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Case Study: British Petroleum (BP) Texas City Explosion 23 March 2005

References:(a) U.S. Chemical Safety And Hazard Investigation Board Investigation

Report No. Refinery Explosion And Fire (15 Killed, 180 Injured), Report 2005-04-I-TX, March 2007

(b) The B.P. U.S. Refineries Independent Safety Review Panel (Baker

Panel Report)

(c) Managing the Risks of Organizational Accidents, James Reason

(d) Managing the Unexpected, Weick and Suttcliff

(e) Fatal Accident Investigation Report, Isomerization Unit Explosion

Interim Report (Mogford Report), Texas City, Texas, May 12, 2005

Summary

A series of failures by BP personnel before and during the startup of the Isomerization (ISOM) process unit in the Texas City refinery led to an explosion and fire that killed 15 workers and injured more than 180 people.  

The proximate cause for the explosion was BP ISOM unit managers and operators greatly overfilled and then overheated the Raffinate Splitter (a distillation column that separates gasoline blending components). The fluid level in the tower at the time of the explosion was nearly 20 times higher than it should have been.  Simply targeting the mistakes of BP’s operators and supervisors misses the underlying and significant cultural, human factors, and organizational causes of the disaster.  The causal chain that led to this organizational accident started more than five years earlier.

The number of deaths and injuries was greatly increased by the presence of workers in temporary trailers near the blow down stack and the failure to evacuate personnel when it became apparent pressure was building in the ISOM unit and that vapors were being vented to the atmosphere.

This case study is based on the U.S. Chemical Safety And Hazard Investigation Board Investigation completed in March 2007 (see their web page for references and videos) since most people who should understand the contributing causes to this accident are not going to read the entire 341 page report. The purpose of this summary of Texas City explosion is to emphasize a) how differently this facility was operated from what is the norm among organizations that aspire to the title of High Reliability Organizations and b) how the operator failures on the day of the explosion were just a small part of the extensive senior leadership failures that existed at the facility.  The causes of this incident are eerily similar to the those faulted for the deaths of five Navy divers aboard the USS Grayback in 1982 (inadequate design, inadequate instrumentation, inadequate maintenance, inadequate procedures, inadequate training, complacent attitude, inadequate communications, acceptance of abnormal conditions, and slow response to casualty).

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