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Lessons Learned from the Texas CityRenery Explosion
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Texas City Renery
•Texas City Refinery,40 miles fromHouston, Texas, USA
•Staff 1600 plus•contractors
•Processing 460,000 arrels of cru!eoil"!ay# −$ne of t%e largest refineries in t%e USA−Supplies aout &' of gasoline use! in US
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The accident
•An explosion an! fire in t%e
refinery(s isomeri)ation unit
•*xplosion occurre! +arc% &,
00- at 1&.0 /Houston time
•1- people !ie! an! many more
ere in2ure!
•3ote. T%e isomeri)ation unit
oosts t%e octane of gasoline
len!stocs#
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Simplied block diaram of Ra!nate Splitter
Feed
BottomProduct
Condensate
Feed Heat Exchanger
Vent Relief system
Ranate
Splitter
Blowdownstac
Furnace
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Ra!nate Splitter and #lo$do$n %r&m Stack
Ranate Splitter !ower
Blowdown "rum Stac
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(erial )hotoraph of *someri+ation ,nit
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(erial )hotoraph of *someri+ation ,nit
Ranate Splitter
Blowdown "rum
!emporary ca#ins
$ther trailer
Control Room
$utside operator shelter
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/hat happened 0
Prior to 5e 1- Temporary trailers place! 1-0 feet from t%e someri)ation
unit#$n 5e 1 Trailers use! y personnel preparing for a turnaroun! at
anot%er part of t%e refinery
+arc% $n nig%t s%ift, raffinate splitter as eing restarte! aftert%e s%ut!on# Raffinate splitter is part of t%e someri)ation
unit t%at !istills c%emicals for t%e someri)ation process+arc% & Splitter as o7er8fille! an! o7er8%eate!
9%en li:ui! suse:uently fille! t%e o7er%ea! line t%e relief7al7es opene!
T%is cause! excessi7e li:ui! an! 7apour to flo to lo!on!rum an! 7ent at top of its stac
An explosion occurre! %ic% ille! 1- people an! in2ure! manyot%ers
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Texas City Refinery March 23, 2005
15 People Killed
Many more injured
A community devastated
Splitter
Vent stac
"e#ris of ca#ins
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*ncident
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*someri+ation ,nit
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Satellite Control Room
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*nside Satellite Control Room
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Coolin To$er
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Trailer
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Catalyst /areho&se
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Storae Tank
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*someri+ation ,nit
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%o&ble/ide Trailer
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2
%o&ble/ide Trailer
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2
5ey *ss&es
•$perator nattention
•5olloing Proce!ures
•Super7isor Asence
•Communication ; S%ift Han!o7er
•Trailers Too Close to Ha)ar!s
•Some nstrumentation
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2
(nimation
Incident Animation
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2
CRITICAL FACTORS: @ Start-up procedures
and managementoversight
@ Loss of containment
@ esign and engineeringof !"o#do#n unit
@ Contro" of #or$ andtrai"er siting
U%&RL'I%( CULTUR&:
@ Insufficient !usiness conte)t
@ Safet* as a priorit*
@ Organi+ationa" comp"e)it*
@ Ina!i"it* to see ris$
@ Lac$ of ear"* #arningindicators
#) incident in6estiation team reports
!he %nterim Report identi&ed ' critical factors( the Final
Report con&rmed the critical factors and identi&edunderlying cultural issues)
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2
,nderlyin C<&ral *ss&es
Business Conte)t• +oti7ation
• +orale
• PAS Score
,rocess. Safet* as a
riorit*• *mp%asis on *n7ironment an!
$ccupational Safety
Organi+ationa" Comp"e)it* /Capa!i"it*• n7estment in People
• =ayers an! Span of Control
• Communication
Ina!i"it* to See Ris$• Ha)ar! !entification Sills
• Un!erstan!ing of Process Safety
• 5acility Siting
• ?e%icles
Lac$ of &ar"* 0arning•
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2
Hazard
Reminder of the 7S$iss Cheese 8odel9
Ha)ar!s are containe! y multipleprotecti7e arriers
>arriers may %a7e eanesses orB%oles(
9%en %oles align %a)ar! energy isrelease!, resulting in t%e potentialfor %arm
>arriers may e p%ysical engineere!
containment or e%a7ioral controls!epen!ent on people
Holes can e latent"incipient, oracti7ely opene! y people
Accident
Protective
‘Barriers’
Weaknesses
Or ‘Holes’
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2
Exercise
ou are t%e n7estigation Team
9%at arriers %a7e faile!D
Plant, process, peopleD
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Inherent Design
Plant Layout
Control, Alarm &Shutdown system
•Operate
outside
envelop•No fail-
safeshutdown•No mass
balance orattention to
other data•Lostprocess
control
•Faulty high
level alarm
not reported
Maintenance &
Inspection
Learning from
the Past
•Previousincidents &
upsets not
reported• dmin!
