Issue Briefing Paper: BP Safety Record – Texas City, Texas

Flathead Basin Commission

Kalispell, MT 59901

406.752.0081

fbc@mt.gov

www.flatheadbasincommission.org

Texas City Incident

On March 23, 2005, explosions at the BP America Refinery in Texas City, Texas occurred that claimed the lives of 15 workers and injured 170 others. The explosions and fires occurred during an infrequent startup of an isomerization (ISOM) unit used to convert low-octane blending feeds into higher-octane components for unleaded gasoline. During startup, a cloud of hydrocarbon vapor was accidentally released from a fractionating column and ignited. All of the fatalities occurred in temporary trailers used by contract workers supporting turnaround work. These trailers were placed too close to process units that handle highly hazardous materials. The U.S. Chemical Safety Board (CSB) issued preliminary findings on October 27, 2005, and the Occupational Safety and Health Administration (OSHA) announced fines of more than $21 million on September 22, 2005. The accident occurred when operators started up a tower called a raffinate splitter. The tower and associated piping were over-filled and over-pressurized. This resulted in hydrocarbons flowing from the tower into a blow-down drum, which was vented to atmosphere through a tall stack. The blow down drum filled completely with flammable liquid, and a geyser erupted out of the stack. A large flammable vapor cloud developed at ground level and drifted underneath the trailers housing the contract workers. The CSB issued recommendations to the BP Global Executive Board of Directors, the American Petroleum Institute (API), and the National Petroleum and Refiners Association (NPRA).

Many of the CSB findings point to management culture issues at BP. Investigators also questioned the effectiveness of programs associated with mechanical integrity, hazards analysis, change control, and incident investigations. Other issues of concern in the March 23 accident include fatigue, downsizing of supervision and training, workload, and the use of obsolete equipment. In regard to fatigue it was noted that on the day of the incident, some of the BP operators had worked 30 straight, 12-hour days, and some had a 2-hour commute time.

Also, it was noted that there were no supervisors with appropriate experience overseeing the startup on the day of the incident. BP Texas City went from 38 trainers in 1998 to just 9 in 2005. In terms of the ISOM unit that malfunctioned, a single control-board operator was responsible for running the controls of three different complex process units, including the ISOM unit. Finally, the blow down drum and stack were 50-year-old technology, and they were rebuilt in the 1990s according to the original design, which was known to be antiquated and unsafe. OSHA conducted an investigation of the refinery accident and, as a result, cited BP with numerous safety violations totaling $21,361,500 in penalties. OSHA inspectors identified 12 willful safety and health violations. Willful violations are those committed with the intentional disregard of, or plain indifference to, the requirements of OSHA regulations. Inspectors also identified 22 serious safety and health violations. A serious violation is one in which there is a substantial probability that death or serious physical harm could result and the employer knew or should have known of the hazard. Many of these violations are not direct causal factors of the accident; however, the sheer number of citations indicates that problems with process safety existed throughout the site. The following are examples of the cited violations:

·               Failure to install intrinsically safe electrical equipment in hazardous locations;

·               Failure to correct deficiencies in equipment that are outside acceptable limits for the pressure relief header subsystem, liquid knockout subsystem, blow down drum stack, blow down snuffing stream, blow down vessel, quench system, raffinate tower sight glass, and 69 pieces of equipment tied into the pressure relief system in the ISOM unit;

·               Failure to adequately evaluate the safety and health impact of a catastrophic blast on temporary trailers located near the ISOM unit;

·               Failure to ensure that the emergency shutdown procedure for ISOM unit included specific;

·               Information for emergency shutdown of the raffinate splitter;

·               Failure to ensure operators followed startup procedure and the procedure was not written;

·               Failure to ensure refresher training at least every 3 years (operators did not understand;

·               Parameters concerning blow down and raffinate tower);

·               Failure to inform each affected contractor prior to startup of the raffinate splitter; and

·               Numerous source vessels relieved to atmosphere through the blow down stack, which was not in a safe location and which was in poor condition.

Despite the fact that DOT does not operate refineries, the six key safety issues identified by CSB have relevance to DOT facility operations, particularly in the use of trailers and temporary structures. It is important to consider area hazards when sitting trailers and to ensure that adequate safety setback is provided for the protection of workers. In many cases, trailers are located for reasons of convenience (e.g., ready access to work areas) rather than for reasons of safety. In the BP accident, the trailers did not need to be located as close as they were to the process areas for the workers to perform their jobs. BP’s policy did not consider danger to the occupants when staging trailers for short periods of time. Unfortunately, none of the fatalities would have occurred if the trailers had been safely located.