BP TEXAS CITY REFINERY,

23 March 2005Group 3

BACKGROUND

The largest and most complex oil refinery, with a rated capacity of 460,000 barrels per day (bpd) and

production of up to 11 million gallons of gasoline a day

It also produces jet fuels, diesel fuels and chemical feed stocks

The refinery has 30 process units spread over a 1,200-acre site and employs about 1,800 permanent

BP staff

The disaster resulting in 15 death and more than 170 injuries and significant

economic losess

INCIDENT

On the morning of March 23, 2005, the raffinate splitter tower in the refinery’s ISOM unit was restarted

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 procedure.

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.

CAUSE OF THE DISASTER

The refinery had been in operation since 1934 but

had not been well maintained in several

years

An alarm meant to warn about the quantity of liquid in the unit was

disabled

The tower had been started by ignoring open

maintenance orders on the tower’s instrumentation

system

Emission of hot flammable vapors and liquids was expelled from the vent

stack.

Lack of drawn-down from the tower was recognized

A diesel pick up truck was parked near the blow

down stack which act as a source of ignition for the Vapor Cloud Explosion

IMPACT OF THE DISASTER

IMPACTExplosions and fires killed 15 people

At least 105 people were injured.

Financial losses exceeding $1.5

billion Houses were damaged as far away as three-

quarters of a mile from the refinery

The explosion and fire left a lot of destruction and

rubble at the plant

It also sent a plume of thick and black smoke hundreds feet into the air.

STANDARD IN THE PRACTICE

OSHA should update and strengthen its 1992 standard on

Process Safety Management of

Highly Hazardous Chemicals

For example, facilities should be

required to report to OSHA when their

use of highly hazardous chemicals

in large quantities meets the standards’

provisions for coverage

The standard currently covers

flammable, explosive and toxic chemicals, but not chemicals that can

undergo a catastrophic

runaway reaction.

• to develop new guidelines to ensure that occupied trailers and similar temporary structures are placed safely away from hazardous areas of process plants

• revise Recommended Practice 521.Guide for Pressure Relieving and Depressuring Systems to identify the hazards of this equipment

American Petroleum

Institute (API)

• To issue a safety alert urging their members to take prompt action to ensure that trailers are safely located

National Petrochemical and

Refiners Association (NPRA)

LESSON LEARNT

For the Baker Report, he focused more on the Process Safety rather than personal safety

It can be divided into 3 component:Corporate Safety CultureProcess Safety Management SystemPerformance Evaluation, Corrective Action, Corporate Oversight

Corporate

Safety Cultur

e

• BP Board did not exercise good Process Safety leadership• BP corporate did not provide appropriate resources to assure

adequate process safety• BP managers did not incorporate process safety into management

decision making

Process

Safety Manageme

nt Syste

ms

• BP’s US refineries did not comply with its own internal process safety standards

• BP refineries did not implement good engineering practices• Process safety knowledge and competence was not

maintained at BP US refineries

Performance Evaluat

ion, Correct

ive Action, Corpor

ate Oversig

ht

• BP measured safety performance through personal injury rate, rather than measuring process safety equipment performance

• The process safety audit system was inadequate

US Chemical Safety and Hazard Investigation Board (CSB)

BP Group Board did not provide effective oversight of the company’s safety culture and

major accident prevention programs.

BP Senior Executives• Inadequately addressed controlling major hazard risk, particularly process safety

performance;• Did not provide effective safety culture leadership and oversight to prevent

catastrophic accidents

BP Texas City Managers• Lacked an effective mechanical integrity program to maintain instruments and

process safety equipment• Incorporate good practice design in the operation of hazardous• chemical systems

RECOMMENDATION

Employee should put safety as the main priority. A course on occupational

and health should be conducted annually.

Put the hazard sign on every hazardous

material.

Replace the blowdown drum

with the inherently flare system.

Put a sensor on the splitter tower, so that liquid can be

measured precisely.

Increase the capacity of the flare system.

Ban the other companies that using the same

blowdown drum.

THANK YOU