BP TEXAS CITY REFINERY, 23 March 2005 Group 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 refinerys 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

Emission of hot flammable vapors and liquids was expelled from the vent stack.

The tower had been started by ignoring open maintenance orders on the towers instrumentation system

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

Financial losses exceeding $1.5 billion

Houses were damaged as far away as threequarters of a mile from the refinery

At least 105 people were injured.

The explosion and fire left a lot of destruction and rubble at the plant

Explosions and fires killed 15 people

IMPACT

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.

American Petroleum Institute (API)

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

To issue a safety alert urging their National members to take prompt action to Petrochemical and ensure that trailers are safely Refiners located 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 Culture Process Safety Management System Performance Evaluation, Corrective Action, Corporate Oversight

Corporate Safety Culture

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

BPs US refineries did not comply with its own internal process safety standards BP refineries did not implement good engineering practices Process Safety Management Process safety knowledge and competence was not maintained at BP US refineries Systems

Performance Evaluation, Corrective Action, Corporate Oversight

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 companys 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.

Put a sensor on the splitter tower, so that liquid can be measured precisely.

Replace the blowdown drum with the inherently flare system.

Increase the capacity of the flare system.

Ban the other companies that using the same blowdown drum.

THANK YOU