Accidental Business Report

By

Farooq Ahmed Memon

Orasoft Institue

BBA 2nd semister

INVESTIGATION REPORT

REFINERY EXPLOSION AND FIRE

BP TEXAS CITY

March 23 2005

S. No. Contents Page

No.

1 Preface

2 Letter of authorization

3 Letter of Transmittal

4 Introduction

5 Text of Report

IntroductionEXECUTIVE SUMMARY

Incident synopsis

Scope of investigations

Bp group and Texas city

Observations

Incident Description

Health and Safety

Ignition Source

6 Conclusion

7 Recommendation

8 Appendix

BP Texas City Company

31, Oil Refinery,

Texas

20 May 2005

Mr. T.M John

131/9 Texas City

Texas.

Dear Sir,

Having accepted your terms and conditions laid down in your letter dated 27th instant., the Board of Directors

authorizes to you to make a report on the commercial prospects of BP Texas City Company to be manufactured

by the firm vide letter No. BP/Rep/85/ dated 20th May 2005. You are requested to submitted your report to the

undersigned with in 15 days by 15th June 2005.

You are hereby, assured of all sorts of assistance and help possible from the staff and Executive at any time.

Let this letter be acknowledge and also mentions the date on which you are going to start your work

Your faithfully,

S/d

Managing Director

BP Texas City Company

131/9, Texas

Texas.

To,

The Managing Director,

BP Texas City Company

Texas.

Dear Sir,

In response of your letter No. BP/RED 85 dated 23 March 2005 regarding a report to be prepared

by me on the subjected which comprises of three parts along with the recommendations and

suggestions. I hope that you will find the report beneficial for the business of the company.

Will you please be kind enough to communicate your views? It would be highly regarded if I were

given a chance to appear before you and explain any of the aspect of the report at your office at

any time by appointment.

Your Truly

s/d

T.M John

EXECUTIVE SUMMARY

Incident synopsis

On March 23, 2005, at 1:20 p.m., the BP Texas City Refinery suffered

one of the worst industrial disasters in recent U.S. history. Explosions

and fires killed 15 people and injured another 180, alarmed the

community, and resulted in financial losses exceeding $1.5 billion. The

incident occurred during the startup of an isomerization1 (ISOM) unit

when a raffinate splitter tower2 was overfilled; pressure relief devices

opened, resulting in a flammable liquid geyser from a blowdown stack

that was not equipped with a flare. The release of flammables led to an

explosion and fire. All of the fatalities occurred in or near office

trailers located close to the blowdown drum. A shelter-in-place order

was issued that required 43,000 people to remain indoors. Houses were

damaged as far away as three-quarters of a mile from the refinery.

The BP Texas City facility is the third-largest oil refinery in the United

States. Prior to 1999, Amoco owned the refinery. BP merged with

Amoco in 1999 and BP subsequently took over operation of the plant.

BP Group and Texas City

The Texas City disaster was caused by organizational and safety

deficiencies at all levels of the BP Corporation. Warning signs of a

possible disaster were present for several years, but company officials

did not intervene effectively to prevent it. The extent of the serious

safety culture deficiencies was further revealed when the refinery

experienced two additional serious incidents just a few months after

the March 2005 disaster. In one, a pipe failure caused a reported $30

million in damage; the other resulted in a $2 million property loss. In

each incident, community shelter-in-place orders were issued.

This investigation was conducted in a manner similar to that used by

the Columbia Accident Investigation Board (CAIB) in its probe of the

loss of the space shuttle. Using the CAIB model, the CSB examined

both the technical and organizational causes of the incident at Texas

City

Incident Description

On the morning of March 23, 2005, the raffinate splitter tower in the refinery’s

ISOM unit was restarted after a maintenance outage. During the startup,

operations personnel pumped flammable liquid hydrocarbons into the tower

for over three hours without any liquid being removed, which was contrary to

startup procedure instructions. Critical alarms and control instrumentation

provided false indications that failed to alert the operators of the high level in

the tower. Consequently, unknown to the operations crew, the 170-foot (52-m)

tall tower was overfilled and liquid overflowed into the overhead pipe at the

top of the tower.

