Case Study: BP Texas City Explosion 23 March 2005
Root and Contributing Causes
BP Group Board did not provide effective oversight of the company’s safety culture and major accident prevention programs.
inadequately addressed controlling major hazard risk. Personal safety was measured, rewarded, and the primary focus, but the same emphasis was not put on improving process safety performance;
did not provide effective safety culture leadership and oversight to prevent catastrophic accidents;
ineffectively ensured that the safety implications of major organizational, personnel, and policy changes were evaluated;
did not provide adequate resources to prevent major accidents; budget cuts impaired process safety performance at the Texas City refinery.
BP Texas City Managers did not:
create an effective reporting and learning culture; reporting bad news was not encouraged. Incidents were often ineffectively investigated and appropriate corrective actions not taken.
ensure that supervisors and management modeled and enforced use of up-to-date plant policies and procedures.
incorporate good practice design in the operation of the ISOM unit. Examples of these failures include:
no flare to safely combust flammables entering the blowdown system;
lack of automated controls in the splitter tower triggered by high-level, which would have prevented the unsafe level; and
inadequate instrumentation to warn of overfilling in the splitter tower.
ensure that operators were supervised and supported by experienced, technically trained personnel during unit startup, an especially hazardous phase of operation; or that
effectively incorporated human factor considerations in its training, staffing, and work schedule for operations personnel.
BP Texas City managers:
lacked an effective mechanical integrity program to maintain instruments and process equipment. For example, malfunctioning instruments and equipment were not repaired prior to startup.
did not have an effective vehicle traffic policy to control vehicle traffic into hazardous process areas or to establish safe distances from process unit boundaries.