CSB's final report cites 'broken safety culture' at BP
BP PLC had a "broken safety culture" at the time of the Mar. 23, 2005, fire and explosion at its 460,000 b/d Texas City, Tex., refinery that killed 15 people and injured 180 others, the US Chemical Safety Board (CSB) said at a news conference Mar. 20 outlining details of its final report.
Senior Staff Writer
HOUSTON, Mar. 20 -- BP PLC had a "broken safety culture" at the time of the Mar. 23, 2005, fire and explosion at its 460,000 b/d Texas City, Tex., refinery that killed 15 people and injured 180 others, the US Chemical Safety Board (CSB) said at a news conference Mar. 20 outlining details of its final report.
The CSB board voted 5-0 late on Mar. 20 to approve the final report at a public meeting in Texas City. BP issued a statement saying it was in disagreement with parts of the report, but it did not elaborate.
Many safety issues that led to the accident were recurring safety problems previously identified in BP internal audits, reports, and investigations, CSB said. BP acquired the refinery when it merged with Amoco Corp. in 1999.
CSB found that "cost-cutting in the 1990s by Amoco and then BP left the Texas City refinery vulnerable to a catastrophe." Over a 30-year period spanning the refinery's ownership by Amoco and BP, 23 workers died there, not counting the 15 workers killed in March 2005, said the report.
"Among other things, cost considerations discouraged refinery officials from replacing the blowdown drum with a flare system, which the CSB previously determined would have prevented or greatly minimized the severity of the accident," CSB investigators said. The explosion involved a C5-C6 isomerization unit with "antiquated equipment," they said.
Hydrocarbons originated from liquid overflow from an F-20 blowdown drum, BP Products North America Inc. has said in its incident investigation report that was released on Dec. 9, 2005. The fire and explosion occurred on the isom unit and involved the raffinate splitter and blowdown drum (OGJ, Jan. 23, 2006, p. 51). Flammable liquid hydrocarbons vented directly into the atmosphere.
"A geyser-like release of highly flammable liquid and vapor" was emitted, and a diesel pickup truck idling nearby ignited the vapor, causing the explosion and fire that resulted in fatalities and injuries in and around work trailers placed "too close" to the isom unit, the CSB report said.
CSB investigator Mark Kasniak developed a vapor and blast model. He calculates 7,600 gal of flammable liquid hydrocarbons was released in less than 2 min. Carolyn W. Merritt, CSB chairwoman and chief executive officer, called the explosion avoidable, saying it was "the inevitable result of a series of actions" by BP executives and its corporate board.
"Among other things, they cut costs that affected maintenance and safety [and] they ignored the implications of previous incidents that were red warning flags," Merritt said. "There was a broken safety culture at BP. The company has, since the accident, taken steps to improve process safety and to change their safety culture."
CSB concluded the Texas City refinery accident stemmed from organizational and safety deficiencies at all levels of BP.
"The boards of directors of oil and chemical companies should examine every detail of their process safety programs to ensure that another terrible tragedy like the one at BP does not occur," Merritt said. She advocates "a new standard of care for corporate boards of directors and CEOs throughout the world."
Process safety programs deserve the same level of attention, investment, and scrutiny as companies now dedicate to maintaining their financial controls, she said. Fielding questions from reporters about industry's reports of improved safety at refineries, Merritt said BP measured its safety record by the number of injuries to individuals at plants. This involves personal safety like slips, falls, and vehicle accidents. Industry needs to better measure risk factors to facilities, she said.
CSB recommends the Occupational Safety and Health Administration increase its petrochemical inspections and enforce safety regulations at refineries and chemical plants.
OSHA conducted only one planned Process Safety Management (PSM) inspection at the Texas City refinery in 1998 even though the refinery experienced fatal accidents from 1985 to 2005, said CSB supervisory investigator Don Holmstrom.
