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    Texaco Refinery, Milford Haven Chemical Processing 1994: Timeline of The Accident

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    Ahmad Pahrin
    1) In March 1994, operators at the Texaco oil refinery in Milford Haven, Wales improperly filled a distillation tower, causing it to overflow and explode. The explosion killed 15 people and injured 180. 2) The operators had received conflicting instructions about the tower's automatic controls and had improperly restarted filling after taking the tower offline. There was also no plant supervisor overseeing operations. 3) A government investigation found safety systems had deficiencies, including alarms that failed to activate and displays that did not clearly show inflows and outflows. Budget cuts had undermined process safety performance.

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    Texaco Refinery, Milford Haven Chemical Processing 1994: Timeline of The Accident

    Uploaded by

    Ahmad Pahrin
    80 views1 page
    1) In March 1994, operators at the Texaco oil refinery in Milford Haven, Wales improperly filled a distillation tower, causing it to overflow and explode. The explosion killed 15 people and injured 180. 2) The operators had received conflicting instructions about the tower's automatic controls and had improperly restarted filling after taking the tower offline. There was also no plant supervisor overseeing operations. 3) A government investigation found safety systems had deficiencies, including alarms that failed to activate and displays that did not clearly show inflows and outflows. Budget cuts had undermined process safety performance.

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    Texaco refinery

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    1) In March 1994, operators at the Texaco oil refinery in Milford Haven, Wales improperly filled a distillation tower, causing it to overflow and explode. The explosion killed 15 people and injured 180. 2) The operators had received conflicting instructions about the tower's automatic controls and had improperly restarted filling after taking the tower offline. There was also no plant supervisor overseeing operations. 3) A government investigation found safety systems had deficiencies, including alarms that failed to activate and displays that did not clearly show inflows and outflows. Budget cuts had undermined process safety performance.

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    © All Rights Reserved
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    80 views1 page

    Texaco Refinery, Milford Haven Chemical Processing 1994: Timeline of The Accident

    Uploaded by

    Ahmad Pahrin
    1) In March 1994, operators at the Texaco oil refinery in Milford Haven, Wales improperly filled a distillation tower, causing it to overflow and explode. The explosion killed 15 people and injured 180. 2) The operators had received conflicting instructions about the tower's automatic controls and had improperly restarted filling after taking the tower offline. There was also no plant supervisor overseeing operations. 3) A government investigation found safety systems had deficiencies, including alarms that failed to activate and displays that did not clearly show inflows and outflows. Budget cuts had undermined process safety performance.

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    © All Rights Reserved
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    Texaco Refinery, Milford Haven Chemical

    Processing 1994
    Timeline of the accident
    0215: Operators started to introduce raffinate into splitter
    1241: Alarm says high pressure at top of tower due to
    tower (to distill & separate gasoline components – the tower
    compression of gases by rising liquid level - Operators opened
    was >100’ tall)
    manual valve to vent gases into the relief system (which vented
    0309: Hi level alarm actuated & failed to actuate.
    unflared gas into atmosphere via a blowdown drum)
    0330: Level indication showed 9’ and feed was stopped by
    Operators also turned off two burners in furnace (assume this
    operators (but level was actually at ~13’) would reduce pressure) & opened valve to allow liquid to go
    0500: Lead operator in satellite CR for ISOM unit gives briefing from bottom of tower to storage tanks
    to CCR and leaves to go home (early) This hot liquid flowed through a heat exchanger with liquid
    0600: New CCR operator arrives (to start his 30th consecutive entering tower, raising temperature of liquid entering tower by
    day doing 12 hour shifts) 141 deg F.
    0715: Day supervisor arrives (late, so he had missed handover) 1300: Contract workers returned from lunch to temporary
    0951: Startup resumed (splitter tower was already over-filled) trailers near blowdown drum
    -  Auto level control valve left closed because of ‘conflicting 1314: Hot feed causes boiling and level rise that tower is filled
    instructions’ completely and spills into vapour line, causing pressure relief
    1000: Furnace lit to start feed heating valves in vapour line to open. 52000 gallons of liquid thereby
    1050: Day supervisor leaves site – no supervisor in CCR contrary vents to blowdown drum, where it overflows and drains into a
    to rules – single operator now running 3 units including ISOM process sewer, setting off control room alarms. High-level alarm
    in blowdown drum failed to actuate. Geyser of liquid and
    unit
    vapour erupts from vent above blowdown drum. Hot gasoline
    1200: Splitter tower level reaches 98’ (15x normal level) but
    forms a large vapour cloud, which was ignited by a running
    level instrument says 8.4’ and gradually falling. Screen displays
    truck engine nearby. Explosion and fire ensued, 15 killed, 180
    did not show flow in and out on same screen, nor calculate
    injured. Temporary trailers housing contractors were destroyed
    total liquid in tower - Maintenance contractors left temporary in blast.
    trailers for a lunch

    Root Cause Lesson learnt


    Inadequately addressed controlling major hazard risk 1) Safety management systems (SMS)
    Did not provide adequate resources to prevent major Store, retrieve and review incident information from the
    accidents; budget cuts impaired process safety history of similar plants.
    performance at the Texas City refinery. 2) Human factors
    Hire trained operators, conduct training
    3) Plant design
    safety critical alarms are distinguishable from other
    operational alarms
    Action taken 4) Plant modifications
    formal, controlled procedure for hazard identification
    Replace and repair the damaged plant
    and operability analysis for modifications (including
    Detailed discussions between HSE and the company
    emergency modifications)
    Replacement of damaged plant; extensive
    5) Inspection systems
    programmes
    All safety critical parts of the plant should be inspected
    Increased inspection frequency
    6) Emergency planning
    Fire brigades; the availability of adequate water supplies
    for fire-fighting and vessel cooling

    Mackenzie, C., Holmstrom, D., & Kaszniak, M. (2007). Human Factors Analysis of
    References the BP Texas City Refinery Explosion. PsycEXTRA Dataset. doi:
    10.1037/e578062012-015

    1. Nur Farah Hanim Binti Rosli PA17004


    2. Arti Amalin Binti Abd Ghani PA17080
    Group 3. Anis Athirah Binti Adnan PA17020

    members 4. Nur Alia Farahanin Binti Mohd Tajuddin PA17037


    5. Suezetty Binti Sulaiman PA17062
    6. Hairi Nazwan Bin Haron PA17033

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