Texas City Refinery Explosion 2005 Emily Ackerman, Yu-Chieh Cheng, Roshni Pillai, Gustavo Santos, Rishikesh Shetty

Outline Overview of the accident Flow Diagram Operational Misbehavior Investigation report findings TELOS Survey Reparations Ethical Implications Safety Environment Cultural Causes Industry Lessons

Overview of the accident BP took over the Texas City Refinery from Amoco in 1999 Produced 11 million gallons of gasoline a day On March 23rd, 2005 a blast occurred during the startup of the isomerization unit which produces materials to boost the octane rating of gasoline The explosion killed 15 workers and injured 180 others Shattered windows of homes and businesses up to three quarters of a mile away from the 1,200 acre refinery

Flow Diagram of Isomerization Unit

Operational Misbehavior The level transmitter (LT): Monitored only the bottom 9 ft section of the tower, with a Low Level Alarm (LAL) and a High Level Alarm (LAH), programmed to sound at 72% and 90%, respectively However, during the unit start-up, operators state that it was common practice to operate at higher liquid levels. Wrong indication of temperature: The temperature ramp was more than 2x higher than it was supposed to be Level control valve failure: When the level was found too high, the bottom pump was turned on in order to drain the bottom of the tower. This increased the feed temperature

Investigation Report Findings The U.S. Chemical Safety and Hazard Investigation Board (CSB) was the primary investigator into the incident Key findings : Lax attitude of BP’s management towards process safety Production pressure controlled the safety culture Weak and dismantled HS&E department BP’s focus on cost cutting and headcount reduction, critically compromised a safe working environment Poor supervision of critical activities like startups and shutdowns highlight the incompetency of BP’s technical staff Unusually, OSHA (Occupational Safety and Health Administration) was criticized for weak inspection and implementation of regulations for such high hazard industries

TELOS Survey: In late 2004, Researchers from safety culture consultant the Telos Group surveyed 1,080 employees, interviewing 112 including the leadership team and supervisors. Important findings : Production pressures impact managers “where it appears as though they must compromise safety” ”Production and budget compliance gets recognized and rewarded before anything else at Texas City” “The pressure for production, time pressure, and understaffing are the major causes of accidents at Texas City” Many employees also reported “feeling blamed when they had gotten hurt or they felt investigations were too quick to stop at operator error as the root cause” with a “culture of casual compliance”

Reparations BP was fined $21 million for the incident for “egregious willful violations” of rules and regulations that governed the industry They also signed a settlement agreement with BP which emphasizes workers and their safety as BP’s primary goal In a 2007 speech, BP's CEO said the company would spend $1.7 billion more on safety each year for the next four years OSHA fined BP $87 million in 2009 (the largest fine in OSHA history) for failing to repair many of the safety problems that led to the blast. BP agreed to pay $50 million in 2010

Safety Ethics Budget cuts reigned the refinery despite safety concerns Training staff was cut, creating an unwelcoming atmosphere and under qualified operators and engineers Downsized from ~30 people to 8 people within 10 years before the accident BP did not replace the known out of date facilities Plans for flare tower implementation in 2002 Created workplace hazard Major process steps and precautions were ignored Lack of training or part of training??

Environmental Ethics After investigation, the plant was charged for violating Texas' air quality laws The plant released 538,000 pounds of toxic chemicals into the air over the period of a month, including 17,300 pounds of benzene, a known carcinogen Environmental experts state that the release ranks among the worst air quality violations in Texas in the last decade BP did not alter its lack of concern and attitude towards the environment The Prudhoe Bay and Deepwater Horizon oil spills occurred soon after Deepwater Horizon

Cultural Causes The United States loves oil and places a large emphasis on domestic production over imports At an all time high since the early 1970’s American jobs are dependent on large corporations People around the refinery accepted the explosion because it was their livelihood Attitude that a tough job comes with risky side effects Lack of concern for those involved 65 people have died in refinery accidents since then (largely underestimated) No changes

Industry Lessons Use past accidents as an example for creating new ethical guidelines When an incident happens, employees should take proper response to address it and learn from the mistakes so that large scale accidents do not occur in the future. Effective monitoring of the facilities ensures that every process design is functioning well and up to date with current technology. Do not use budget cuts to justify the use of outdated equipment This awareness contributes to the cultivation of a safe and ethical workplace

References 1 - "BP Texas City Explosion - YouTube." 2008. 13 Nov. 2015 <https://www.youtube.com/watch?v=VCcN4SQkb9A> 2 - 2013. U.S. Chemical Safety and Hazard Investigation Board. Investigation Report - Refinery Fire and Explosion and Fire. BP Texas City March 23, 2005 3 - full CSB response to OSHA's Request for Information - US ..." 2014. 13 Nov. 2015 <http://www.csb.gov/assets/1/16/CSB_RFIcomments.pdf> 4 -- "Final Investigation Report - US - - Chemical Safety and ..." 2013. 13 Nov. 2015 <http://www.csb.gov/assets/1/19/csbfinalreportbp.pdf> 5 - BP OSHA Settlement Agreement - US - - Chemical Safety ..." 2013. 12 Nov. 2015 <http://www.csb.gov/assets/1/19/BP_OSHA_Settlement_Agreement.pdf> 6 - "2012 - 07/12/2012 - BP agrees to pay more than $13 million ..." 2012. 12 Nov. 2015 <https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=22680> 7 - "Blast at BP Texas Refinery in '05 Foreshadowed Gulf Disaster." 2010. 12 Nov. 2015 <http://www.propublica.org/article/blast-at-bp- texas-refinery-in-05-foreshadowed-gulf-disaster> 8 - "A Deadly Industry - EHS Today." 2015. 12 Nov. 2015 <http://ehstoday.com/safety/deadly-industry>

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