lessons learned from texas city refinery explosion
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Lessons Learned From Texas City Refinery Explosion
Bill RigotEFCOG
Human Performance Task GroupMay, 2007
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BP: Employees caused deadly blast - Oil company says employee failures led to deaths of 15 people at Texas City, Texas, refinery in March.
May 18, 2005: 5:41 AM EDT
TEXAS CITY, Texas (Dow Jones)-- BP PLC (BP) said Tuesday that failures by its employees were responsible for an explosion at its Texas City refinery on March 23, the deadliest industrial accident in 15 years.
BP Products will take disciplinary action against supervisors and hourly employees who were directly responsible for operating the isomerization unit on March 22 and 23. These actions will range from warnings to termination of employment. As the investigation continues and new information is discovered, others may also be disciplined, the company said.
"If ISOM unit management had properly supervised the startup, or if ISOM unit operators had followed procedures or taken corrective action earlier, the explosion would not have occurred", said Ross Pillari, president of BP Products North America.
BP: Employees caused deadly blast - Oil company says employee failures led to deaths of 15 people at Texas City, Texas, refinery in March.
May 18, 2005: 5:41 AM EDT
TEXAS CITY, Texas (Dow Jones)-- BP PLC (BP) said Tuesday that failures by its employees were responsible for an explosion at its Texas City refinery on March 23, the deadliest industrial accident in 15 years.
BP Products will take disciplinary action against supervisors and hourly employees who were directly responsible for operating the isomerization unit on March 22 and 23. These actions will range from warnings to termination of employment. As the investigation continues and new information is discovered, others may also be disciplined, the company said.
"If ISOM unit management had properly supervised the startup, or if ISOM unit operators had followed procedures or taken corrective action earlier, the explosion would not have occurred", said Ross Pillari, president of BP Products North America.
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Accident Summary
• 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 $1.5B. The incident occurred during startup of an isomerization1 (ISOM) unit when a raffinate splitter tower was overfilled; pressure relief devices opened, resulting in a flammable liquid geyser from a blowdownstack that was not equipped with a flare. The release of flammables led to an explosion and fire.
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The Chemical Safety Board
• The U.S. Chemical Safety and Hazard Investigation Board (CSB) final report of the Texas City Explosion was released 3/26/2007- The CSB is an independent federal agency charged with investigating
industrial chemical accidents- CSB Board members are appointed by the president and confirmed by the
Senate- CSB investigations look at all aspects of chemical accidents, including physical
causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems
- The CSB does not issues citations or fines, but does make safetyrecommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA
- The CSB Accident Reports and video reconstruction are available on their website, www.csb.gov
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The Baker Report
• Pursuant to an urgent recommendation from the CSB interim report, BP commissioned former Secretary of State James Baker to conduct a third party review of BP corporate practices leading up to the Texas City explosion
• Secretary Baker completed his review January 2007• The Baker Panel focused principally on Process Safety
rather than personal safety
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Baker Panel Findings
• Corporate Safety Culture- BP Board did not exercise good Process Safety leadership- At Texas City particularly, BP managers did not empower
employees in the Corporate Safety Culture- BP corporate did not provide appropriate resources to assure
adequate process safety- BP managers did not incorporate process safety into
management decision making- BP corporate did not assure a common, unifying Process Safety
culture among its US refineries
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Baker Panel Findings (Cont.)
• Process Safety Management Systems- BP Process Risk Assessment and Analysis was flawed- BP’s US refineries did not comply with its own internal process
safety standards- BP refineries did not implement good engineering practices- Process safety knowledge and competence was not maintained
at BP US refineries- BP’s corporate process safety management system was
ineffective and not measurable
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Baker Panel Findings (Cont.)
• Performance Evaluation, Corrective Action, Corporate Oversight- BP measured safety performance through personal injury rate,
rather than measuring process safety equipment performance- BP’s causal analysis methods were inadequate and flawed- The process safety audit system was inadequate- BP managers did not provide timely correction of process safety
deficiencies- BP corporate oversight of refinery specific process safety
information was flawed
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CSB Identified Root Causes
• BP Group Board did not provide effective oversight of the company’s safety culture and major accident prevention programs.
