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

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

3. 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

4. Flow Diagram of Isomerization Unit

5. 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

6. 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

7. 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”

8. 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

9. 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??

10. 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

11. 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

12. 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

13. References
1 - "BP Texas City Explosion - YouTube." Nov <
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 ..." Nov <
4 -- "Final Investigation Report - US - - Chemical Safety and ..." Nov <
5 - BP OSHA Settlement Agreement - US - - Chemical Safety ..." Nov <
6 - " /12/ BP agrees to pay more than $13 million ..." Nov <
7 - "Blast at BP Texas Refinery in '05 Foreshadowed Gulf Disaster." Nov < texas-refinery-in-05-foreshadowed-gulf-disaster>
8 - "A Deadly Industry - EHS Today." Nov <

14. THANK YOU!
QUESTIONS?