On March 23, 2005, an explosion and fire occurred at the BP Texas City refinery, killing 15 people. The incident was caused when operators overfilled a raffinate splitter tower during startup, causing flammable liquid to overflow and be released uncontrollably from a blowdown stack without a flare to burn off vapors. The released liquid evaporated and formed a large flammable vapor cloud that was ignited by a nearby truck, causing an explosion. A investigation found organizational and safety deficiencies throughout BP contributed to the incident. Warnings signs of problems had been present for years but not addressed by the company.

1. Accidental Business Report
By
Farooq Ahmed Memon
Orasoft Institue
BBA 2nd semister

2. INVESTIGATION REPORT
REFINERY EXPLOSION AND FIRE
BP TEXAS CITY
March 23 2005

3. S. No. Contents Page
No.
1 Preface
2 Letter of authorization
3 Letter of Transmittal
4 Introduction
5 Text of Report
Introduction
EXECUTIVE SUMMARY
Incident synopsis
Scope of investigations
Bp group and Texas city
Observations
Incident Description
Health and Safety
Ignition Source
6 Conclusion
7 Recommendation
8 Appendix

4. BP Texas City Company
31, Oil Refinery,
Texas
20 May 2005
Mr. T.M John
131/9 Texas City
Texas.
Dear Sir,
Having accepted your terms and conditions laid down in your letter dated 27th instant., the Board of Directors
authorizes to you to make a report on the commercial prospects of BP Texas City Company to be manufactured
by the firm vide letter No. BP/Rep/85/ dated 20th May 2005. You are requested to submitted your report to the
undersigned with in 15 days by 15th June 2005.
You are hereby, assured of all sorts of assistance and help possible from the staff and Executive at any time.
Let this letter be acknowledge and also mentions the date on which you are going to start your work
Your faithfully,
S/d
Managing Director
BP Texas City Company

5. 131/9, Texas
Texas.
To,
The Managing Director,
BP Texas City Company
Texas.
Dear Sir,
In response of your letter No. BP/RED 85 dated 23 March 2005 regarding a report to be prepared
by me on the subjected which comprises of three parts along with the recommendations and
suggestions. I hope that you will find the report beneficial for the business of the company.
Will you please be kind enough to communicate your views? It would be highly regarded if I were
given a chance to appear before you and explain any of the aspect of the report at your office at
any time by appointment.
Your Truly
s/d
T.M John

7. EXECUTIVE SUMMARY
Incident synopsis
On March 23, 2005, at 1:20 p.m., the BP Texas City Refinery suffered
one of the worst industrial disasters in recent U.S. history. Explosions
and fires killed 15 people and injured another 180, alarmed the
community, and resulted in financial losses exceeding $1.5 billion. The
incident occurred during the startup of an isomerization1 (ISOM) unit
when a raffinate splitter tower2 was overfilled; pressure relief devices
opened, resulting in a flammable liquid geyser from a blowdown stack
that was not equipped with a flare. The release of flammables led to an
explosion and fire. All of the fatalities occurred in or near office
trailers located close to the blowdown drum. A shelter-in-place order
was issued that required 43,000 people to remain indoors. Houses were
damaged as far away as three-quarters of a mile from the refinery.

The BP Texas City facility is the third-largest oil refinery in the United
States. Prior to 1999, Amoco owned the refinery. BP merged with
Amoco in 1999 and BP subsequently took over operation of the plant.

8. 
BP Group and Texas City

The Texas City disaster was caused by organizational and safety
deficiencies at all levels of the BP Corporation. Warning signs of a
possible disaster were present for several years, but company officials
did not intervene effectively to prevent it. The extent of the serious
safety culture deficiencies was further revealed when the refinery
experienced two additional serious incidents just a few months after
the March 2005 disaster. In one, a pipe failure caused a reported $30
million in damage; the other resulted in a $2 million property loss. In
each incident, community shelter-in-place orders were issued.

This investigation was conducted in a manner similar to that used by
the Columbia Accident Investigation Board (CAIB) in its probe of the
loss of the space shuttle. Using the CAIB model, the CSB examined
both the technical and organizational causes of the incident at Texas
City

9. 
Incident Description
On the morning of March 23, 2005, the raffinate splitter tower in the refinery’s
ISOM unit was restarted after a maintenance outage. 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
startup procedure instructions. 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.
This blowdown system was an antiquated and unsafe design; it was originally
installed in the 1950s, and had never been connected to a flare system to safely
contain liquids and combust flammable vapors released from the process.