"OSHA's national focus is on inspecting facilities with high injury rates. While that is important, it has resulted in reduced attention to preventing less-frequent but catastrophic process safety incidents such as the one at Texas City," Holmstrom said. "Available evidence indicates that OSHA has an insufficient number of qualified inspectors to enforce the PSM standard at oil and chemical facilities," he said.
The report calls on OSHA to identify plants at the greatest risk of a catastrophic accident and then to conduct comprehensive inspections at those plants. It also recommends that OSHA hire or train new, specialized inspectors and expand its national PSM training curriculum. CSB concluded that existing rules likely could have prevented the Texas City accident.
"But if a company is not following those rules, year-in and year-out, it is ultimately the responsibility of the federal government to enforce good safety practices before more lives are lost," Merritt said. "These facilities simply have too many potentially catastrophic hazards to be overlooked."
CSB is an independent federal agency that investigates industrial chemical accidents, including the root causes of the accident such as equipment failure as well as regulations. It does not issue citations or fines but makes safety recommendations to plants, industry organizations, labor groups, and regulatory agencies.
The report recommends BP appoint an additional board member having expertise in process safety, and it also calls for BP senior executives to establish an improved incident reporting program and to use new indicators to measure safety performance.
An independent panel commissioned by BP and led by former US Sec. of State James A. Baker III raised similar issues that the industry needs to address, Holmstrom and Merritt said.
The CSB team recommends that the American Petroleum Institute and the United Steelworkers International Union work together to develop standards to prevent employee fatigue in the oil and chemical industry. Last week, API officials said US refiners already are applying lessons learned from the Texas City refinery (OGJ Online, Mar. 16, 2007).
Investigators said a valve allowing liquid to drain into storage tanks was left closed for over 3 hr during the isom unit startup on Mar. 23, contrary to unit start-up procedures. CSB concluded that human factors, including fatigue, led to this error.
"By Mar. 23, operators had been working 12-hr shifts for 29 or more consecutive days," CSB investigators said, adding "There are no fatigue-prevention guidelines that are widely used and accepted in the oil and chemical sector." The transportation industry has such regulations.
The report said BP had failed to investigate previous abnormal isom unit start-ups, and that a Mar. 23 decision by a control board operator to keep the drain valve closed was influenced by ineffective communication and by false instrument readings.
The normal liquid level in the tower was 6½ ft, but the level on Mar. 23 reached 158 ft shortly before the accident. This was unknown to operators. The CSB determined the level transmitter was miscalibrated, using a setting from outdated data sheets that likely had not been updated since 1975. CSB citied "lack of effective preventive maintenance, lack of change reviews and pre-startup reviews, and incomplete hazard analyses."
The refinery only investigated three of eight known previous isom blowdown release incidents where vapor was released from the same blowdown drum involved in the Mar. 23 accident. In 2004 an internal BP audit graded the refinery's analysis of incident information as "poor," CSB said.
CSB also determined that both the blowdown drum and relief-valve disposal piping were undersized. BP was required by federal regulations to conduct a study of the tower's pressure relief system but this study was 13 years overdue by 2005.
The refinery had longstanding process safety deficiencies, Merritt said, but she believes BP and industry in general are learning from this. She said she is confident that chemical and oil industry workplaces will be safer in the future as a result of the CSB recommendations.
BP said it voluntarily provided CSB with over 6 million pages of documents and made over 300 witnesses available for CSB interviews, including some of its most senior executives.
"Notwithstanding the company's strong disagreement with some of the content of the CSB report, particularly many of the findings and conclusions, BP will give full and careful consideration to CSB's recommendations, in conjunction with the many activities already under way to improve process safety management," the company said in a statement.
BP described itself as "willing and able to achieve the goal of becoming an industry leader in process safety management."
In the 2 years since the accident, BP said it has worked to address causes of the explosion, to reduce risk, and improve process safety management and performance at its five US refineries.
"This effort continues. BP is committed to preventing such a tragedy from occurring again," the company said.
Contact Paula Dittrick at firstname.lastname@example.org