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Case Study: BP Texas City Explosion 23 March 2005

Process unit startup is a significantly more hazardous period compared to normal oil refinery operations and BP’s Texas City policies and procedures acknowledged this, recommending that supplemental, experienced supervisors, operating specialists, or technically trained personnel be assigned during unit startups and shutdowns. A basis for this policy was a previous explosion at Texas City during startup. In 1996, the prior owner of Texas City, Amoco, analyzed data from 15 years of operations and concluded that incidents during startups were 10 times more likely than during normal operation.  Despite these guidelines and increased risks, there is no record that management formally evaluated application of these policies or waived them for the ISOM startup (ERROR). This is just one of many instances of wide deviation between written policies and actual practice at Texas City.

Unit Staffing

In the years preceding the incident, the concern about insufficient staffing had been raised numerous times. In 2001, a Management of Change (MOC) analysis was conducted when a new process unit was added to the refinery and its board responsibilities were added to those of the ISOM board operator. An action item stated: “Extend the requirement to have two board operators for any planned startup or planned shutdown activities.” Even though the MOC analysis required two Board Operators for any startup, Texas City management did not implement this recommendation for startups of the raffinate section of the ISOM unit. Instead, a second board operator was brought in only during selected times during ISOM startup.

This was not the first time that operations personnel recognized the need for two board operators during startup and shutdown. A 1996 Amoco staffing assessment of all units in the refinery stated: “Personnel are concerned that under a minimum staffing scenario they would be unable to manage historic upsets [problems we have seen before and should expect to experience again].” Then in 1999, a MOC for the consolidation of the ISOM with another unit resulted in a recommendation to revise the ISOM planned startup and shutdown procedures to require that an additional independent/dedicated board operator be present to help with critical transitions during times of unit startup and shutdown. Five months prior to the incident, an experienced ISOM supervisor expressed concern to Operations Management that two board operators were needed to safety operate all three units, particularly during times of unit upsets. In January 2005, the Telos safety culture assessment informed BP management that at the production level, plant personnel felt that one major cause of accidents at the Texas City facility was understaffing, and that staffing cuts went beyond what plant personnel considered safe levels for plant operation.

Despite a history of recommendations and requests for additional staffing during times of unit startup and shutdown, Amoco and BP management cut staffing budgets in the years prior to the March 23, 2005, incident.


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