The overhead pipe ran down the side of the tower to pressure relief valves located

148 feet (45 m) below. As the pipe filled with liquid, the pressure at the bottom

rose rapidly from about 21 pounds per square inch (psi) to about 64 psi. The

three pressure relief valves opened for six minutes, discharging a large

quantity of flammable liquid to a blowdown drum with a vent stack open to

the atmosphere. The blowdown drum and stack overfilled with flammable

liquid, which led to a geyser-like release out the 113-foot (34 m) tall stack.

This blowdown system was an antiquated and unsafe design; it was originally

installed in the 1950s, and had never been connected to a flare system to safely

contain liquids and combust flammable vapors released from the process.

Incident Description

The released volatile liquid evaporated as it fell to the ground

and formed a flammable vapor cloud. The most likely source

of ignition for the vapor cloud was backfire from an idling

diesel pickup truck located about 25 feet (7.6 m) from the

blowdown drum. The 15 employees killed in the explosion

were contractors working in and around temporary trailers

that had been previously sited by BP as close as 121 feet (37

m) from the blowdown drum.

BP Corporate and Texas City Refinery Background

On March 23, 2005, an explosion and fires occurred at the BP refinery in

Texas City, Texas, 30 miles southeast of Houston. The refinery, the

company’s largest worldwide, can produce about 10 million gallons of

gasoline per day (about 2.5 percent of the gasoline sold in the United States)

for markets primarily in the Southeast, Midwest, and along the East Coast. It

also produces jet fuels, diesel fuels, and chemical feed stocks; 29 oil refining

units and four chemical units cover its 1,200 acre site. The refinery employs

approximately 1,800 BP workers, and at the time of the incident,

approximately 800 contractor workers were onsite supporting turnaround13

work. The site has also had numerous changes in management at both the

refinery and corporate levels.

Raffinate Splitter Section

On the day of the incident, the startup of the ISOM raffinate splitter section

was initiated. It was during this startup that the tower was overfilled with

liquid. This section describes the relevant equipment involved in the startup

on March 23, 2005.

The raffinate splitter section took raffinate -- a non-aromatic, primarily

straight-chain hydrocarbon mixture -- from the Aromatics Recovery Unit

(ARU) and separated it into light and heavy components. About 40 percent

of the raffinate feed was recovered as light raffinate (primarily

pentane/hexane). The remaining raffinate feed was recovered as heavy

raffinate, which was used as a chemicals feedstock, JP-4 jet fuel, or

blended into unleaded gasoline. The raffinate splitter section could process

up to 45,000 barrels per day (bpd)16 of raffinate feed.

Flammable Vapor Cloud Formation and Fire

The liquid hydrocarbon release time was calculated using computerized control

system data points and the flow times from DIERS modeling (Appendix H). The

flammable vapor cloud reached a wide area, as is clearly evident by the burned

area shown in a post-explosion photo (Figure 10).

The burned area is estimated to be approximately 200,000 square feet (18, 581

m2). Two mechanisms explain how the vapor cloud covered an area this size in

such a short interval: the first was direct dispersion from evaporation prior to

ignition that was responsible for the bulk of the dispersal, and the second was

“pushing” of flammable vapors as subsonic flames burned through the flammable

cloud. The hydrocarbon liquid cascading down the stack and blowdown drum

coupled with the impact of the falling liquid onto process equipment, structural

components, and piping, promoted fragmentation into relatively small droplets,

thereby enhancing evaporation and the formation of the flammable vapor cloud

Atmospheric wind also helped push the vapors and small

droplets downwind, causing them to mix with air. The wind

direction at the time of the incident was reported to be out of the

northwest traveling southeast at 5 miles (8 km) per hour and as

Figure 10 shows, the burned area is elongated in that direction.

However, portions of the vapor cloud also went upwind and

cross wind (Appendix H.10.1), which placed the trailer area

within the flammable cloud covered area.

Ignition Source

Blast Pressure

Once ignited, the flame rapidly spread through the flammable

vapor cloud, compressing the gas ahead of it to create a blast

pressure wave. Furthermore, the flame accelerated each time a

combination of congestion/confinement and flammable mix

allowed, greatly intensifying the blast pressure in certain areas.

These intense pressure regions, or sub-explosions, produced

heavy structural damage locally and left a pattern of structural

deformation away from the blast center in all directions. A computer

simulation49 and a blast overpressure map were developed based

on site observations, structural analysis, and blast modeling.