• BP Senior Executives:- Inadequately addressed controlling major hazard risk, particularly
process safety performance;- Did not provide effective safety culture leadership and oversight
to prevent catastrophic accidents;- Ineffectively evaluated safety implications of major organizational
changes; and- Did not provide adequate resources to its refineries
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CSB Identified Root Causes (Cont.)
• BP Texas City Managers did not:- Create an effective reporting and learning culture; i.e. bad news
was not welcomed (by inference a Just Culture was not achieved either);
- Effectively investigate accidents;- Hold supervisors and managers accountable for process safety
performance;- Incorporate good practice design in the operation of hazardous
chemical systems;- Ensure that operators were supervised and supported during unit
startup; and- Effectively incorporate human factor considerations in its training,
staffing and work schedule for operations personnel
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CSB Identified Contributing Causes
• BP Texas City Managers:- Lacked an effective mechanical integrity program to maintain
instruments and process safety equipment;- Did not have an effective vehicle traffic policy to control traffic into
hazardous process areas or to establish safe distances from process unit boundaries;
- Ineffectively implemented Pre-Startup Safety Review policy; non-essential personnel were not removed from areas in and around process units during the hazardous unit startup; and
- Located trailers in close proximity to hazardous operations.
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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• Insufficient staffing• Lack of human fatigue-prevention strategy• Inadequate operator training for abnormal and startup
conditions• Failure to establish effective safe operating limits
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Latent Organizational Weaknesses (Cont.)
• Ineffective incident investigation management system• Ineffective Lessons Learned program• No coordinates line management self-assessment process• No flare on blowdown drum• No automatic safety shutdown system• Occupied trailers too close to hazardous operations• Key operational indicators and alarms inoperative• Ineffective response to serious safety problems and events• Focus on injury and illness statistics, not process safety
- This was an observed Latent Organizational Weakness for their OSHA regulator as well
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Latent Organizational Weaknesses (Cont.)
• Poor implementation of Process Hazards Analyses (PHA) and Management of Change (MOC) processes (equivalent to USQ)
• Ineffective follow-up to audit reports• Problem reporting not encouraged• Inadequate implementation of OSHA Process Safety
Management regulations• Inadequate OSHA inspections and enforcement• Gaps in applicable industry standards
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The INPO ViewAnatomy of an Event
Event
ErrorPrecursors
Vision, Beliefs, &
Values
LatentOrganizationalWeaknesses
Mission
Goals
Policies
Processes
Programs
FlawedDefenses
InitiatingAction
Vision, Beliefs, &
Values
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Self-Checking Place-Keeping
3-Part Communication
Double (dual)Verification
Procedure Use& Adherence
Supervision
ManagementMonitoring
Stop WhenUncertain
Critical Parameters
Problem-solvingMethodology
ConservativeDecision-Making
TeamSkills
Peer-Checking
RecognizingError Traps
Rigor ofExecution
ChallengeFlagging
CommunicationPractices & Plan
Reviews &Approvals
ChangeMgmt.
