October 31, 2006 |

EXPLOSION ROOT CAUSE ANALYSIS: Comments on the CSB Press Release about the BP Texas City Refinery Explosion and Fire

Yesterday the CSB issued a press release with some new information about the BP Texas City Refinery Explosion. The more I read … the madder I got.

I thought about not writing this article. Writing it certainly won’t win me any friends at BP. But if I can get the attention of just a few people who are in a position to:

• Stand up when bad decisions are being made.

• Tell their boss that a decision is wrong

• Resist budget cuts that erode safety margins.

• Enforce procedure usage and safety rules.

Then I may have helped save a life – or save multiple lives. And the risk I take will be worth it.

Also, remember that I have sympathy for everyone – including management – that was involved in the tragic accident. But the CSB press release posted yesterday in this blog and quoted below has convinced me that the explosion at the BP Texas City Refinery was NOT an accident.

15 people died in a very preventable disaster.

A disaster that management could have and should have prevented. Not an accident … even though we call it one.

CSB press release statements below are in red. Bold typeface is my emphasis (not the CSB’s). My comments are in blue.

The CSB lead investigator said:

“…eight previous instances where flammable hydrocarbon vapors were discharged from the same blowdown drum between 1994 and 2004. In two of these incidents the blowdown system caught on fire. The eight incidents were
not properly investigated, and appropriate corrective actions were not implemented. The investigation of a 1994 incident resulted in an action item to analyze the adequacy of the blowdown drum. The area superintendent was responsible for the completion of this item. However, the item was never finished, and management officials did not follow up to assure completion.”

MY COMMENT: This quote points to the following root causes:

1. Inadequate incident investigation and root cause analysis from 1994-2004.

2. Inadequate corrective actions from 1994-2004.

3. Inadequate tracking of corrective actions and implementation from 1994 on.

Note that this failure existed for over a DECADE before the explosion at Texas City.

Also, this new information casts doubt on the “independent” Post Accident Process and Operational Audit Report that was recently released by BP. One of that report’s findings was that BP investigation process as implemented at Texas City was a “good practice“. That’s hard to justify if the findings above are true. Or can BP show that there has been a radical change in the incident investigation, root cause analysis, and corrective action processes being used by BP since 2004? And if these “good practices” come from corporate, then what does that say about the rest of the BP refineries and the rest of BP worldwide?

More from the CSB press release (in red) about BP management before the “accident”:

“The history of major accidents and fatalities at the plant was summarized in a meeting held in November 2004 by the refinery manager for 100 supervisors. He gave a sobering presentation entitled “Safety Reality” on the 23 deaths at the plant in the previous 30 years; on average, one worker had died every 16 months.”

Mr. Holmstrom (the CSB lead investigator) said, “In 2004, BP Texas City had the lowest injury rate in its history, nearly one-third the oil refinery sector average. However, the injury rate does not take account of catastrophic hazards or distinguish between injuries and fatalities. That year, the refinery experienced three major accidents that resulted in a total of three fatalities. One of these accidents was a major process-related fire. In late 2004, following these major accidents and other near misses, the Texas City leadership was attempting to improve the refinery’s safety performance. Several years of audits and reports had identified serious safety system deficiencies. However, the safety initiatives that were undertaken focused largely on improving personnel safety – such as slips, trips and falls – rather than management systems, equipment design, and preventative maintenance programs to help prevent the growing risk of major process accidents.”

“When personnel safety statistics improved, the refinery leadership believed they had turned the corner,” Mr. Holmstrom said. However, existing process safety metrics and the results of a safety culture survey indicated continuing serious problems with safety systems and concerns about another major accident. A Health, Safety, and Environment Business Plan presented on March 15, 2005 – just eight days before the ISOM unit accident – identified as a key risk that the Texas City refinery “kills someone in the next 12-18 months.”


It is hard to read about three fatalities and bad audit findings and understand how management could fool themselves into believing that they have “turned the corner“. With those statistics how could they believe that they had greatly improved safety? Maybe they had been living with bad practices for so long that they had no idea what good practices looked like.

Many people mistake the efforts needed to prevent cut fingers with the efforts needed to prevent major disasters. Although there can be some crossover, the proactive efforts needed are not the same. Don’t fool yourself. If minor injuries are decreasing, this could be because reporting has been discouraged. Engineering, management knowledge and involvement, adequate budgets, procedure compliance, and continuous improvement are needed to make and keep a hazardous facility safe.

And where was CORPORATE senior management? Is it OK in the BP culture to have three fatalities at one refinery? How many dead bodies are required to get corporate management’s attention? At DuPont, one fatality got the PLANT MANAGER replaced.

