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After Katrina: Special Precautions Needed During Oil and Chemical Facility Startup

Overview

CSB Safety Bulletin warning that the startup of major processes is a hazardous phase in the operation of oil refineries and chemical plants. The bulletin was issued after Hurricane Katrina disrupted production at numerous petrochemical facilities in the Gulf Coast region and caused extensive water and wind damage to facilities in hard-hit areas. It emphasizes that restarting facilities over the coming weeks and months requires special attention to process safety requirements to assure a safe and expeditious return to operation.

Incident Snapshot

Field Value
Facility / Company Not specified
Location Not specified
Incident Date 09/08/2005
Investigation Status Safety Bulletin released September 8, 2005; not a single incident investigation
Accident Type Oil and Refining - Fire and Explosion Investigation Status
Final Report Release Date 09/08/2005

What Happened

  • Hurricane Katrina disrupted production at numerous petrochemical facilities in the Gulf Coast region.
  • Hurricane Katrina caused extensive water and wind damage to facilities in hard-hit areas.
  • Facilities were expected to restart over the coming weeks and months.
  • The bulletin advised facilities to pay particular attention to process safety requirements during startup.
  • The bulletin advised facilities to follow established startup procedures and checklists and carefully perform pre-startup safety reviews.
  • The bulletin advised facilities to thoroughly evaluate equipment, tanks, and instrumentation for damage prior to startup.

Facility and Process Context

  • oil refineries
  • chemical plants
  • petrochemical facilities in the Gulf Coast region
  • facilities in hard-hit areas damaged by Hurricane Katrina
  • continuous process equipment
  • batch processes
  • major processes
  • large-scale equipment

Consequences

  • Fatalities: 22 deaths, from three catastrophic startup incidents cited by CSB since 1998
  • Injuries: more than 170 injuries, from three catastrophic startup incidents cited by CSB since 1998
  • Environmental release: Not specified
  • Facility damage: extensive water and wind damage to facilities in hard-hit areas
  • Operational impact: Hurricane Katrina disrupted production at numerous petrochemical facilities in the Gulf Coast region; facilities were expected to restart over the coming weeks and months

Key Findings

Immediate Causes

  • No direct causes were identified in the source.

Contributing Factors

  • Startup of major processes is a hazardous phase in the operation of oil refineries and chemical plants.
  • Numerous activities are occurring simultaneously during startup.
  • Many automatic systems are run under manual control during startup.
  • Human performance may be compromised due to crisis conditions.
  • Equipment, tanks, and instrumentation should be thoroughly evaluated for damage prior to startup.

Organizational and Systemic Factors

  • Established startup procedures and checklists should be followed.
  • Pre-startup safety reviews should be carefully performed.
  • Appropriate management-of-change (MOC) processes should be used before modifying any startup procedures, equipment, or staffing arrangements due to the impact of the hurricane.
  • Adequate staffing and expertise should be available before starting up.
  • Up-to-date startup procedures should be used, and available staff should be trained in how to execute them.
  • Nonessential personnel, including personnel in trailers, should be evacuated from the vicinity of process units that are starting up.

Failed Safeguards or Barrier Breakdowns

  • established startup procedures and checklists
  • pre-startup safety reviews
  • management-of-change (MOC) processes
  • adequate staffing and expertise
  • up-to-date startup procedures
  • trained staff
  • evacuation of nonessential personnel from the vicinity of process units that are starting up
  • thorough evaluation of equipment, tanks, and instrumentation for damage prior to startup
  • test grounding integrity
  • test motors for ground faults (megohmmeter testing)
  • verify lubrication systems are functional on associated equipment
  • conduct infrared scans to detect hot-spots in equipment upon energizing

Recommendations

  1. Recommendation ID: Not specified. Recipient: Not specified. Status: Not specified. Summary: Use established startup procedures and checklists and carefully perform pre-startup safety reviews; use appropriate management-of-change (MOC) processes before modifying any startup procedures, equipment, or staffing arrangements due to the impact of the hurricane; make sure that adequate staffing and expertise are available before starting up; use up-to-date startup procedures and ensure that the available staff are trained in how to execute them; evacuate nonessential personnel, including personnel in trailers, from the vicinity of process units that are starting up.
  2. Recommendation ID: Not specified. Recipient: Not specified. Status: Not specified. Summary: Thoroughly evaluate equipment, tanks, and instrumentation for damage prior to startup, including examining large bulk storage tanks, pressure vessels and small storage tanks, insulation systems, sewers and drains, furnace systems, electric motors and drives, switchgear, conduit, electrical boxes, electronic and pneumatic instrumentation, emergency warning systems, and emergency equipment.

Key Engineering Lessons

  • Startup of major processes is a hazardous phase and requires strict adherence to established startup procedures, checklists, and pre-startup safety reviews.
  • After hurricane damage, equipment, tanks, and instrumentation should be thoroughly evaluated before energizing or restarting process units.
  • Management-of-change controls are necessary when startup procedures, equipment, or staffing arrangements are altered due to emergency conditions.
  • Adequate staffing, expertise, and current training are critical during restart activities when many systems are operating under manual control.
  • Nonessential personnel should be removed from the vicinity of process units during startup to reduce exposure during a high-risk phase.

Source Notes

  • Source is a CSB Safety Bulletin, not a single incident report with a specific event sequence or direct cause.
  • Priority 1 source states that the bulletin cites three catastrophic startup incidents since 1998 causing 22 deaths and more than 170 injuries.
  • No facility company, specific location, or chemicals were identified in the provided source extracts.

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