U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD INVESTIGATION REPORT REFINERY EXPLOSION AND FIRE (15 Killed, 180 Injured) KEY ISSUES: BP SAFETY CULTURE TEXAS CITY, TEXAS REGULATORY OVERSIGHT MARCH 23, 2005 PROCESS SAFETY METRICS HUMAN FACTORS REPORT NO. 2005-04-I-TX MARCH 2007 BP Texas City Final Investigation Report 3/20/2007 BP Texas City Final Investigation Report 3/20/2007 Contents FIGURES AND TABLES ..........................................................................................................................10 ACRONYMS AND ABBREVIATIONS ...................................................................................................13 1.0 EXECUTIVE SUMMARY ...........................................................................................................17 1.1 Incident synopsis ........................................................................................................................17 1.2 Scope of Investigation ................................................................................................................17 1.2.1 BP Group and Texas City .................................................................................................18 1.2.2 OSHA ...............................................................................................................................20 1.3 Incident Description ...................................................................................................................21 1.4 Conduct of the Investigation.......................................................................................................22 1.5 Key Technical Findings..............................................................................................................22 1.6 Key Organizational Findings......................................................................................................25 1.7 Recommendations ......................................................................................................................26 1.7.1 New Recommendations ....................................................................................................26 1.7.2 Previously Issued Recommendations ...............................................................................27 1.8 Organization of the Report .........................................................................................................29 2.0 INCIDENT OVERVIEW ..............................................................................................................31 2.1 BP Corporate and Texas City Refinery Background..................................................................31 2.2 ISOM Unit Process.....................................................................................................................31 2.2.1 Raffinate Splitter Section..................................................................................................32 2.2.2 Raffinate Splitter Tower ...................................................................................................33 2.2.3 Safety Relief Valves .........................................................................................................36 2.2.4 Disposal Header Collection Systems................................................................................37 2.2.5 Blowdown Drum and Stack..............................................................................................37 2.2.6 ISOM Unit Sewer System.................................................................................................40 2.3 Turnaround Activities.................................................................................................................40 2.3.1 Ultracracker Unit and Aromatics Recovery Unit Turnaround..........................................40 2.3.2 Partial ISOM Unit Shutdown............................................................................................41 2.4 The Hazards of Unit Startup.......................................................................................................44 2.5 Incident Description ...................................................................................................................44 2.5.1 Unit Staffing .....................................................................................................................45 2.5.2 Preparations for the ISOM Startup ...................................................................................47 2.5.3 Initial Tower Filling and Shutdown..................................................................................49 2.5.4 Inadequate Shift Turnover ................................................................................................51 2.5.5 Raffinate Tower Startup....................................................................................................52 2.5.6 Tower Overfills.................................................................................................................54 2.5.7 Tower Overflows ..............................................................................................................58 2.5.8 Safety Relief Valves Open................................................................................................59 2.5.9 Hydrocarbon Liquid Flows Into Collection Header .........................................................61 2.5.10 Flammable Liquid Flow Into ISOM Sewer System..........................................................61 2.5.11 Flammable Liquid Flow Out of the Blowdown Stack ......................................................62 2.5.12 Flammable Vapor Cloud Formation and Fire...................................................................64 2.5.13 Ignition Source..................................................................................................................66 2.5.14 Blast Pressure....................................................................................................................66 2.5.15 Post-Explosion Fires.........................................................................................................67 3 BP Texas City Final Investigation Report 3/20/2007 2.5.16 Fatalities and Injuries........................................................................................................68 2.5.17 Equipment and Facility Damage.......................................................................................68 2.5.18 Offsite Damage.................................................................................................................70 2.5.19 Post-Incident Emergency Response..................................................................................70 3.0 SAFETY SYSTEM DEFICIENCIES IN UNIT STARTUP .........................................................71 3.1 Work Environment Encouraged Procedural Deviations.............................................................72 3.1.1 Procedures Did Not Reflect Actual Practice.....................................................................73 3.1.2 Procedural Changes Without Management of Change (MOC) ........................................76 3.1.3 Startup Procedure Lacked Sufficient Instructions ............................................................77 3.1.4 Summary...........................................................................................................................78 3.2 Ineffective and Insufficient Communication Among Operations Personnel..............................79 3.3 Malfunctioning Instrumentation .................................................................................................81 3.4 Poor Computerized Control Board Display................................................................................83 3.5 Ineffective Supervisory Oversight and Technical Assistance During Unit Startup....................85 3.6 Insufficient Staffing During Start Up .........................................................................................86 3.6.1 Refining and Corporate Management Decisions Affected Staffing .................................88 3.7 Operator Fatigue.........................................................................................................................89 3.7.1 Fatigue Factors..................................................................................................................90 3.7.2 Operator Performance Impaired by Fatigue......................................................................91 3.7.3 Lack of a BP Fatigue Prevention Policy ...........................................................................93 3.8 Inadequate Operator Training.....................................................................................................94 3.8.1 Training for Abnormal Situation Management.................................................................94 3.8.2 Verifying Operator Knowledge and Qualifications..........................................................96 3.8.3 Simulators Not Used to Train for Hazardous Scenarios...................................................96 3.8.4 Refinery and Corporate Management Decisions Affected Training.................................98 3.9 Failure to Establish Effective Safe Operating Limits ...............................................................100 3.10 Distraction Not a Factor ...........................................................................................................101 3.11 Summary...................................................................................................................................102