tower implementation in 2002
❏ Created workplace hazard
❏Major process steps and precautions were ignored
❏ Lack of training or part of training??
Environmental Ethics
❏After investigation, the plant was charged for violating Texas' air quality laws
❏The plant released 538,000 pounds of toxic chemicals into the air over the period of a month, including 17,300 pounds of benzene, a known carcinogen
❏Environmental experts state that the release ranks among the worst air quality violations in Texas in the last decade
❏BP did not alter its lack of concern and attitude towards the environment
❏ The Prudhoe Bay and Deepwater Horizon oil spills occurred soon after
Deepwater Horizon
Cultural Causes
❏The United States loves oil and places a large emphasis on domestic production over imports
❏ At an all time high since the early 1970’s
❏American jobs are dependent on large corporations ❏ People around the refinery accepted the explosion because it was their
livelihood
❏Attitude that a tough job comes with risky side effects❏ Lack of concern for those involved
❏65 people have died in refinery accidents since then (largely underestimated)
❏ No changes
Industry Lessons
❏Use past accidents as an example for creating new ethical guidelines
❏When an incident happens, employees should take proper response to address it and learn from the mistakes so that large scale accidents do not occur in the future.
❏Effective monitoring of the facilities ensures that every process design is functioning well and up to date with current technology.
❏Do not use budget cuts to justify the use of outdated equipment
❏This awareness contributes to the cultivation of a safe and ethical workplace
References1 - "BP Texas City Explosion - YouTube." 2008. 13 Nov. 2015 <https://www.youtube.com/watch?v=VCcN4SQkb9A>
2 - 2013. U.S. Chemical Safety and Hazard Investigation Board. Investigation Report - Refinery Fire and Explosion and Fire. BP Texas City March 23, 2005
3 - full CSB response to OSHA's Request for Information - US ..." 2014. 13 Nov. 2015 <http://www.csb.gov/assets/1/16/CSB_RFIcomments.pdf>
4 -- "Final Investigation Report - US - - Chemical Safety and ..." 2013. 13 Nov. 2015 <http://www.csb.gov/assets/1/19/csbfinalreportbp.pdf>
5 - BP OSHA Settlement Agreement - US - - Chemical Safety ..." 2013. 12 Nov. 2015 <http://www.csb.gov/assets/1/19/BP_OSHA_Settlement_Agreement.pdf>
6 - "2012 - 07/12/2012 - BP agrees to pay more than $13 million ..." 2012. 12 Nov. 2015 <https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=22680>
7 - "Blast at BP Texas Refinery in '05 Foreshadowed Gulf Disaster." 2010. 12 Nov. 2015 <http://www.propublica.org/article/blast-at-bp-texas-refinery-in-05-foreshadowed-gulf-disaster>
8 - "A Deadly Industry - EHS Today." 2015. 12 Nov. 2015 <http://ehstoday.com/safety/deadly-industry>
THANK YOU!
QUESTIONS?