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BP America (Texas City) Refinery Explosion

Overview

On March 23, 2005, a severe explosion and fire occurred at the BP Texas City refinery during startup of the isomerization (ISOM) unit. A raffinate splitter tower was overfilled with flammable hydrocarbons. Pressure relief devices opened. Flammable liquid was discharged to an undersized blowdown drum and stack open to the atmosphere. A geyser-like release formed a vapor cloud and ignited. Fifteen workers were killed and about 180 others were injured. The final report identified failures in instrumentation, training, fatigue management, trailer siting, relief system design, and BP's process safety management and oversight.

Incident Snapshot

Field Value
Facility / Company BP America / BP Texas City refinery
Location Texas City, TX
Incident Date 03/23/2005
Investigation Status The Board approved its final report by a vote of 5-0 at a public meeting in Texas City on March 20, 2007.
Accident Type Oil and Refining - Fire and Explosion
Final Report Release Date 03/20/2007

What Happened

  • On March 23, 2005, at approximately 1:20 p.m., a series of explosions occurred at the BP Texas City refinery during the restarting of a hydrocarbon isomerization unit.
  • During startup, the raffinate splitter tower was overfilled with liquid hydrocarbons.
  • The tower overpressurized and three pressure relief valves opened, discharging flammable liquid to the blowdown system.
  • The blowdown drum and stack overfilled, causing a geyser-like release of flammable liquid out of the stack.
  • The released liquid evaporated and formed a flammable vapor cloud.
  • The vapor cloud ignited, causing explosions and fire.
  • Many of the victims were in or around work trailers located near the blowdown drum and stack.
  • The final report concluded that fatigue likely contributed to the overfilling of the raffinate splitter tower and that inadequate training for operations personnel contributed to the incident.

Facility and Process Context

  • BP Texas City refinery
  • isomerization (ISOM) unit
  • raffinate splitter tower
  • blowdown drum and stack
  • central control room
  • occupied work trailers near the ISOM unit
  • refinery startup after a maintenance turnaround

Consequences

  • Fatalities: 15
  • Injuries: 180
  • Environmental release: Flammable liquid was released from the blowdown stack, evaporated as it fell to the ground, and formed a flammable vapor cloud.
  • Facility damage: The explosion and fire severely damaged the ISOM unit area; more than 40 trailers were damaged, 13 were destroyed, the satellite control room was severely damaged, the catalyst warehouse was destroyed, and many vehicles and storage tanks were damaged.
  • Operational impact: The refinery experienced a major explosion and fire during startup; the ISOM unit was shut down and the site underwent extensive investigation and later restart activities.

Key Findings

Immediate Causes

  • The raffinate splitter tower was overfilled during startup.
  • The tower overpressurized and pressure relief valves opened, discharging flammable liquid to the blowdown system.
  • The blowdown drum and stack overfilled and released flammable liquid to the atmosphere.
  • The released vapor cloud ignited and exploded.

Contributing Factors

  • The tower level indicator showed the tower level was declining when it was actually overfilling.
  • The redundant high level alarm did not activate.
  • The control board display did not provide adequate information on the imbalance of flows in and out of the tower.
  • The level sight glass was dirty and non-operational.
  • The pressure control valve PCV-5002 failed to function during pre-startup testing.
  • The blowdown drum was undersized for the liquid release.
  • The emergency relief system design did not address the potential of a large liquid release if the tower overfilled.
  • The startup procedure was not followed; liquid was pumped into the tower for over three hours without any liquid being removed.
  • The Day Board Operator and the operations crew were likely experiencing significant fatigue.
  • Operations personnel were inadequately trained, particularly for abnormal situations and board operator duties.
  • Occupied trailers were sited too close to the ISOM unit.
  • The blowdown drum and stack were not connected to a flare system.
  • The unit startup occurred despite previously reported malfunctions of the tower level indicator, level sight glass, and pressure control valve.
  • The startup lacked qualified supervisory oversight and technically trained personnel.

