its about the Texas oil refinery explosion took place on 23rd march 2005 at texas

1. Texas oil refinery
explosion
Arpit Mathur
M.Tech DM Ist year

2. Accident data
• Industry name :- British Petroleum oil
refinery
• When :- march 23rd , 2005
• Where :- Texas, USA
• Time :- between 12:30 pm to 1 pm
• Deaths :- 15
• Injuries:- 170
• Reason:- A hydrocarbon vapour cloud
exploded at the ISOM isomerization process
unit

3. 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. BP acquired the Texas City
refinery as part of its merger with Amoco in
1999.

4. ISOM UNIT
Closed
Closed
Sight-glass dirty &
unreadable –
Leveltransmitter not
calibrated Indicated 10 ft
and falling
Inoperative
Inoperative
Redundant
Alarm
Inoperative

5. The Causes
• Actions and errors by operations
personnel were the immediate causes of
the accident.
• Latent conditions and safety system
deficiencies influenced personnel actions
and contributed to the accident - and
collectively influenced the decisions and
actions of operations personnel.
• Safety system deficiencies created a
workplace ripe for human error

6. 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 that control
valves had tested satisfactorily
– Functionality checks of alarms and instruments not
completed
– Review of startup procedures by operators and
supervisors not completed
• Night Lead Operator did not use startup procedure or
record completed steps when startup was partially
completed on night shift

7. Personnel Actions & Errors (Cont’d)
• Night Lead Operator left an hour before end of shift
• ISOM-experienced Day Supervisor A arrived over an hour
late - did not conduct shift turnover with night shift
personnel
• Day Supervisor B 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 50 percent
• Day Supervisor left the plant due to family emergency as
unit was being heated

8. Latent Organizational Weaknesses
• Work environment encouraged procedural
noncompliance
• Ineffective communications for shift change and
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 abnormal and
startup conditions
• Failure to establish effective safe operating limits

9. Latent Organizational Weaknesses
• Ineffective incident investigation management
system
• Ineffective lessons learned program
• No coordinated line management self-assessment
process
• 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

10. • Poor implementation of Process Hazards Analyses (PHA)
and Management of Change (MOC) processes (equivalent
to USQ)
• Ineffective follow-up on audit reports
• Problem reporting not encouraged
• Inadequate implementation of OSHA Process Safety
Management regulations
• Inadequate OSHA inspections and enforcement
• Gaps in applicable industry standards
Latent Organizational Weaknesses

11. Aftermath
• In 1991, the Amoco refining planning department
proposed eliminating blowdown systems that vented
to the atmosphere, but funding for this plan was not
included in the budget.
• In 1992, OSHA issued a citation to Amoco for unsafe
design of similar pressure-relief systems at the plant.
However, Amoco successfully persuaded OSHA to drop
this citation by relying on the less-stringent
requirements in API Recommended Practice 521.
• In 1993, the Amoco Regulatory Cluster project
proposed eliminating atmospheric blowdown systems,
but again, funding was not approved.

12. 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.
• Despite Amoco's process safety standard No. 6, which
prohibited new atmospheric blowdown systems and called
for the phasing out of existing ones, in 1997, Amoco
replaced the 1950s-era blowdown drum/vent stack that
served the raffinate splitter tower with an identical system,
instead of upgrading to recommended alternatives that
were safer.

13. 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 the ISOM relief
system into the new NDU flare system was not
taken, due to a US$150,000 incremental cost.

14. 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,
the Clean Streams project proposed adding a
wet/dry system to the ISOM instead.
• 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

15. Result
• As a result of the accident, BP said that it would
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 the time

16. 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

17. Subsequent incidents
• On July 28, 2005, a hydrogen gas heat exchanger pipe on
the reside hydrotreater unit ruptured.
• On August 10, 2005, there was an incident in a gas-oil
hydrotreater that resulted in a community order to shelter.
• On January 14, 2008, William Joseph Gracia, 56, a veteran
BP operations supervisor, died following head injuries
sustained as workers prepared to place in service a water
filtration vessel at the refinery's ultracracker unit.
• On September 21, 2010, an incident in the Pipestill 3B unit
left two workers with serious steam burns.