10. Incident Description
The released volatile liquid evaporated as it fell to the ground
and formed a flammable vapor cloud. The most likely source
of ignition for the vapor cloud was backfire from an idling
diesel pickup truck located about 25 feet (7.6 m) from the
blowdown drum. The 15 employees killed in the explosion
were contractors working in and around temporary trailers
that had been previously sited by BP as close as 121 feet (37
m) from the blowdown drum.

11. BP Corporate and Texas City Refinery Background
On March 23, 2005, an explosion and fires occurred at the BP refinery in
Texas City, Texas, 30 miles southeast of Houston. The refinery, the
company’s largest worldwide, can produce about 10 million gallons of
gasoline per day (about 2.5 percent of the gasoline sold in the United States)
for markets primarily in the Southeast, Midwest, and along the East Coast. It
also produces jet fuels, diesel fuels, and chemical feed stocks; 29 oil refining
units and four chemical units cover its 1,200 acre site. The refinery employs
approximately 1,800 BP workers, and at the time of the incident,
approximately 800 contractor workers were onsite supporting turnaround13
work. The site has also had numerous changes in management at both the
refinery and corporate levels.

12. Raffinate Splitter Section
On the day of the incident, the startup of the ISOM raffinate splitter section
was initiated. It was during this startup that the tower was overfilled with
liquid. This section describes the relevant equipment involved in the startup
on March 23, 2005.
The raffinate splitter section took raffinate -- a non-aromatic, primarily
straight-chain hydrocarbon mixture -- from the Aromatics Recovery Unit
(ARU) and separated it into light and heavy components. About 40 percent
of the raffinate feed was recovered as light raffinate (primarily
pentane/hexane). The remaining raffinate feed was recovered as heavy
raffinate, which was used as a chemicals feedstock, JP-4 jet fuel, or
blended into unleaded gasoline. The raffinate splitter section could process
up to 45,000 barrels per day (bpd)16 of raffinate feed.

13. Flammable Vapor Cloud Formation and Fire
The liquid hydrocarbon release time was calculated using computerized control
system data points and the flow times from DIERS modeling (Appendix H). The
flammable vapor cloud reached a wide area, as is clearly evident by the burned
area shown in a post-explosion photo (Figure 10).
The burned area is estimated to be approximately 200,000 square feet (18, 581
m2). Two mechanisms explain how the vapor cloud covered an area this size in
such a short interval: the first was direct dispersion from evaporation prior to
ignition that was responsible for the bulk of the dispersal, and the second was
“pushing” of flammable vapors as subsonic flames burned through the flammable
cloud. The hydrocarbon liquid cascading down the stack and blowdown drum
coupled with the impact of the falling liquid onto process equipment, structural
components, and piping, promoted fragmentation into relatively small droplets,
thereby enhancing evaporation and the formation of the flammable vapor cloud

14. Atmospheric wind also helped push the vapors and small
droplets downwind, causing them to mix with air. The wind
direction at the time of the incident was reported to be out of the
northwest traveling southeast at 5 miles (8 km) per hour and as
Figure 10 shows, the burned area is elongated in that direction.
However, portions of the vapor cloud also went upwind and
cross wind (Appendix H.10.1), which placed the trailer area
within the flammable cloud covered area.

15. Ignition Source

16. Blast Pressure
Once ignited, the flame rapidly spread through the flammable
vapor cloud, compressing the gas ahead of it to create a blast
pressure wave. Furthermore, the flame accelerated each time a
combination of congestion/confinement and flammable mix
allowed, greatly intensifying the blast pressure in certain areas.
These intense pressure regions, or sub-explosions, produced
heavy structural damage locally and left a pattern of structural
deformation away from the blast center in all directions. A computer
simulation49 and a blast overpressure map were developed based
on site observations, structural analysis, and blast modeling.

