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Case Study: BP Texas City Explosion 23 March 2005


The Texas City refinery is owned and operated by BP Products North America, Inc. It is BP’s largest and most complex refinery with a rated capacity of 460,000 barrels per day and an ability to produce 11 million gallons of gasoline a day.



Isomerization is a refining process that alters the fundamental arrangement of atoms in the molecule without adding or removing anything from the original material. The ISOM unit converts low octane blending feeds into higher octane components for blending to unleaded regular gasoline and JP-4 jet fuel.  The unit at Texas City consists of four sections: a desulfurizer, a reactor, a vapor recovery/liquid recycle unit, and a raffinate splitter. The Splitter section consists of a surge drum, fired heater reboiler and a fractionating column 164 feet tall.


Organizational Accidents

Organizational accidents have been defined as low-frequency, high-consequence events with multiple causes that result from the actions of people at various levels in organizations with complex and often high-risk technologies (Reason, 1997). Safety culture authors have concluded that safety culture, risk awareness, and effective organizational safety practices found in high reliability organizations (HROs) are closely related, in that “[a]ll refer to the aspects of organizational culture that are conducive to safety” (Hopkins, 2005). These authors indicate that safety management systems are necessary for prevention, but that much more is needed to prevent major accidents. Effective organizational practices, such as encouraging that incidents be reported and allocating adequate resources for safe operation, are required to make safety systems work successfully (Hopkins, 2005 citing Reason, 2000).


Safety Culture

The U.K. Health and Safety Executive describes safety culture as “the product of individual and group values, attitudes, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organization’s health and safety programs” (HSE, 2002). The CCPS cites a similar definition of process safety culture as the “combination of group values and behaviors that determines the manner in which process safety is managed” (CCPS, 2007, citing Jones, 2001). Well-known safety culture authors James Reason and Andrew Hopkins suggest that safety culture is defined by collective practices, arguing that this is a more useful definition because it suggests a practical way to create cultural change. More succinctly, safely culture can be defined


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