Texas City accident

Recent analyses of a large number of major accidents, irwluding NASA s... accidents BP s Texas City accident and the banking crisis, have implicated the culture of those organizations. 

So, two accidents and one company, within just over 5 years the most expensive accident of any sort ever, and one of the most expensive refinery accidents ever. However, as we shall see further on, the differences between the two accidents greatly outweigh any similarities. The Texas City accident was at an old refinery, carrying out routine production operations. The Ma.caaAo-Deepwater Horizon accident occurred on a state-of-the-art drilling rig while exploring for oil in very deep seawater-right at the boundaries of current technology. 

Table 14.1 Root causes and contributory factors to the Texas City accident...

In addition to these formal studies of human error in the CPI, almost all the major accident investigations in recent years, for example, Texas City, Piper Alpha, Phillips 66, Feyzin, Mexico City, have shown human error as a significant causal factors in design, operations, maintenance or the management of the process. Figures 4.4-1 and 4.4-2 show the effects of human error on nuclear plant operation. 

Davenport (1986) describes the following accident. On May 30, 1978, at 2 00 a.m., the overfilling with isobutane of sphere 409 in the tank farm of a refinery at Texas City, Texas (Figure 2.27) caused the sphere to crack at a bad weld and resulted in... 

The Texas City Disaster is generally considered to be one of the most significant industrial accidents in US history. The following provides a brief summary of the event. 

An ammonium nitrate explosion in Texas City, Texas, on April 16, 1947, was responsible for the worst industrial accident in U.S. history. While being loaded into two ships at the Texas City harbor, more than 7.5 million kilograms (17 million pounds) of the ammonium nitrate was exposed to flames and exploded. The... 

On April 16, an ammonium nitrate explosion in Texas City, Texas, becomes the worst industrial accident in U.S. 

Examples of major accidents that have happened in the industry are the Piper Alpha platform tire and explosion in 1988 that was caused by permit to work (PTW) system failure and layout issues where 165 people died the Bombay High platform, where in 2005 a multi service vessel (MSV) collided with the platform, causing riser damage and a fire that killed 22 people and the Texas City Refinery, where in 2005, maintenance and process start-up flaws caused a petroleum distillate to overflow, causing an explosion and a flash fire that killed 15 people. 

The discussion in Chapter 1 showed how safety and risk management programs developed over the last 200 years. Typically new programs and approaches were introduced once existing systems had become mature and well established. The discussion also showed that current risk management initiatives are largely to do with the topic of culture and employee participation. Hence much of the recent literature to do with Process Safety Management (PSM) speaks to the topic of company culture. For example, the Baker Commission report to do with the 2005 accident at Texas City... 

In the next section, we provide an application of the concepts for different phases from the sequence of events that lead to the Texas City, BP Refinery accident on March 23, 2005 and emphasize how a defense strategy augmented with the appropriate diagnosis mechanisms, could have supported the prevention of this accident or mitigated its consequences. 

TEXAS CITY, BP REFINERY ACCIDENT AN ILLUSTRATIVE MODELING WITHIN THE DES FRAMEWORK... 

In this section, we present an illustrative modeling of the accident within the DES framework based on the CSB safety video regarding the Texas City, BP Refinery accident (CBS 2008). For the purpose of this work, we provide a simple modeling of the accident sequence, using a small munber of states. The discussion that follows, highlights how dramatically the degraded observabihty / diagnosabihty capacity of the isomerization unit of the Texas City, BP Refinery affected the accident s initiation and evolution. 

To demonstrate the connection between observability / diagnos ability and the safety performance of the isomerization unit of the Texas City, BP Refinery within the DES framework, it suffices to model the accident sequence using nominal and hazardous states oidy. In particular, we assiune that initially the system was operating safely and according to the standard procedures (nominal state A).The accident (state... 

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