17. Fatalities and Injuries
In the explosion, 15 contract employees working in or near the trailers
sited between the ISOM and the NDU unit were killed. Autopsy reports
revealed that the cause of death for all 15 was blunt force trauma,
probably resulting from being struck by structural components of the
trailers. Three occupants in the Quality Assurance/Quality Control
(QA/QC) trailer perished, and 12 of 20 workers inside the double-wide
trailer were killed; the others were seriously injured.
A total of 180 workers at the refinery were injured, 66 seriously enough
that they had days away from work, restricted work activity, or medical
treatment. The majority of these suffered multiple injuries, typically
combinations of: fractures, lacerations, punctures, strains, sprains,
and/or second- and third-degree burns. Of the seriously injured, 14
were BP employees; the rest were contractor employees from 13
different firms. Of the 114 workers given first aid, 35 were BP
employees; 79 were contract employees from 14 different contracting
firms. None of the contract workers in the area surrounding the ISOM
were personnel essential to the startup of the unit.

18. Equipment and Facility Damage
The most severe blast damage occurred within the ISOM unit, from the
trailer area to the catalyst warehouse (Figure 13), and the surrounding
parking areas. The satellite control room was severely damaged and the
catalyst warehouse was destroyed. Many of the approximately 70
vehicles in the vicinity of the ISOM unit were damaged and a number
were destroyed. More than 40 trailers were damaged; 13 were destroyed.
On June 30, 2006, the CSB released a detailed analysis of the trailer
damage, which can be viewed or downloaded from the CSB website,

19. Post-Incident Emergency Response
The emergency response teams made a rapid and effective effort to help the
injured and recover the victims. Texas City Industrial Mutual Aid System
(IMAS) member companies responded and assisted with fire hose lines and
search-and-rescue. None of the emergency response personnel were injured
during rescue efforts.
The blast produced a large debris field of damaged trailers and vehicles
located between the NDU and ISOM units. To recover victims from this area,
the site was necessarily disturbed by the emergency responders. Debris,
vehicles, and equipment were moved to initiate search-and-rescue and
recover the fatally injured. As operators and emergency responders entered
the ISOM unit to isolate the plant, some valve positions were changed, but no
records were kept to document these changes. Therefore, there was no
record of the actual state of some of the valves at the time of the incident,
information that is important when trying to reconstruct the incident and
determine its causes.

20. Ineffective and Insufficient Communication Among Operations Personnel
Two critical miscommunications occurred among operations personnel on
March 23, 2005, that led to the delay in sending liquid raffinate to storage: 1)
the instructions for routing raffinate products to storage tanks were not
communicated from Texas City management and supervisors to operators;
and 2) the condition of the unit – specifically, the degree to which the unit
was filled with liquid raffinate – was not clearly communicated from night
shift to day shift.68 These lapses in communication were the result of BP
management’s lack of emphasis on the importance of communication. BP
had no policy for effective shift communication,69 nor did it enforce formal
shift turnover or require logbook/procedural records to ensure
communication was clearly and appropriately disseminated among
operating crew

21. BP Actions After the Explosion
In its internal investigation of the March 23, 2005 explosion,
BP adopted new policies for trailer siting at its facilities.
Appendix 37 in the “Fatal Accident Investigation Report”
(Mogford, 2005) outlines the specifics of BP’s new siting
policy; trailer siting is now based on exclusion zones for
areas where explosions are possible, and all occupied trailers
should be located outside of vulnerable areas even if this
means a location outside the refinery. A large number of
Texas City personnel were relocated to a permanent building
away from the refinery after the incident.

22. Conclusion
Based on the analysis of the relief system, the blowdown drum was
undersized and the emergency relief system design did not address the
potential of a large liquid release in the event the raffinate splitter tower
overfilled. After the March 23, 2005, incident, BP evaluated the 22 blowdown
systems at its five U.S. refineries and found that 17 handled flammables. BP
has publicly pledged to eliminate all atmospheric blowdown systems in
flammable service at all five of its U.S. refineries. requires that relief system
designs comply with “recognized and generally accepted good engineering
practices.” Published PSM compliance guidelines call for inspections to
ensure that “destruct systems, such as flares, are in place and operating”
and that “pressure relief valves and rupture discs are properly designed
and discharge to a safe area” (CPL 2-2.45A, 1994). Therefore, the CSB
recommended that OSHA implement a special emphasis program for oil
refineries to focus on blowdown drums that discharge directly to the
atmosphere and their design

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