BP Texas Oil

Refinery Explosion
Usman Ali
M. Umair
Accident data
• Industry name :- British Petroleum Oil
Refinery
• When :- March 23rd ,2005
• Where :- Texas,USA
• Time :- Between 12:30 pm to 1pm
• Deaths :- 15
• Injuries:- 170
• Reason:- A Hydrocarbon Vapor Cloud
Exploded at The ISOM Isomerization Process
Unit
ABOUT THE INDUSTRY
• The Texas City Refinery was the second-largest oil
refinery in the state, and the third-largest in the
United States with an input capacity of 437,000
barrels (69,500 m3) per day as of January 1, 2000.
BPacquired the Texas City refinery as part of its
merger with Amoco in 1999.
Accident Description March 23, 2005

03:09 AM:
• 1st High level alarm 7.6 ft (Blink Operate stops this )
• 2nd High level alarm 7.9 ft (Failed)
05:00 AM: After completion of filling the tower,
transmitter reads 8.95 ft (actually 13.3 ft), Night Lead
Operator leaves the refinery an hour before his scheduled
shift. ( No turn over brief)
10:47 AM: Day Supervisor leaves refinery early due to a
family emergency.
12:41 PM: High pressure alarm is received at 33 psig.
Operator is unsure of system status; reduces pressure by
opening the 8-inch NPS chain valve.
12:42 PM: Fuel gas to the furnace is reduced. The tower
level indicator reads 8 ft, but the actual level is 140 ft.
1:04 PM: The tower level indicator reads 7.9 ft, but the
actual level is 158 ft.
1:14 PM: Hydrocarbon flows out of the top of the tower into
overhead piping. Tower pressure spikes to 63 psig. All three
relief valves open, sending 52,000 gallons of flammable
liquid to a blowdown drum, which over flowed, sending
alarms to the control board.
1:20 PM: A nearby pickup truck ignites the vapors, releasing
a powerful explosion. Secondary explosions soon followed.
Workers inside trailers were caught in the path of the
explosions.
Distillation Tower
The Causes
• Actions and errors by operations personnel
were the immediate causesof the accident.

• Latent conditions and safety system

deficiencies influenced personnel actions
and contributed to the accident.

• Safety system deficiencies created a

workplace ripe for human error
Personnel Actions & Errors
• Required pre-start actions not completed
– Pre-Startup Safety Review not performed
– Key malfunctioning instrumentation not repaired
– Malfunctioning pressure control valve not repaired
– supervisor signed off on startup procedure thatcontrol
valves had tested satisfactorily
– Functionality checks of alarms and instrumentsnot
completed
– Review of startup procedures by operatorsand
supervisors not completed
• Night Lead Operator did not use startup procedureor
record completed steps when startup was partially
completed on night shift
Personnel Actions & Errors(Cont’d)
• Night Lead Operator left an hour before end of shift
• ISOM-experienced Day Supervisor arrived over an hour late
- did not conduct shift turnover with night shift personnel
• Day Supervisor was told that startup could not proceed
because storage tanks were full - not communicated to
ISOM operations personnel
• Day Board Operator closed automatic tower level control
valve – although procedure required valve to be placed in
“automatic” and set at 50percent
• Day Supervisor left the plant due to family emergency as
unit was beingheated
Latent Organizational Weaknesses
• Work environment encouraged procedural
noncompliance
• Ineffective communications for shift changeand
hazardous operations (such as unit startup)
• Malfunctioning instrumentation and alarms
• Poorly designed computerized control system
• Ineffective supervisory oversight
• Insufficient staffing
• Lack of a human fatigue-prevention policy
• Inadequate operator training for abnormaland
startup conditions
• Failure to establish effective safe operatinglimits
Latent Organizational Weaknesses
• Ineffective incident investigation management
system
• Ineffective lessons learned program
• No flare on blow down drum
• No automatic safety shutdown system
• Key operational indicators and alarms inoperative
• Ineffective response to serious safety problems and
events
• Focus on injury and illness statistics, not process
safety
Latent Organizational Weaknesses
• Poor implementation of Process Hazards Analyses (PHA) and
Management of Change (MOC) processes.

• Ineffective follow-up on auditreports

• Problem reporting not encouraged

• Inadequate implementation of OSHA Process Safety

Management regulations

• Inadequate OSHA inspections and enforcement

• Gaps in applicable industry standards

Aftermath
• In 1991, the Amoco refining planning department
proposed eliminating blowdown systems thatvented to
the atmosphere, but funding for this plan was not
included in the budget.

• In 1993, the Amoco Regulatory Cluster project proposed

eliminating atmospheric blowdownsystems, but again,
funding was notapproved.
Aftermath
• In 1995, a refinery belonging to Pennzoil suffered a disaster when
two storage tanks exploded, engulfing a trailer and killing five
workers.

• The conclusion was that trailers should not be located near

hazardous materials. However, BP ignored the warnings, and they
believed that because the trailer where most of the deaths
happened was empty most of the year, the risk was low.
Aftermath
• In 2002, engineers at the plant proposed replacing the
blow down drum/vent system as part of an
environmental improvement initiative, but this line-
item was cut from the budget, due to cost pressures.

• Also in 2002, an opportunity to tie theISOM relief

system into the new NDU flare system was not taken,
due to a US$150,000 incremental cost.
Aftermath
• During 2002, BP's Clean Streams project proposed
converting the blow down drum to a flare knock-out
tank, and routing discharges to a flare. When it was
found that a needed relief study of the ISOM system had
not been completed due to budget constraints.

• Between 1994 and 2004, at least eight similar cases

occurred in which flammable vapors were emitted by a
blow down drum/vent stack. Effective corrective action
was not taken at the BP plant
Result
• As a result of the accident, BP said that itwould
eliminate all blow down drums/vent stack systems
in flammable service. The CSB, meanwhile,
recommended to the American Petroleum Institute
that guidelines on the location of trailers be made.
• OSHA ultimately found over 300 safety violations
and fined BP US$ 21 million —the largest fine in
OSHA history at thetime.
Legal actions
• BP was charged with criminal violations of federal
environmental laws, and has been named in lawsuits
from the victims'families.

• The Occupational Safety and Health

Administration gave BP a record fine for
hundreds of safety violations.

• In 2009 imposed an even larger fine after claiming

that BP had failed to implement safety
improvements following the disaster
Thank You