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Case Study: BP Texas City Explosion 23 March 2005

of these suffered multiple injuries, typically combinations of: fractures, lacerations, punctures, strains, sprains, and/or second- and third-degree burns.  None of the contract workers in the area surrounding the ISOM were personnel essential to the startup of the unit.


In their initial analysis of the accident at Texas City (the Mogford Report), BP identified five main underlying causes:

Firstly, over the years the working environment had eroded to one characterized by resistance to change and lack of trust, motivation and purpose. Expectations around supervisory and management behavior were unclear. Rules were not followed consistently. Individuals felt disempowered from suggesting or initiating improvements

Secondly, process safety, operations performance and systematic risk reduction priorities had not been set nor consistently reinforced by management. Safety lessons from other parts of BP were not acted on.

Thirdly, many changes in a complex organization – both of structure and personnel - led to a lack of clear accountabilities and poor communication. The result was workforce confusion over roles, responsibilities and priorities

The fourth cause focused on poor hazard awareness and understanding of process safety on the site - resulting in people accepting higher levels of risk.

And finally, poor performance management and vertical communication in the refinery meant there was no adequate early warning system of problems and no independent means of understanding the deteriorating standards in the plant through thorough audit of the organization.


With an incident of this scale, the lessons learned are almost endless. But at the facility level seven stand out:

The need to ensure plant leadership teams have the time to focus on day-to-day operations and aren’t distracted by too many competing demands. Managers need to know what’s happening in their control rooms and on the plant.

The need to capture the right metrics that indicate process safety trends; do not get seduced by personal accident measures, they have their place but do not warn of incidents such as this one.

Procedures are ineffective if they are not up-to-date and routinely followed.

The importance of two-way communication. If people believe leaders aren’t listening or don’t appear to be taking team members’ concerns seriously, then soon they stop raising them. We must keep our promises to each other. It’s the first step in rebuilding trust and the only way to earn the respect and obtain the commitment of the workforce. This is about staying in touch, being aware, being responsible and listening.


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