Presentation to the 40th Loss Prevention Symposium

CSB Investigation of the Explosionsand Fire at the BP Texas City Refinery on March 23, 2005

April 26, 2006Orlando, Florida

CSB Lead Investigator Don Holmstrom

Disclaimer

The PowerPoint presentation is given for general informational purposes only. The presentation represents the individual views of the Board member and all references, conclusions or other statements regarding current on going CSB investigations are preliminary in nature and do not represent a formal adopted product of the entire Board. Users of this presentation should also note that the contents were compiled solely for this presentation. For specific and accurate information on completed investigations, please refer to the final printed version by going to the CSB website at www.csb.gov. and clicking on the specific report desired under completed investigations

Incident Summary• March 23, 2005

• Flammable vapor cloud, explosions, fire, and toxic release

• 15 deaths

• 170 injuries

• Offsite property damage

• Occurred during startup

• Tower overfilled and overpressured

• Blowdown drum filled

• Vapor cloud formed

• Trailers too close to blowdown drum

Incident Summary

Preliminary Findings

Trailer Siting All of the fatalities and many of the serious

injuries occurred in or around the nine contractor trailers that were sited near process areas and as close as 121 feet from the isom blowdown drum

Trailers had been periodically sited in and around process areas handling highly hazardous materials for reasons of convenience such as ready access to work areas

Trailer Siting

• Trailers were placed in an unsafe location, too close to a process unit handling highly hazardous materials

Trailer Siting

Under BP’s siting policy, trailers used for short periods of time such as turnaround trailers were considered as posing little or no danger to occupants

This approach conforms with the safety guidance published in Recommended Practice 752 by the American Petroleum Institute (API)

Trailer Siting

API 752 provides no minimum safe distances from process hazards for the location of trailers used in refineries and other chemical facilities

Trailers are not generally designed to protect the occupants from fire and explosion hazards

The CSB issued urgent recommendations to API and NPRA on ensuring the safe location of occupied trailers away from hazardous process areas

Unit Start-up: Mechanical Integrity Issues The raffinate splitter tower was started up

despite malfunctioning key process instrumentation and equipment on the day of the incident

– Tower level indicator and sight glass

– Tower high level alarm

– Blowdown drum high level alarm

– Tower 3 lb. pressure valve

Unit Start-up: Mechanical Integrity Issues

Proper working order of key process instrumentation was not checked as required by the start-up procedure

Unit operations management turned away instrument technicians and signed off on the checks as if they had been completed

The unit should not have been started up with existing malfunctions of the level indicator, level alarm, and a control valve

Unit Start-ups Operations personnel did not open the tower

level control valve at the time specified in the start-up procedures; the operator did not balance the flow of hydrocarbons in and out of the tower

The tower level was actually rising rapidly for three hours

A false level indication showing the tower level declining was a factor in the delay in removing liquid from the tower

Unit Start-ups Start-up procedures did not address the

importance of maintaining a balance of hydrocarbon flow in and out of the tower

The tower was not equipped with additional instrumentation indicating tower level

A History of Abnormal Unit Start-ups

In 16 startups of the ISOM unit from April 2000 to March 23, 2005:

– Eight experienced at least two times the normal pressure (> 40 psi vs. 20 psi)

– Thirteen had liquid levels above the range of the level indicator (> 10 ft, some lasting as long as four hours)

A History of Abnormal Unit Start-ups BP did not investigate previous raffinate

splitter tower start-ups with high pressures and high levels, despite being required by BP policy

Investigations of these incidents could have resulted in improvements to tower design, instrumentation, procedures, and controls

Management Oversight and Accountability

BP management did not assure that an experienced supervisor was in the unit during startup to provide oversight, as specified in BP policies

At 10 am the supervisor in charge left the unit for a family emergency, but no substitute with ISOM operating experience was assigned

Process Design The blowdown drum and stack

were outdated and unsafe because they released flammable hydrocarbons to the atmosphere that ignited rather than to a safe location, such as a flare system

Process Design Amoco safety standards last revised in

1994 state that blowdown drums should be connected to a flare when major modifications are made

In 1997, Amoco replaced the blowdown drum and stack with identical equipment rather than connecting the drum to a safer location such as a flare system

After the merger in 1999, BP adopted the Amoco safety standard for blowdown drums

Process Design

In 2002, BP evaluated connecting the blowdown drum to a flare system as part of an environmental initiative but did not pursue this option

Previous Blowdown Drum and Stack Incidents In 1992, OSHA cited and fined Amoco on the

hazardous design of a similar blowdown drum and stack at the Texas City refinery

In a settlement agreement, OSHA withdrew the citation and the fine, and the refinery continued to use blowdown drums without flares

Previous Blowdown Drum and Stack Incidents

Since 1995, four releases from the blowdown drum sent hydrocarbons to the stack and sewer, generating flammable vapor clouds at ground level

Vehicles

BP’s traffic policy allowed vehicles unrestricted access near process units

Approximately 55 vehicles were located in the vicinity of the blowdown drum and stack

Two running vehicles may have provided sources of ignition for the incident; one was within 25 feet of the blowdown drum

The CSB issued an urgent recommendation that BP form an independent panel to study their safety culture.

Future Investigative Activities

Analyze root causes and develop additional safety recommendations

Issue final report at public meeting in Texas City in Fall 2006

Questions