Texas City Refinery Explosion 2005

Emily Ackerman, Yu-Chieh Cheng, Roshni Pillai, Gustavo Santos, Rishikesh Shetty

Outline

❏Overview of the accident❏Flow Diagram❏Operational Misbehavior❏Investigation report findings❏TELOS Survey ❏Reparations❏Ethical Implications

❏ Safety❏ Environment

❏Cultural Causes ❏Industry Lessons

Overview of the accident

❏BP took over the Texas City Refinery from Amoco in 1999

❏Produced 11 million gallons of gasoline a day

❏On March 23rd, 2005 a blast occurred during the startup of the isomerization unit which produces materials to boost the octane rating of gasoline

❏The explosion killed 15 workers and injured 180 others

❏Shattered windows of homes and businesses up to three quarters of a mile away from the 1,200 acre refinery

Flow Diagram of Isomerization Unit

Operational Misbehavior

❏The level transmitter (LT):

❏ Monitored only the bottom 9 ft section of the tower, with a Low Level Alarm (LAL) and a High Level Alarm (LAH), programmed to sound at 72% and 90%, respectively

❏ However, during the unit start-up, operators state that it was common practice to operate at higher liquid levels.

❏Wrong indication of temperature:

❏ The temperature ramp was more than 2x higher than it was supposed to be

❏Level control valve failure: ❏ When the level was found too high, the bottom pump was turned on in

order to drain the bottom of the tower. This increased the feed temperature

Investigation Report Findings

❏ The U.S. Chemical Safety and Hazard Investigation Board (CSB) was the primary investigator into the incident

❏ Key findings : Lax attitude of BP’s management towards process safety Production pressure controlled the safety culture Weak and dismantled HS&E department

❏ BP’s focus on cost cutting and headcount reduction, critically compromised a safe working environment

❏ Poor supervision of critical activities like startups and shutdowns highlight the incompetency of BP’s technical staff

❏ Unusually, OSHA (Occupational Safety and Health Administration) was criticized for weak inspection and implementation of regulations for such high hazard industries

TELOS Survey:❏In late 2004, Researchers from safety culture consultant the Telos

Group surveyed 1,080 employees, interviewing 112 including the leadership team and supervisors.

❏ Important findings :❏ Production pressures impact managers “where it appears as though

they must compromise safety”❏ ”Production and budget compliance gets recognized and rewarded

before anything else at Texas City”❏ “The pressure for production, time pressure, and understaffing are

the major causes of accidents at Texas City”❏ Many employees also reported “feeling blamed when they had gotten

hurt or they felt investigations were too quick to stop at operator error as the root cause” with a “culture of casual compliance”

Reparations

❏BP was fined $21 million for the incident for “egregious willful violations” of rules and regulations that governed the industry

❏ They also signed a settlement agreement with BP which emphasizes workers and their safety as BP’s primary goal

❏In a 2007 speech, BP's CEO said the company would spend $1.7 billion more on safety each year for the next four years

❏OSHA fined BP $87 million in 2009 (the largest fine in OSHA history) for failing to repair many of the safety problems that led to the blast.

❏ BP agreed to pay $50 million in 2010

Safety Ethics

❏Budget cuts reigned the refinery despite safety concerns ❏Training staff was cut, creating an unwelcoming atmosphere and

under qualified operators and engineers ❏ Downsized from ~30 people to 8 people within 10 years before the

accident❏BP did not replace the known out of date facilities

❏ Plans for flare tower implementation in 2002

❏ Created workplace hazard

❏Major process steps and precautions were ignored

❏ Lack of training or part of training??

Environmental Ethics

❏After investigation, the plant was charged for violating Texas' air quality laws

❏The plant released 538,000 pounds of toxic chemicals into the air over the period of a month, including 17,300 pounds of benzene, a known carcinogen

❏Environmental experts state that the release ranks among the worst air quality violations in Texas in the last decade

❏BP did not alter its lack of concern and attitude towards the environment

❏ The Prudhoe Bay and Deepwater Horizon oil spills occurred soon after

Deepwater Horizon

Cultural Causes

❏The United States loves oil and places a large emphasis on domestic production over imports

❏ At an all time high since the early 1970’s

❏American jobs are dependent on large corporations ❏ People around the refinery accepted the explosion because it was their

livelihood

❏Attitude that a tough job comes with risky side effects❏ Lack of concern for those involved

❏65 people have died in refinery accidents since then (largely underestimated)

❏ No changes

Industry Lessons

❏Use past accidents as an example for creating new ethical guidelines

❏When an incident happens, employees should take proper response to address it and learn from the mistakes so that large scale accidents do not occur in the future.

❏Effective monitoring of the facilities ensures that every process design is functioning well and up to date with current technology.

❏Do not use budget cuts to justify the use of outdated equipment

❏This awareness contributes to the cultivation of a safe and ethical workplace

References1 - "BP Texas City Explosion - YouTube." 2008. 13 Nov. 2015 <https://www.youtube.com/watch?v=VCcN4SQkb9A>

2 - 2013. U.S. Chemical Safety and Hazard Investigation Board. Investigation Report - Refinery Fire and Explosion and Fire. BP Texas City March 23, 2005

3 - full CSB response to OSHA's Request for Information - US ..." 2014. 13 Nov. 2015 <http://www.csb.gov/assets/1/16/CSB_RFIcomments.pdf>

4 -- "Final Investigation Report - US - - Chemical Safety and ..." 2013. 13 Nov. 2015 <http://www.csb.gov/assets/1/19/csbfinalreportbp.pdf>

5 - BP OSHA Settlement Agreement - US - - Chemical Safety ..." 2013. 12 Nov. 2015 <http://www.csb.gov/assets/1/19/BP_OSHA_Settlement_Agreement.pdf>

6 - "2012 - 07/12/2012 - BP agrees to pay more than $13 million ..." 2012. 12 Nov. 2015 <https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=22680>

7 - "Blast at BP Texas Refinery in '05 Foreshadowed Gulf Disaster." 2010. 12 Nov. 2015 <http://www.propublica.org/article/blast-at-bp-texas-refinery-in-05-foreshadowed-gulf-disaster>

8 - "A Deadly Industry - EHS Today." 2015. 12 Nov. 2015 <http://ehstoday.com/safety/deadly-industry>

THANK YOU!

QUESTIONS?