Organizational and Systemic Factors

  • BP's approach to safety largely focused on personal safety rather than major hazard control.
  • BP had a history of releases, fires, fatalities, and other process safety incidents before the March 23, 2005 incident.
  • The 2004 PSM audit revealed poor process safety management performance, especially in mechanical integrity, training, process safety information, and management of change.
  • BP's mechanical integrity program did not ensure deficiencies were identified and repaired prior to failure.
  • BP did not effectively implement its pre-startup safety review policy.
  • BP did not have a shift turnover communication requirement for operations staff.
  • BP had no corporate or site-specific fatigue prevention policy.
  • BP management did not ensure that knowledgeable supervisors or technically trained personnel were assigned to the startup.
  • BP's management of change process was not effectively used for procedural, organizational, personnel, and policy changes.
  • BP's safety culture emphasized personal injury metrics rather than process safety indicators.
  • BP's decentralized approach to safety led to a loss of focus on process safety.
  • BP's board and senior executives did not provide effective oversight of major accident prevention.
  • Budget cuts and production pressures impaired process safety performance at Texas City.

Failed Safeguards or Barrier Breakdowns

  • level transmitter LT-5100
  • high level alarm LSH-5102
  • high level alarm LSH-5020
  • pressure control valve PCV-5002
  • level sight glass
  • control board display
  • blowdown drum high level alarm
  • redundant high level alarm
  • startup procedure for the raffinate splitter
  • pre-startup safety review
  • shift turnover communication
  • fatigue prevention policy
  • flare system for the blowdown drum and stack
  • mechanical integrity program
  • management of change reviews
  • qualified supervisory oversight during startup

Recommendations

  1. 2005-4-I-TX-R1 | Recipient: BP Group Executive Board of Directors | Status: accepted | Summary: Commission an independent panel to assess and report on the effectiveness of BP North America’s corporate oversight of safety management systems at its refineries and its corporate safety culture.
  2. 2005-4-I-TX-R2 | Recipient: American Petroleum Institute (API) | Status: agreed to develop new guidelines | Summary: Revise Recommended Practice 752 or issue a new Recommended Practice to ensure the safe placement of occupied trailers and similar temporary structures away from hazardous areas of process plants.
  3. 2005-4-I-TX-R3 | Recipient: American Petroleum Institute & the National Petrochemical and Refiners Association | Status: published information | Summary: Issue a safety alert to membership to take prompt action to ensure the safe placement of occupied trailers away from hazardous areas of process plants.
  4. 2005-4-I-TX-R4 | Recipient: American Petroleum Institute (API) | Status: Closed - Acceptable Action | Summary: Revise API Recommended Practice 521 to identify overfilling vessels as a hazard, adequately size disposal drums for credible worst-case liquid relief scenarios, and warn against atmospheric blowdown drums and stacks attached to collection piping systems that receive flammable discharges from multiple relief valves.
  5. 2005-4-I-TX-R5 | Recipient: Occupational Safety and Health Administration (OSHA) | Status: Closed - Acceptable Action | Summary: Implement a national emphasis program for oil refineries focusing on blowdown drums and stacks that release flammables to the atmosphere and the need for adequately sized disposal knockout drums based on accurate relief valve and disposal collection piping studies.
  6. 2005-4-I-TX-R6a | Recipient: American Petroleum Institute (API) | Status: Closed – Acceptable Alternative Action | Summary: Work with the United Steelworkers International Union to develop a consensus ANSI standard for process safety indicators in the refinery and petrochemical industries, including leading and lagging indicators for public reporting and use at individual facilities.
  7. 2005-4-I-TX-R6b | Recipient: United Steelworkers International Union (USW) | Status: Closed – Acceptable Action | Summary: Work with the American Petroleum Institute to develop a consensus ANSI standard for process safety indicators in the refinery and petrochemical industries, including leading and lagging indicators for public reporting and use at individual facilities.
  8. 2005-4-I-TX-R7a | Recipient: American Petroleum Institute (API) | Status: Closed – Acceptable Action | Summary: Develop a consensus ANSI standard for process safety indicators in the refining and petrochemical industries.
  9. 2005-4-I-TX-R7b | Recipient: United Steel Workers (USW) | Status: Closed – Acceptable Action | Summary: Develop fatigue prevention guidelines for the refining and petrochemical industries that limit hours and days of work and address shift work.
  10. 2005-4-I-TX-R8 | Recipient: Occupational Safety and Health Administration (OSHA) | Status: Closed – Acceptable Alternative Action | Summary: Strengthen the planned comprehensive enforcement of the OSHA Process Safety Management standard, including identifying highest-risk facilities, conducting comprehensive inspections, building inspector capability, and expanding PSM training.
  11. 2005-4-I-TX-R9 | Recipient: Occupational Safety and Health Administration (OSHA) | Status: Open – Unacceptable Response | Summary: Amend the OSHA PSM standard to require management of change reviews for organizational changes that may impact process safety, including mergers, acquisitions, reorganizations, staffing changes, and budget cutting.
  12. 2005-4-I-TX-R10 | Recipient: Center for Chemical Process Safety (CCPS) | Status: | Summary: Issue management of change guidelines that address the safe control of major organizational changes, policy and budget changes, personnel changes, and staffing during startups, shutdowns, and other abnormal conditions.
  13. 2005-4-I-TX-R11 | Recipient: BP Board of Directors | Status: Closed – Acceptable Alternative Action | Summary: Appoint an additional non-executive member of the Board of Directors with specific professional expertise and experience in refinery operations and process safety.
  14. 2005-4-I-TX-R12 | Recipient: BP Board of Directors | Status: | Summary: Ensure and monitor that senior executives implement an incident reporting program throughout the refinery organization that encourages reporting without fear of retaliation, requires prompt corrective actions, tracks closure of action items, and communicates key lessons learned.
  15. 2005-4-I-TX-R13 | Recipient: BP Board of Directors | Status: Closed – Acceptable Action | Summary: Ensure and monitor that senior executives use leading and lagging process safety indicators to measure and strengthen safety performance in the refineries.
  16. 2005-4-I-TX-R14 | Recipient: BP Texas City Refinery | Status: | Summary: Evaluate refinery process units to ensure that critical process equipment is safely designed.
  17. 2005-4-I-TX-R15 | Recipient: BP Texas City Refinery | Status: | Summary: Ensure that instrumentation and process equipment necessary for safe operation is properly maintained and tested.
  18. 2005-4-I-TX-R16 | Recipient: BP Texas City Refinery | Status: | Summary: Work with the United Steelworkers Union and Local 13-1 to establish a joint program that promotes reporting, investigation, and analysis of incidents, near-misses, process upsets, and major plant hazards without fear of retaliation.
  19. 2005-4-I-TX-R17 | Recipient: BP Texas City Refinery | Status: | Summary: Improve the operator training program.
  20. 2005-4-I-TX-R18 | Recipient: BP Texas City Refinery | Status: | Summary: Require additional board operator staffing during the startup of process units.
  21. 2005-4-I-TX-R19 | Recipient: BP Texas City Refinery | Status: | Summary: Require knowledgeable supervisors or technically trained personnel to be present during especially hazardous operation phases such as unit startup.
  22. 2005-4-I-TX-R20 | Recipient: BP Texas City Refinery | Status: | Summary: Ensure that process startup procedures are updated to reflect actual process conditions.
  23. 2005-4-I-TX-R21 | Recipient: United Steelworkers International Union and Local 13-1 | Status: | Summary: Work with BP to establish a joint program that promotes reporting, investigating, and analyzing incidents, near-misses, process upsets, and major plant hazards without fear of retaliation.

