Case Study: BP Texas City Explosion 23 March 2005
Trailers are primarily used as temporary offices at the Texas City Refinery to support contract workers involved in project work and turnarounds. When a trailer is to be sited within 350 feet of a process unit there is specific requirement that a Facility Siting Analysis be performed.
Several trailers involved in the incident were located between two operating units, the ISOM and the Naphtha Desulfurization Unit (NDU). When the site completed a comprehensive study of occupied buildings in 1997, this location for siting trailers was not identified as an area of concern (ERROR). The closest trailer, a doublewide J.E. Merit trailer, was located within 150ft of the base of the F-20, and is where most of the fatalities were located at the time of the explosion..
A Dangerous Place to Work
In the 30 years before the ISOM incident, the Texas City site suffered 23 fatalities. In 2004 alone three major incidents caused three fatalities. Many of the safety problems that led to the March 23, 2005, disaster were recurring problems that had been previously identified in audits and investigations.
The disaster at Texas City had organizational causes, which extended beyond the ISOM unit, embedded in the BP refinery’s history and culture. BP Group executive management became aware of serious process safety problems at the Texas City refinery starting in 2002 and through 2004 when three major incidents occurred. BP Group and Texas City managers were working to make safety changes in the year prior to the ISOM incident, but the focus was largely on personal rather than process safety (process safety is “a discipline that focuses on the prevention of fires, explosions and accidental chemical releases at chemical process facilities.” Process safety management applies management principles and analytical tools to prevent major accidents rather than focusing on personal safety issues such as slips, trips and falls). As personal injury safety statistics improved, BP Group executives stated that they thought safety performance was headed in the right direction.
Process safety performance continued to deteriorate at Texas City. This decline, combined with a legacy of safety and maintenance budget cuts from prior years, led to major problems with mechanical integrity, training, and safety leadership. In the wake of the merger with Amoco, the resulting organizational changes to safety management led to a de-emphasis of major accident prevention.