Texas City refinery accident

This accident occurred on March 23, 2005 at the British Petroleum (BP) Texas City Refinery, the third largest oil refinery in fhe United States, when a hydrocarbon vapor cloud exploded at the isomerization process unit [8]. More specifically, on March 23, 2005 at the refinery, an isomerization unit s start-up whose raffinate tower was overfilled resulted in the raffinate overheating and pressure relief devices opening, and then consequently led to a flammable liquid geyser from a blow down stack unequipped with flare and then an explosion and fire [1,9]. The accident killed 15 workers and injured over 170 others [1,8,9]. 

Some of the active influencing maintenance factors were as follows [1,9]  

Additional information on the Texas City Refinery accident influencing maintenance-related factors is available in References 1,8, and 9. 

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Hydrocarbon processing, transport and storage are nndoubtedly very hazardous, high risk activities, and they also feature elsewhere in this book - the Buncefield accident is discussed in Chapter 6, and the Texas City refinery accident is discussed in Chapter 14. The hazards and risks mainly arise because they process hydrocarbons at high temperature and high pressure ... 

The Texas City refinery accident killed 15 people and injured a further 180. The accident had a financial cost exceeding 1.5 billion, making it the most expensive refinery accident in history. A highly critical report was published by the US Chenucal Safety and Hazard Investigation Board, who also produced an excellent 55-minute video about the accident. 

The Texas City refinery accident and the Macondo-Deepwater Horizon accident are completely dissimilar - it is very difficult to identily any similarities between the... 

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. 

One of the very best all-around CSB videos is titled An Anatomy of Disaster Explosion at BP Texas City Refinery, March 28,2005 [13]. It tells the story of one of the worst industrial accidents in recent US history in words, animation and site footage. This refinery explosion arrd fire killed 15 workers, injured 180 others and resrrlted in billions of dollars in econorrtic losses. This video is nearly 56 rrrin long, but is divided into chapters. So, you can select chapters to show to certain audiences. 

John Mogford, at the time senior group vice president, safety operations, for BP, conceded this blind spot in 2006 in his speech to the Center for Chemical Process Safety, 2nd Global Congress on Process Safety Do not get seduced by personal accident measures they have their place but do not warn of incidents (Editor s note such as the BP Texas City refinery explosion). There is a need to capture the right metrics that indicate process safety trends. ... 

Unfortunately, today, we are still making very similar mistakes that we saw at Flixborough decades ago and other disasters. For example, the accident investigation into the BP Texas City Refinery explosion and fire in 2005 found eerily similar accident causes and precursors ... 

Refinery operations at Texas City refinery had been taking place since 1934. The refinery had been owned by Amoco until it merged with BP in 1998. Under Amoco s ownership, at least three opportunities had been missed to carry our modifications that would have prevented the accident ... 

The irony of this stretches belief. It also says something about the working environment at Texas City refinery that a mere one month without a lost-time injury was considered sufficient to merit a celebratory lunch. Also, Ido not understand how this is consistent with the claim of "zero lost time accidents in 2004, unless the celebratory lunch was something that had happened every month for a long time. 

Sharing of past major incidents with other oil and gas industries provides useful input data for similar process industries in order to identify the most critical barriers and improve their safety processes. One poignant example highlights this matter. In 1998 there was an accident in the gas compression stage of a Middle East oil and gas plant which caused 7 dead as a result of fuel accumulation and vapor cloud explosion which was very similar to the Texas City Refinery disaster on March 23, 2005 in which a distillation tower was overfilled and an uncontrolled release of hydrocarbons led to a major explosion and fires. Fifteen people were killed and 180 were injured in the worst disaster in the United States in a decade. In both incidents, excess hydrocarbons were diverted into a pressure relief system that included a blowdown stack. In the Iranian case, it was equipped with a flare, but one which the operator didn t ignite in Texas City the blowdown stack was not equipped with a flare to burn off hydrocarbons as they were released. As a result, the flammable overflow from the tower entered the atmosphere. Ignition of the escaped hydrocarbons was enabled by startup of a nearby vehicle resulted in the explosion and subsequent fires (Hopkins, 2008). This example shows the repetitive patterns of accidents, and root causes of events all over the world in this sector. The lesson of this paper is that accidents in one country, where the scenarios are very similar, can and should serve as lessons to prevent the same scenario being actualized in other countries. 

Past experiences indicate that industries such as petroleum and chemical that handle hazardous substances are more prone to major accidents. Maintenance can play a major role in the occurrence of such accidents. Some examples of the major accidents in the area of oil and gas industrial sector in which maintenance, directly or indirectly, has played a major role are Piper Alpha Disaster, Texas City Refinery Explosion, Sodegaura Refinery Disaster, and the Bhopal Gas Tragedy [1]. 

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... 

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... 

The March 2005 Texas City, Texas, refinery incident -the most tragic US refinery accident of the decade... 

At 1 20 PM. on March 23, 2005, a large flammable vapor cloud was ignited by the backfire of an idling diesel pickup truck, resulting in a massive explosion and fire in the ISOM unit at the BP refinery in Texas City, Texas. Fifteen workers were killed and 180 others were injured in the worst industrial accident in recent US. history. 

The Baker Panel had a broader focus than the BP investi tion by the CSB. It was charged with a review of all five BP US refineries. The panel was directed not to seek to affix blame or apportion responsibility for aity past event furthermore it shonld avoid duplicating the efforts of the CSB to determine the specific root canses of the accident at Texas City [17]. ... 

On March 23,2005, at a BP Products North America-owned and -operated refinery, a fire and explosion resulted in 15 deaths, 170 injuries, and extensive property damage. An investigation team led by BP employee J. Mogford released a report titled Fatal Accident Investigation Report, Isomerization Unit Explosion Final Report, Texas City, Texas, USA. The 192 page report may be accessed at the website listed in the end-of-chapter references. 

It is easier to write about a culture that includes safety as a core value than it is to factually describe a situation in which the culture deteriorates over time, the effect the deterioration has on increasing risk and the position in which such deterioration places a safety professional. The following are excerpts taken from a report that was internally produced by BP Products North America (2005) pertaining to a fire and explosion that occurred on March 23,2005, at an owned and operated refinery in Texas City, Texas. As a result of that incident, 15 people were killed and over 170 were harmed. It is important to note that these excerpts, taken from the Executive Summary— Fatal Accident Investigation Report, represent a self-evaluation. 

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. 

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