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Case Study: BP Texas City Explosion 23 March 2005

Texas City management’s cost-cutting resulted in a greater reliance on its operations personnel, specifically the frontline operators, and less on hardware improvements. Yet the company had been significantly reducing the number of these frontline operators since the 1996 Amoco staffing study examined all units for potential staffing cutbacks. And training of the reduced operations personnel was less than adequate because [surprise] the train staff had been downsized.

While the ISOM unit was shut down, the operators were on a tight schedule and split into two crews working 12-hour shifts with no days off, which would continue for the duration of the shutdown and until the unit was back to normal operation after the shutdown (in excess of 30 days for some). The ISOM day shift shut down maintenance crew consisted of one board operator (six years experience) and five outside operators (two with over 15 years ISOM experience, one with seven months experience, and two trainees).

Incident Description

Now we are ready to properly understand the blow by blow account of the incident details.  The startup of the raffinate section of the ISOM unit took place over two shifts: the night shift on March 22, 2005, and the day shift that began at 6 a.m. on March 23.

The incident occurred during the startup of the raffinate splitter section of the ISOM unit when the raffinate splitter tower was overfilled. Flammable liquid was released, vaporized, and ignited, resulting in an explosion and fire. The following section describes the events leading up to the incident, the resulting damage, and the key errors that created the accident.

Pre-Startup Safety Review (PSSR)

BP had a rigorous pre-startup procedure prior to the incident that required all startups after maintenance to go through a Safety Review. While the PSSR had been applied to unit startups after turnarounds for two years prior to this incident, the process safety coordinator responsible for an area of the refinery that includes the ISOM was unfamiliar with it, and therefore, no PSSR procedure was conducted. If the PSSR, which called for a formal safety review by a technical team led by the operations superintendent, had been implemented, a technical team would have been assigned to verify the adequacy of all ISOM safety systems and equipment, including procedures and training, process safety information, alarms and equipment functionality, and instrument testing and calibration. The PSSR required sign-off that all non-essential personnel had been removed from the unit and neighboring units and that the operations crew had reviewed the startup procedure. Given the dubious safety culture maturity in affect at the time of the accident (more details below) and the cavalier attitude toward procedural compliance that management tolerated it seems doubtful the PSSR would have accomplished much even if one had been done.  Higher level management, such as the Texas City Operations


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