Problem-Solving
Scheduling /Sequencing
ClearExpectations
RoleModels
SafetyPhilosophy
TaskAllocation
MeetingsRewards &
Reinforcement
Trend Analysis
OE
Training
Handoffs
Accountability
Simple / EffectiveProcesses
ProcedureRevisions
WorkPlanning
Corrective ActionProgram
Self-AssessmentBenchmarking
CompatibleGoals & Priorities
StrategicHU Plans
Management Practices
SafeguardsEquipment
ReactorProtectionSystems
Containment
EquipmentReliability
Equipment Labeling& Condition
Procedure / WorkPackage Quality
Worker Knowledge,Skill, & Proficiency
Fitness-for-Duty
Uneasy Attitude
Equipment Ergonomics& Human Factors
Tool Quality& Availability
Roles &Responsibilities
HousekeepingEnvironmentalConditions
ForeignMaterial
Exclusion
Lockout /Tagout
PersonalMotives
Intolerance forError Traps
Morale
RWPs
Performance ModelPerformance Modelw/ example defenses
Leadership
Post-jobCritiques
ProblemReporting
Root CauseAnalysis
PerformanceIndicators
FACILITYRESULTS
JOB-SITECONDITIONS
ORGANIZATIONPROCESSES
& VALUES
WORKERBEHAVIOR
ProperReactions
HighStandards
Reinforcement
Coaching
Questioning Attitude
Respectfor Others
Open & HonestCommunication
CompellingVision
HealthyRelationships
Courage &Integrity
Motivation
Example
Pre-jobBriefing
Just-in-timeOperatingExperience
Task Preview
TurnoverClearance Walkdown
Walkdowns
PerformanceFeedback
Task Assignment
HP Surveys
Task Qualification
QC Hold Points
IndependentVerification
InterlocksPersonalProtectiveEquipment
Alarms
ForcingFunctions
FME
Questioning AttitudeWork-arounds &Inconveniences
Staffing
LaborRelations
Socialization
Design & Configuration Control
Values &Beliefs
Independent Oversight
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Self-Checking Place-Keeping
3-Part Communication
Double (dual)Verification
Procedure Use& Adherence
Supervision
ManagementMonitoring
Stop WhenUncertain
Critical Parameters
Problem-solvingMethodology
ConservativeDecision-Making
TeamSkills
Peer-Checking
RecognizingError Traps
Rigor ofExecution
ChallengeFlagging
CommunicationPractices & Plan
Reviews &Approvals
ChangeMgmt.
Problem-Solving
Scheduling /Sequencing
ClearExpectations
RoleModels
SafetyPhilosophy
TaskAllocation
MeetingsRewards &
Reinforcement
Trend Analysis
OE
Training
Handoffs
Accountability
Simple / EffectiveProcesses
ProcedureRevisions
WorkPlanning
Corrective ActionProgram
Self-AssessmentBenchmarking
CompatibleGoals & Priorities
StrategicHU Plans
Management Practices
SafeguardsEquipment
ReactorProtectionSystems
Containment
EquipmentReliability
Equipment Labeling& Condition
Procedure / WorkPackage Quality
Worker Knowledge,Skill, & Proficiency
Fitness-for-Duty
Uneasy Attitude
Equipment Ergonomics& Human Factors
Tool Quality& Availability
Roles &Responsibilities
HousekeepingEnvironmentalConditions
ForeignMaterial
Exclusion
Lockout /Tagout
PersonalMotives
Intolerance forError Traps
Morale
RWPs
Performance ModelPerformance ModelB/P Texas City
Leadership
Post-jobCritiques
ProblemReporting
Root CauseAnalysis
PerformanceIndicators(injury rates
FACILITYRESULTS
JOB-SITECONDITIONS
ORGANIZATIONPROCESSES
& VALUES
WORKERBEHAVIOR
ProperReactions
HighStandards
Reinforcement
Coaching
Questioning Attitude
Respectfor Others
Open & HonestCommunication
CompellingVision
HealthyRelationships
Courage &Integrity
Motivation
Example
Pre-jobBriefing
Just-in-timeOperatingExperience
Task Preview
TurnoverClearance Walkdown
Walkdowns
PerformanceFeedback
Task Assignment
HP Surveys
Task Qualification
QC Hold Points
IndependentVerification
InterlocksPersonalProtectiveEquipment
Alarms
ForcingFunctions
FME
Questioning AttitudeWork-arounds &Inconveniences
Staffing
LaborRelations
Socialization
Design & Configuration Control
Values &Beliefs
Independent Oversight(by BOD)
Cost cutting,Failure to invest,Production pressures
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Lessons Learned to DOE Contractors
• Could this really apply to us?
• Do we have higher or lower consequence events?
• What is our relationship with our regulator(s)?
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Areas of Similarity
• Aging facilities• Safety Culture not well understood with revolving DOE
contractors• Budget limitations• Causal Analysis weaknesses• Equipment Reliability strategies• Uneven quality of written operating and maintenance
procedures• Weak management self-assessment processes• Focus on injury and illness statistics
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