Fatalities and Injuries

In the explosion, 15 contract employees working in or near the trailers

sited between the ISOM and the NDU unit were killed. Autopsy reports

revealed that the cause of death for all 15 was blunt force trauma,

probably resulting from being struck by structural components of the

trailers. Three occupants in the Quality Assurance/Quality Control

(QA/QC) trailer perished, and 12 of 20 workers inside the double-wide

trailer were killed; the others were seriously injured.

A total of 180 workers at the refinery were injured, 66 seriously enough

that they had days away from work, restricted work activity, or medical

treatment. The majority of these suffered multiple injuries, typically

combinations of: fractures, lacerations, punctures, strains, sprains,

and/or second- and third-degree burns. Of the seriously injured, 14

were BP employees; the rest were contractor employees from 13

different firms. Of the 114 workers given first aid, 35 were BP

employees; 79 were contract employees from 14 different contracting

firms. None of the contract workers in the area surrounding the ISOM

were personnel essential to the startup of the unit.

Equipment and Facility Damage

The most severe blast damage occurred within the ISOM unit, from the

trailer area to the catalyst warehouse (Figure 13), and the surrounding

parking areas. The satellite control room was severely damaged and the

catalyst warehouse was destroyed. Many of the approximately 70

vehicles in the vicinity of the ISOM unit were damaged and a number

were destroyed. More than 40 trailers were damaged; 13 were destroyed.

On June 30, 2006, the CSB released a detailed analysis of the trailer

damage, which can be viewed or downloaded from the CSB website,

Post-Incident Emergency Response

The emergency response teams made a rapid and effective effort to help the

injured and recover the victims. Texas City Industrial Mutual Aid System

(IMAS) member companies responded and assisted with fire hose lines and

search-and-rescue. None of the emergency response personnel were injured

during rescue efforts.

The blast produced a large debris field of damaged trailers and vehicles

located between the NDU and ISOM units. To recover victims from this area,

the site was necessarily disturbed by the emergency responders. Debris,

vehicles, and equipment were moved to initiate search-and-rescue and

recover the fatally injured. As operators and emergency responders entered

the ISOM unit to isolate the plant, some valve positions were changed, but no

records were kept to document these changes. Therefore, there was no

record of the actual state of some of the valves at the time of the incident,

information that is important when trying to reconstruct the incident and

determine its causes.

Ineffective and Insufficient Communication Among Operations Personnel

Two critical miscommunications occurred among operations personnel on

March 23, 2005, that led to the delay in sending liquid raffinate to storage: 1)

the instructions for routing raffinate products to storage tanks were not

communicated from Texas City management and supervisors to operators;

and 2) the condition of the unit – specifically, the degree to which the unit

was filled with liquid raffinate – was not clearly communicated from night

shift to day shift.68 These lapses in communication were the result of BP

management’s lack of emphasis on the importance of communication. BP

had no policy for effective shift communication,69 nor did it enforce formal

shift turnover or require logbook/procedural records to ensure

communication was clearly and appropriately disseminated among

operating crew

BP Actions After the Explosion

In its internal investigation of the March 23, 2005 explosion,

BP adopted new policies for trailer siting at its facilities.

Appendix 37 in the “Fatal Accident Investigation Report”

(Mogford, 2005) outlines the specifics of BP’s new siting

policy; trailer siting is now based on exclusion zones for

areas where explosions are possible, and all occupied trailers

should be located outside of vulnerable areas even if this

means a location outside the refinery. A large number of

Texas City personnel were relocated to a permanent building

away from the refinery after the incident.

Conclusion

Based on the analysis of the relief system, the blowdown drum was

undersized and the emergency relief system design did not address the

potential of a large liquid release in the event the raffinate splitter tower

overfilled. After the March 23, 2005, incident, BP evaluated the 22 blowdown

systems at its five U.S. refineries and found that 17 handled flammables. BP

has publicly pledged to eliminate all atmospheric blowdown systems in

flammable service at all five of its U.S. refineries. requires that relief system

designs comply with “recognized and generally accepted good engineering

practices.” Published PSM compliance guidelines call for inspections to

ensure that “destruct systems, such as flares, are in place and operating”

and that “pressure relief valves and rupture discs are properly designed

and discharge to a safe area” (CPL 2-2.45A, 1994). Therefore, the CSB

recommended that OSHA implement a special emphasis program for oil

refineries to focus on blowdown drums that discharge directly to the

atmosphere and their design

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