rather than
"#$solutions•%ierarchyof control
not applied
Operations
Procedures
ffecti!e
Super!ision "Leadership
#raining &Competency
"nadeuate%'"$ s(illsLac( of
underpinning
(nowledgeFailure tofollow
procedures
$or% Control
•Failure to
recogni)e ha)ard
to trailers fromstart-up•People notnotified of start-up•*ultiple sources
of ignition inad+acent areas
Support to e't of(in & In)ured
*elief and
+lowdown System
•No up todate relief
study -design basis
unclear •,apacity ofblowdown
drum
eceeded
Audit & Self*egulation
•Pre-start-up review
not performed•Procedural
compliance not
chec(ed•#upervisor offsite•No interventions•"nadeuate .P"/sfor process safety
•No 0 incomplete
*O,/s for trailersiting•1lowdown drummodified without
rigorous *O,
Management ofChange
Acti!e & Passi!e
ire Protection
scape "Access
*escue &
*eco!ery
HAZARD
Normal%ydrocarbon
"nventory in2affinate
#plitter
In!estigation &
Lessons Learned
• ctive &
passive fire
protection
• ccess & escape route
diversity• ccess to scene
•3mergency response
by site and eternalauthorities
•%ospitali)ation
HAZARD
REALIZATION
Loss of
containment
"gnition
3plosion
*ultiple fatalities
and in+uries•"nventory
increased•Proimity of
non-
essential
personnel toha)ard•Flare notused
4eas ,ity 3plosion
5 %a)ard *anagement $iagram
%ierarchy of control 5 1ias towards hardware0inherent safety & reducing the scope for human error 5 multi barrier defence
Communication
•,onfusion over
who was incharge•No verification
on procedures inuse• bsent fromunit at critical
times
•Proceduresnot followed•#teps not
signed off •6se of 7local
practices/
•No effective
handover
between shifts•6nit alarm not
sounded
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2
Exercise
*f yo& $ere Renery 8anaer
/hat actions $o&ldyo& implement0
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2
Strateic concepts
*n order to red&ce the potential for f&t&re ma:or incidents and losses; three layers of protectionare to be considered<
• plant = enineerin hard$are; control systems; and layo&ts to eliminate; control andmitiate potential ha+ards to people; and impro6e prod&cti6ity
• processes = manaement systems to identify; control and mitiate risks; and dri6econtin&o&s operational impro6ement
• people = capability of o&r people in terms of leadership skills; rele6ant kno$lede andexperience; and the orani+ational c<&re they create
*n layers of protection; 7hard barriers9 are more reliable than 7soft barriers9; b&t all rely on people
hazard accidentor loss
‘hard’ barriers ‘soft’ barriershazardreduction
physical
controlsprocedures
generic
systems
people’s
behaiors
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3
)rincipal actions
"ant@ 3o trailers or temporary accommo!ation to e place! insi!e areas /ofrefineries containing %y!rocarons, e7en if t%e assessment of ris isnegligile
@ >lo!on stacs use! for lig%t %y!rocaron to e p%ase! out as
:uicly as possile
rocess
@ $perating proce!ures to e clear, appropriate for t%eir purpose, an!alays folloe!
eop"e
@ >uil! capaility for operational lea!ers%ip, super7isors, an! tec%nicians
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3
>ther (ctions
Te)as Cit*
• $rgani)ation, accountailities, communication,
• E1 illion in7estment program, off8site offices, facility siting stu!y, trailersremo7e!, re!uce! 7e%icles, lo!on stacs in lig%t %8c !uty eing remo7e!,engineering stu!ies /relief systems an! SC*,
• Super7isory o7ersig%t, operator training#
B (roup• Safety F $perations organi)ation,
• Assessment of temporary uil!ings, remo7al of lo!on !rums, engineering stu!iesof atmosp%eric 7ents
• Re7ie of operating proce!ures,
•
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3
/hat can $e learn from this incident 0
@ Temporary uil!ing siting is a critical step in managing
flammale " toxic riss
@ Atmosp%eric 7enting nee!s careful !esign an! operation
@ Proce!ures are ineffecti7e if t%ey are not up8to8!ate an!
routinely folloe!@ Competency an! e%a7iors of $perations lea!ers%ip,super7ision an! orforce are fun!amental to safeoperations
$t%er lessons in7ol7e management 7isiility an! accountaility, %a)ar!i!entification, %a)ar!s of startup operations, performance measures forprocess safety, emergency !rills, etc#
nci!ent in7estigation report a7ailale at. #presponse#org