Presentation to the 40th

1
Presentation to the 40th Loss Prevention
Symposium
CSB Investigation of the Explosionsand Fire at
the BP Texas City Refinery on March 23, 2005
CSB Lead Investigator Don Holmstrom
April 26, 2006 Orlando, Florida
2
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

3
Incident Summary

• March 23, 2005
• Flammable vapor cloud, explosions, fire, and
  toxic release
• 15 deaths
• 170 injuries
• Offsite property damage

4
Incident Summary

• Occurred during startup
• Tower overfilled and overpressured
• Blowdown drum filled
• Vapor cloud formed
• Trailers too close to blowdown drum

5
(No Transcript)
6
Preliminary Findings
7
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

8
Trailer Siting

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

9
Trailer Siting

• Under BPs 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)

10
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

11
The CSB issued urgent recommendations to API and
NPRA on ensuring the safe location of occupied
trailers away from hazardous process areas
12
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

13
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

14
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

15
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

16
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 (gt 40 psi vs. 20 psi)
• Thirteen had liquid levels above the range of the
  level indicator (gt 10 ft, some lasting as long as
  four hours)

17
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

18
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

19
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

20
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

21
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

22
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

23
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

24
Vehicles

• BPs 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

25
The CSB issued an urgent recommendation that BP
form an independent panel to study their safety
culture.
26
Future Investigative Activities

• Analyze root causes and develop additional safety
  recommendations
• Issue final report at public meeting in Texas
  City in Fall 2006

27

• Questions