BP Texas City Refinery Explosion

Wednesday afternoon, March 23 At approximately 1:20 p.m. on Wednesday, March 23, a series of explosions occurred at the BP Texas City refinery during the restarting of a hydrocarbon isomerization unit. Fifteen workers were killed and about 170 others were injured. Many of the victims were in or around work trailers located near an atmospheric vent stack. CSB investigators have reported that the explosions occurred when a distillation tower flooded with hydrocarbons and was overpressurized, causing a geyser-like release from the vent stack.

BP Texas City Video Clip

CSB Investigation• Trailers sited in unsafe location

(occupied, adjacent operating unit)• Raffinate splitter should not have been

started up because of existing malfunctions to the level indicator, level alarm and control valve

• Raffinate splitter had a history of abnormal startups that included recurrent high liquid levels and pressures.

CSB Investigation• In March 2005, the blowdown drum vented

highly flammable material directly into the atmosphere. Since its construction in the 1950’s the drum had never been connected to the flare. Amoco, the previous owner, replaced the blowdown drum and stack in 1997 with identical equipment. Amoco safety standards recommended connecting the drum to a flare when such major changes were undertaken.

CSB Investigation• Between 1995 and 2005 there were 4 other

serious releases of flammable material from the unit blowdown drum and stack that led to ground level vapor clouds, fortunately none ignited.

• In 1992, OSHA cited a similar blowdown drum and stack at the refinery because it vented flammable materials directly to the atmosphere. However, OSHA dropped the citation and the drum was never connected to a flare system.

Baker Panel Review• “The passing of time without a process

accident is not necessarily an indication that all is well and may contribute to a dangerous a growing sense of complacency”

• “When people lose an appreciation for how their safety systems were intended to work, safety systems and controls can deteriorate, lessons can be forgotten, and hazards and deviations from safe operating procedures can be accepted.”

Baker Panel - Culture• “BP has emphasized personnel safety

in recent years and has achieved significant improvement in personnel safety performance, but BP did not emphasize process safety. BP mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance at its U.S. refineries”

Baker Panel – Culture• “A good process safety culture requires a

positive, trusting and open environment with effective lines of communication between management and the workforce, including employee representatives”

• “At Texas City, Toledo, and Whiting, BP has not established a positive, trusting and open environment with effective lines of communication”

Sunoco • Sunoco was working on improvement

opportunities in the area Risk Management before the Texas City Explosion and will continue to do so.

• BP Texas City has reaffirmed and provided an urgency in our efforts to effectively manage risks that are inherent to our facilities. It has also provided valuable reminders and lessons not only Sunoco, but for our industry.

Sunoco Risk Management• Sunoco Risk Methodology Standard

– Defined Risk Criteria (Qualitative and Quantitative) – Risk Based Decision Making

• Layers of Protection Analysis (LOPA)– Single Scenario Analysis

• Initiating event frequency and consequence, evaluated against independent layers of protection = RISK

– PHA integration/interlock evaluations– Identifies what systems are critical and what isn’t

• Safety Instrumented Systems (SIS) Analysis (ISA 84)– Evaluation of current Safety Instrumented Systems (Detect,

Decide, Deflect) with regard to redundancy and independence with assigned testing and inspection frequencies.

Sunoco Facility Siting• Baker Risk Analysis of all sites

– OSHA recognized (BP Texas City)

• Sunoco Portable Building and Alternative Enclosure Standard– Approved Trailer Lots– MOC and risk review inside “Restricted

Areas”– Clearing of “non-essentials” during start-up

Process Safety Auditing

• Corporate PSM Audit every three years for each site (independent)– Management Systems Evaluated

• Trending/Lessons (across the company)– PSM Forum/Chemicals PSMTT

• BP Texas City Gap Assessment• Sunoco PSM Audits

Sunoco Management Commitment• Safety Culture

– Positive, Trusting, Open– Effective Communication

• Effective Risk Management– Facility Siting– PHA/LOPA/QRAs– SIL – Reliability/Mechanical Integrity – OD/MWP = Operating Excellence

• Root Cause Analysis– Level 2 and 3 Events– Trending across the business (internally and externally)

Sunoco Employee Engagement• Total Event Reporting (TERs)

– Stating block for effective risk management

• Hazard Recognition– Quality PHAs, Incident Investigations, inspections– Quality Safe Plan of Action (SPAs)

• Personal Hazard Review

– Quality Observation Processes• 3rd Party Hazard Review

• JSC and local Safety Committee– Safety Action that targets Risk Reduction, not jackets

• Challenge Our Assumptions