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Process Safety Series 1 - BP Texas City: Sharing The Experience

During the start-up of an isomerization unit at the BP Texas City Refinery in March 2005, the raffinate splitter tower and blowdown drum overfilled, releasing liquid hydrocarbon that formed a vapor cloud and subsequently exploded and caught fire. The explosion killed 15 people and injured 180 others. Investigations found that procedural deviations during start-ups of the unit were common in the past, including overfilling of the distillation tower. A lack of effective communication, operator fatigue, insufficient staffing and training, and other organizational and safety system failures contributed to the incident.

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Ella Agbettor
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243 views7 pages

Process Safety Series 1 - BP Texas City: Sharing The Experience

During the start-up of an isomerization unit at the BP Texas City Refinery in March 2005, the raffinate splitter tower and blowdown drum overfilled, releasing liquid hydrocarbon that formed a vapor cloud and subsequently exploded and caught fire. The explosion killed 15 people and injured 180 others. Investigations found that procedural deviations during start-ups of the unit were common in the past, including overfilling of the distillation tower. A lack of effective communication, operator fatigue, insufficient staffing and training, and other organizational and safety system failures contributed to the incident.

Uploaded by

Ella Agbettor
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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PROCESSSAFETYSERIES1 BPTEXASCITY

Sharingtheexperience
BPTexasCityRefinery IncidentSummary
Duringstartup,towerandblowdowndrumoverfilled.Liquid
hydrocarbonreleased,vapourcloudformedfollowedbyan
ignitedexplosionandfire
Theexplosionhappenedat13:20(Houstontime)onMarch23,2005
15deathsand180injuries
Note:Theisomerizationunit
booststheoctaneofgasoline
Blendstocks.

2
IncidentTimeline
PriortoFeb.15
Temporarytrailersplaced150feetfromtheIsomerizationunit.Theywerebeingusedby
personnelpreparingforaturnaroundatanotherparoftherefinery

Feb.21
ShutdownpartoftheIsomerizationunittorefreshthecatalystinthefeedunit

March22
Onthenightshift,theraffinate splitterwasbeingrestartedaftertheshutdown.The
raffinate splitterispartoftheIsomerizationunitthat distilschemicalsfortheIsomerization
process

March23
Splitterwasoverfilledandoverheated
Whenliquidsubsequentlyfilledtheoverheadlinethereliefvalvesopened
Thiscausedexcessiveliquidandvapourtoflowtoblowdowndrumandventattopofthe
stack
Anexplosionoccurredwhichkilled15peopleandinjuredmanyothers

Slide3
Mainlessonsfromincident

Historicaldeviationsofstartup,Proceduraldeviationscommonin19startupsofthe
unitfrom2000to2005resultingintheoverfillingofthedistillationtower
Noinvestigationofrootcauseofpreviousfailures
Communicationwasineffectivebetweenoperationspersonnel
Sixpiecesofinstrumentationmalfunctionedonthedayoftheincident
Fatiguedoperatorsandlackofapolicyformaximumallowablehours
SupervisorandOperatorStaffingwasInsufficient
OperatorTrainingwasnoteffective
Theplacementofthecontractorworktrailersadjacenttohighhazardprocessunits
Theuseofablowdowndrumandstackthatopentotheatmosphere,opportunitiesto
upgradetheflaresystemwhereignored
Lackofearlywarningsignsi.e.noprocesssafetyKPIsonlyrelyingonpersonalsafetyKPI
forsafety

4
SwissCheeseFailures

Slide5
CompanieswithaPositiveSafetyCulture

Learnfrompreviousincidentsandsafety deficiencies
Encouragereportingofsafetyconcerns, issues,and
problemsbyalllevelsofstaffandtakevisibleandconcrete
actionstoremedytheissues
Focusoncontrollingtherisksofmajorhazards
Provideadequateresourcesforsafe operation

Slide6
PROCESSSAFEYCULTURE whereareYOU!!!!!!!
isacontinuumofbehaviorswithincreasinglevelsofsafetyawarenessandactivity

- Chronicunease(Mindfulness)
Generative
Safetyishowwedobusiness Safetyisseenasgoodbusiness
aroundhere Newideasarewelcomed

- Resourcesareavailabletofixthingsbeforeanaccident
Proactive
Weworkonproblemsthat Managementisopenbutstillobsessedwithstatistics
westillfind Proceduresareownedbytheworkforce

Calculative WehaveourHSEMSnailed!
Wehavesystemsinplaceto Lotsandlotsofaudits
manageallhazards Wecollectlotsofstatistics

Reactive Weareserious,butwhydontpeopledoastheyaretold?
Safetyisimportant wedoalotof Lotsofdiscussionstoreclassifyaccidents
iteverytimewehaveanaccident! Youhavetoconsidertheconditionsunderwhichweareworking.

Thelawyerssaiditwasokay.
Pathological IvedonemypartforHSSEthisyear.
whocaressolongaswere Ofcoursewehaveaccidents;itsadangerousbusiness
notcaught! Firethepersonwhohadtheaccident! 7

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