Prevent Tragedies - Lessons learned from Texas City Refinery Explosion 2005 and RISK MANAGEMENT modules, AND THE PROACTIVE SAFETY METHOD, RISKS AND EMERGENCIES

 

Figure 1 - Texas City Refinery Explosion 2005

Lessons learned from Texas City Refinery Explosion 2005 and ProSREM

Reference: Organizational Accidents Revisited - James Reason

Background

In March 2005, a hydrocarbon vapor cloud exploded at BP’s Texas City refinery, killing 15 workers and injuring over 170 others. The site was designed to convert low octane hydrocarbons, through various processes, into higher octane hydrocarbons that could be blended into unleaded petrol. This was the second-largest oil refinery in Texas and the third-largest in the US. BP acquired the Texas City refinery as part of its merger with Amoco in 1999.

The refinery was built in 1934 but had been badly maintained for several years. A consulting firm had examined conditions at the plant. It released its report in January 2005, which found many safety issues that included ‘broken alarms, thinned pipe, chunks of falling concrete, bolts falling 60ft and staff being overcome with fumes’. The refinery had had five managers since BP had inherited it in its 1999 merger.

I visited a BP site in Sale Victoria (Australia) in 2001 and was impressed by its various safety management systems. They looked very sophisticated on paper in their fat ring binders. They included a Management of Change (MOC) process, a BP Pre-Startup Safety Review (PSSR), and (see more later ) an impressive overriding safety process called the Operating Management System (OMS). I came away thinking ‘these are the good guys.

After remedial work had been completed on the 170 ft raffinate tower (used for separating lighter hydrocarbon components), the PSSR was conducted. Its purpose was to establish that safety checks had been carried out and that all non-essential personnel was clear during the start-up. Once completed, the PSSR would be signed off by senior managers, but these essential safety procedures were not completed. These included an inoperative pressure control valve, a defective high-level alarm, and a defective sight tower-level transmitter that had not been calibrated. It was also discovered that one of the trailers, used to accommodate contractors, was too close to the process and thus liable to severe damage in the event of an explosion.

The explosion occurred on 23 March 2005. According to BP’s own accident report, the direct cause was ‘heavier than air hydrocarbon vapors combusting after coming into contact with the ignition source, probably a running vehicle engine’. The hydrocarbons came from the liquid overflow from the blowdown stack following the activation of the splitter tower’s over-pressure protection system. This, in turn, was due to the overfilling and overheating of the tower contents.

Both the BP and the Chemical Safety and Hazard Investigation Board reports identified numerous technical and organizational failures at the refinery and within corporate BP. These organizational failings included:

• Corporate cost-cutting.

• A failure to invest in the plant’s infrastructure.

• A lack of corporate oversight on both safety culture and accident investigation programs.

• A focus on occupational safety (lost time injuries) and not process safety.

• A defective management of the change process.

• The inadequate training of operators.

• A lack of competent supervision for start-up operations.

• Poor communications.

• The use of outdated and ineffective work procedures.

Technical failures included the following:

• A too-small blowdown drum.

• A lack of preventative maintenance on safety-critical systems

such as imperative alarms and level sensors.

• The continued use of outdated blowdown drum and stack technology when replacements had been feasible alternatives for several years.

BP was charged with criminal violations of federal environmental laws and was named in several lawsuits from victims’ families. The Occupational Safety and Health Administration (OSHA) gave BP a record fine for hundreds of safety violations. In 2009, OSHA imposed an even larger fine after claiming that BP had failed to implement safety improvements after the disaster. In 2011, BP announced it was selling the refinery to pay for ongoing compensation claims and remedial activities following the Deepwater Horizon disaster in 2010.

For more information, videos, and complementary materials, about Security, access the link at the end of this post. Are we paying attention to the essential issues for the Security of Organizations? How many lives, what social, environmental, patrimonial impact, in the image of the organization and others, would be spared? It is important to look into these issues, and to deepen academic studies, with application in companies, to develop proposals to avoid these tragedies. Below is the proposal for preventing and mitigating major and fatal negative events, which I developed based on studies and applications in organizations. It is important to present models, principles and structured forms, together with lessons learned from Major and Fatal Negative Events, which facilitate the analysis of these tragedies, That's why I created the Prevent Tragedy Course - Proactive Safety, Risks, and Emergencies Methodology (ProSREM). I developed ProSREM, in my Ph.D., in progress, in Production Engineering at UFRJ, and used as academic bases: Ergonomics, Resilience Engineering, Integrated Management Systems (Quality, Safety, and Environment), among other methods and tools, and my database to build this proposal, was the biggest and fatal negative events, prominent in the world and in Brazil, I apply this methodology at Fiocruz, where I am a public servant and in organizations, companies, sectors, and activities. If you are interested in the proposal, send me an email, and when there is the availability of e-learning training, of the Introductory Course of the Proactive Safety Method, Risks and Emergencies, I can contact you, the email is (at the moment, only in Portuguese): washington.fiocruz@gmail.com I will send you a form, for your registration, for the e-learning training, or you can access the form, with the initial guidelines at (at the moment, only in Portuguese): https://drive.google.com/drive/u/2/folders/1A4DBxbZ_cM5mv5j2YxuzqsomyarkSXWI If you are a professional with experience in the area of ​​safety, risk management, or similar areas, the initial training will consist of two 1-hour meetings, plus guided reading of the modules, complementary materials, and other guidelines, which I will send. I will assemble these training, in order of registration, so speed up yours, to start the course earlier. This course will be free of charge and will help me at this stage of my research, for the Doctorate in Production Engineering at UFRJ. Prevent Tragedy Course - Reports of professionals from the course's study cycle: - They liked the proposal, it lacks this approach with application in the industry (deficiency in the training), very didactic, motivating for the theme, bringing reality, bringing disasters, it could be avoided, ANDEST (National Association of Teachers in Engineering Safety at Work in Brazil) identified a deficiency in risk management in the training of the safety eng., posts of proactive safety are important, you raise the ball, it is up to people to absorb the lessons of the post, I encourage them to understand what happened, think about all the aspects, awaken this need for analysis. Access the link to the Proactive Security online course (in Portuguese, but you can translate the Blog pages into your language by clicking on the mouse, on the right side, and translating the page. I'm starting posts in English, and in the future, I'll be offering an e-learning course in English):

https://gestaoproativawb.blogspot.com/2022/05/prevencao-de-tragedias-apresentacao-da.html

English:

https://gestaoproativawb.blogspot.com/2023/03/article-sociotechnical-construction-of.html

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