Case Study: BP Texas City Explosion 23 March 2005
The importance of investigating process incidents and loss of containment incidents the same way serious injuries are investigated. Document all incidents thoroughly. Share what you learn.
The value of having an effective feedback loop to capture and incorporate into operating procedures and training programs lessons learned from earlier incidents and process upsets
And lastly, keep non-essential personnel out of process areas. Take a hard look at any potential blast impact zones. And if you must have temporary structures near process areas make sure they are blast resistant. The safest way to protect your people is to move them outside of blast zones.
So in conclusion, the factors which contributed to the explosion at Texas City were years in the making and will require concerted, sustained commitment to rectify.
These lessons look very similar to the safety culture of the Navy Nuclear Power Program.
From the Baker Panel report (Admiral Bowman was one of the panel members):
Preventing process accidents requires vigilance. The passing of time without a process accident is not necessarily an indication that all is well and may contribute to a dangerous and growing sense of complacency. When people lose an appreciation of how their safety systems were intended to work, safety systems and controls can deteriorate, lessons can be forgotten, and hazards and deviations from safe operating procedures can be accepted. Workers and supervisors can increasingly rely on how things were done before, rather than rely on sound engineering principles and other controls. People can forget to be afraid. When systems and controls deteriorate, everything can come together in the worst possible way. Equipment malfunctions and controls fail. An explosion and fire occur. People lose their lives or suffer horrible injuries. Families and communities are devastated.