Key Engineering Lessons

  • Do not rely on a single level indicator or alarm for critical startup control; multiple independent and functioning safeguards are needed.
  • Control room displays must provide operators with information that reveals flow imbalance and true vessel inventory during startup.
  • Relief and blowdown systems must be sized for credible liquid overfill scenarios, not only vapor relief.
  • Atmospheric blowdown drums and stacks are not an adequate safeguard for large flammable liquid releases from multiple relief valves.
  • Critical instrumentation and control valves must be tested, maintained, and verified before startup.
  • Startup procedures must reflect actual process conditions and abnormal situations, including the need to remove liquid from the tower during filling.
  • Flare systems provide a safer alternative to atmospheric blowdown systems for flammable discharges.
  • Trailer siting near hazardous process units can convert a process release into a mass-casualty event.

Source Notes

  • Priority 1 final report findings were used to resolve conflicts and establish the authoritative incident narrative.
  • Supporting documents were used only to supplement details consistent with the final report and to capture recommendation status changes where explicitly stated.
  • The final report identified the incident as a raffinate splitter tower overfill during startup in the ISOM unit, with a blowdown drum and stack open to the atmosphere.
  • The final report stated that fatigue likely contributed to the overfilling and that inadequate training for operations personnel contributed to the incident.
  • The final report stated that BP's placement of occupied trailers close to the ISOM unit was a key factor leading to fatalities.
  • The final report stated that the blowdown drum was undersized and the emergency relief system design did not address the potential of a large liquid release.
  • The final report stated that BP's approach to safety largely focused on personal safety rather than major hazards.

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