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BP TEXAS CITY REFINERY,
23 March 2005Group 3
BACKGROUND
The largest and most complex oil refinery, with a rated capacity of 460,000 barrels per day (bpd) and
production of up to 11 million gallons of gasoline a day
It also produces jet fuels, diesel fuels and chemical feed stocks
The refinery has 30 process units spread over a 1,200-acre site and employs about 1,800 permanent
BP staff
The disaster resulting in 15 death and more than 170 injuries and significant
economic losess
INCIDENT
On the morning of March 23, 2005, the raffinate splitter tower in the refinery’s ISOM unit was restarted
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 procedure.
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.
CAUSE OF THE DISASTER
The refinery had been in operation since 1934 but
had not been well maintained in several
years
An alarm meant to warn about the quantity of liquid in the unit was
disabled
The tower had been started by ignoring open
maintenance orders on the tower’s instrumentation
system
Emission of hot flammable vapors and liquids was expelled from the vent
stack.
Lack of drawn-down from the tower was recognized
A diesel pick up truck was parked near the blow
down stack which act as a source of ignition for the Vapor Cloud Explosion
IMPACT OF THE DISASTER
IMPACTExplosions and fires killed 15 people
At least 105 people were injured.
Financial losses exceeding $1.5
billion Houses were damaged as far away as three-
quarters of a mile from the refinery
The explosion and fire left a lot of destruction and
rubble at the plant
It also sent a plume of thick and black smoke hundreds feet into the air.
STANDARD IN THE PRACTICE
OSHA should update and strengthen its 1992 standard on
Process Safety Management of
Highly Hazardous Chemicals
For example, facilities should be
required to report to OSHA when their
use of highly hazardous chemicals
in large quantities meets the standards’
provisions for coverage
The standard currently covers
flammable, explosive and toxic chemicals, but not chemicals that can
undergo a catastrophic
runaway reaction.
• to develop new guidelines to ensure that occupied trailers and similar temporary structures are placed safely away from hazardous areas of process plants
• revise Recommended Practice 521.Guide for Pressure Relieving and Depressuring Systems to identify the hazards of this equipment
American Petroleum
Institute (API)
• To issue a safety alert urging their members to take prompt action to ensure that trailers are safely located
National Petrochemical and
Refiners Association (NPRA)
LESSON LEARNT
For the Baker Report, he focused more on the Process Safety rather than personal safety
It can be divided into 3 component:Corporate Safety CultureProcess Safety Management SystemPerformance Evaluation, Corrective Action, Corporate Oversight
Corporate
Safety Cultur
e
• BP Board did not exercise good Process Safety leadership• BP corporate did not provide appropriate resources to assure
adequate process safety• BP managers did not incorporate process safety into management
decision making
Process
Safety Manageme
nt Syste
ms
• 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
Performance Evaluat
ion, Correct
ive Action, Corpor
ate Oversig
ht
• BP measured safety performance through personal injury rate, rather than measuring process safety equipment performance
• The process safety audit system was inadequate
US Chemical Safety and Hazard Investigation Board (CSB)
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
BP Texas City Managers• Lacked an effective mechanical integrity program to maintain instruments and
process safety equipment• Incorporate good practice design in the operation of hazardous• chemical systems
RECOMMENDATION
Employee should put safety as the main priority. A course on occupational
and health should be conducted annually.
Put the hazard sign on every hazardous
material.
Replace the blowdown drum
with the inherently flare system.
Put a sensor on the splitter tower, so that liquid can be
measured precisely.
Increase the capacity of the flare system.
Ban the other companies that using the same
blowdown drum.
THANK YOU