BP Final Report 03.23.07

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    U.S. CHEMICAL SAFETY AND HA ZARD INVESTIGATION B OARD

    INVESTIGATION REPORT

    REPORT NO.2005-04-I-TX

    REFINERY EXPLOSION AND FIRE

    (15 Kil led, 180 Injured)

    KEY ISSUES: BP

    SAFETY CULTURE TEXAS CITY,TEXASREGULATORY OVERSIGHT MARCH 23,2005

    PROCESS SAFETY METRICS

    HUMAN FACTORS

    MARCH 2007

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    BP Texas City Final Investigation Report 3/20/2007

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    BP Texas City Final Investigation Report 3/20/2007

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    Contents

    FIGURES AND TABLES..........................................................................................................................10

    ACRONYMS AND ABBREVIATIONS...................................................................................................13

    1.0 EXECUTIVE SUMMARY ...........................................................................................................171.1 Incident synopsis........................................................................................................................171.2 Scope of Investigation................................................................................................................17

    1.2.1 BP Group and Texas City.................................................................................................181.2.2 OSHA ...............................................................................................................................20

    1.3 Incident Description...................................................................................................................211.4 Conduct of the Investigation.......................................................................................................221.5 Key Technical Findings..............................................................................................................221.6 Key Organizational Findings......................................................................................................251.7 Recommendations......................................................................................................................26

    1.7.1 New Recommendations....................................................................................................261.7.2 Previously Issued Recommendations...............................................................................27

    1.8 Organization of the Report.........................................................................................................29

    2.0 INCIDENT OVERVIEW ..............................................................................................................302.1 BP Corporate and Texas City Refinery Background..................................................................302.2 ISOM Unit Process.....................................................................................................................30

    2.2.1 Raffinate Splitter Section..................................................................................................312.2.2 Raffinate Splitter Tower ...................................................................................................332.2.3 Safety Relief Valves.........................................................................................................342.2.4 Disposal Header Collection Systems................................................................................352.2.5 Blowdown Drum and Stack..............................................................................................35

    2.2.6 ISOM Unit Sewer System.................................................................................................382.3 Turnaround Activities.................................................................................................................382.3.1 Ultracracker Unit and Aromatics Recovery Unit Turnaround..........................................392.3.2 Partial ISOM Unit Shutdown............................................................................................39

    2.4 The Hazards of Unit Startup.......................................................................................................422.5 Incident Description...................................................................................................................43

    2.5.1 Unit Staffing.....................................................................................................................432.5.2 Preparations for the ISOM Startup...................................................................................442.5.3 Initial Tower Filling and Shutdown..................................................................................472.5.4 Inadequate Shift Turnover................................................................................................492.5.5 Raffinate Tower Startup....................................................................................................492.5.6 Tower Overfills.................................................................................................................52

    2.5.7 Tower Overflows..............................................................................................................562.5.8 Safety Relief Valves Open................................................................................................572.5.9 Hydrocarbon Liquid Flows Into Collection Header .........................................................592.5.10 Flammable Liquid Flow Into ISOM Sewer System..........................................................592.5.11 Flammable Liquid Flow Out of the Blowdown Stack......................................................602.5.12 Flammable Vapor Cloud Formation and Fire...................................................................622.5.13 Ignition Source..................................................................................................................632.5.14 Blast Pressure....................................................................................................................642.5.15 Post-Explosion Fires.........................................................................................................64

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    2.5.16 Fatalities and Injuries........................................................................................................652.5.17 Equipment and Facility Damage.......................................................................................662.5.18 Offsite Damage.................................................................................................................672.5.19 Post-Incident Emergency Response..................................................................................67

    3.0 SAFETY SYSTEM DEFICIENCIES IN UNIT STARTUP .........................................................693.1 Work Environment Encouraged Procedural Deviations.............................................................70

    3.1.1 Procedures Did Not Reflect Actual Practice.....................................................................713.1.2 Procedural Changes Without Management of Change (MOC) ........................................743.1.3 Startup Procedure Lacked Sufficient Instructions............................................................753.1.4 Summary...........................................................................................................................76

    3.2 Ineffective and Insufficient Communication Among Operations Personnel..............................773.3 Malfunctioning Instrumentation.................................................................................................793.4 Poor Computerized Control Board Display................................................................................803.5 Ineffective Supervisory Oversight and Technical Assistance During Unit Startup....................823.6 Insufficient Staffing During Start Up.........................................................................................83

    3.6.1 Refining and Corporate Management Decisions Affected Staffing.................................85

    3.7 Operator Fatigue.........................................................................................................................873.7.1 Fatigue Factors..................................................................................................................883.7.2 Operator Performance Impaired by Fatigue......................................................................893.7.3 Lack of a BP Fatigue Prevention Policy...........................................................................90

    3.8 Inadequate Operator Training.....................................................................................................913.8.1 Training for Abnormal Situation Management.................................................................923.8.2 Verifying Operator Knowledge and Qualifications..........................................................933.8.3 Simulators Not Used to Train for Hazardous Scenarios...................................................943.8.4 Refinery and Corporate Management Decisions Affected Training.................................95

    3.9 Failure to Establish Effective Safe Operating Limits.................................................................973.10 Distraction Not a Factor .............................................................................................................983.11 Summary...............................