After reading the CSB press release, I don’t think that senior management at BP can seriously claim that they didn’t know. If they didn’t, it was because they were sticking their head in the sand. Just read the following: (from the CSB press release)

Earlier, a 2003 external BP audit referred to the Texas City refinery’s infrastructure and assets as “poor” and found what it termed a “checkbook mentality.” Budgets were not large enough to manage all the risks, but rather than expanding the budget, expenditures were restricted to the money on hand, in the opinion of the BP auditors.

A 2004 BP Group internal audit of 35 business units including Texas City found significant common gaps, including a lack of leadership competence which pointed to “systematic underlying issues,” widespread tolerance of noncompliance with basic safety rules, and poor implementation and monitoring of safety management systems and processes.

Chairman Merritt (CSB Chairman) stated that stringent budget cuts throughout the BP system caused a progressive deterioration of safety at the Texas City refinery. “BP implemented a 25% cut on fixed costs from 1998 to 2000 that adversely impacted maintenance expenditures and infrastructure at the refinery,” she said. Maintenance spending fell throughout the 1990’s at the then-Amoco refinery, and following the merger with BP further cuts were imposed. “Every successful corporation must contain its costs. But at an aging facility like Texas City, it is not responsible to cut budgets related to safety and maintenance without thoroughly examining the impact on the risk of a catastrophic accident.”

By 2002, an internal BP report had identified the cost reductions as contributing to a decline of infrastructure in Texas City that would require significant investment to correct. These findings were corroborated in a survey of the refinery’s safety culture in 2005 just prior to the accident, known as the Telos study. The survey interview with the Texas City refinery manager identified a history of decapitalization and a culture of “things not getting fixed.”

“The refinery manager was not alone in this candid assessment,” Chairman Merritt said. “Large majorities of the survey respondents reported significant maintenance backlogs that were harming safety. Disturbingly, most employees agreed that ‘production and budget compliance gets recognized and rewarded before anything else at Texas City.’”

Economic pressures were evident in numerous decisions that were causally related to the March 23, 2005, accident.


Management shouldn’t try to claim that they didn’t know that dramatic and prolonged budget cuts would have a negative impact on safety at a refinery. When they cliam such things, they are either:

a) Proving that they don’t know enough to be in their job.


b) Lying.

I know senior managers and they are smart enough to know.

Many (but not all) big oil companies cut expenditures in the refining end of the business when the price of oil and the refining margins were low (the 1990’s). But from 1995-2005, the BP/Amoco refineries had more fatalities (22) than all the other US refiners combined (21).(reference) BP managers and others should have known they were taking risks. My belief is that they hoped that the safety margins were large enough that they could delay maintenance and capital projects without experiencing any significant accidents or process outages. But well before 2005 they should have seen that this was not true. The signs were there if they were willing to see.

Since the price of oil and refining margins are now very positive, the same maintenance that was delayed due to lack of funds is now being delayed (at some refineries – but not all) because the units are making so much money that the companies say that they can’t afford to shut them down.

ALL REFINERY MANAGERS SHOULD BE AWARE: Skimping on maintenance of hazardous processes will come back to haunt the process owners. Warning signs can only be ignored for so long before an explosion and fire points out the weakest link in the safety chain.

We know – by the results – that BP erred too far toward the side of cost cutting and profit maximazation. The question that others must answer is … WHAT IS YOUR SAFETY MARGIN? Have other refiners learned from the BP accident?

Are they taking a hard stand against deferring maintenance and engineering upgrades despite the money that the downtime costs?

Are they insisting on insightful root cause analysis and effective corrective actions?

Are they tracking corrective actions to see if they are implemented and validating that the corrective actions were effective?

Are they enforcing procedure usage and positively reinforcing management system standards?

Are they continuously improving performance with the use of best practices that they find inside and outside the refining industry?

I know the BEST are. But here is a message to the REST:


BP had adequate warning prior to the 2005 explosion. The deaths could and should have been prevented.

The whole management chain will have to live with their consciences. They should thank their lucky stars that this refinery wasn’t in the UK, or senior management might be facing jail time (which is rare in the US).

Hindsight is too late to prevent the 15 deaths at the BP Texas City Refinery. So the question that YOU need to ask is:


If you are at a refinery or some other hazardous facility … Are you waiting for your own disaster to provide an opportunity to improve?

Don’t be penny wise and pound foolish.

Don’t cut corners for short-term profit gains.

Don’t put people’s lives at risk to look good on the quarterly report.

If you are in senior management, your job is NOT to kill people to maximize shareholder return.


You must know what is going on.

You must know enough about the operations of your company to be able to judge the impact of budget cuts.

You must have proactive indicators that tell you if efforts to economize have gone too far. They must be proactive so that you prevent fatalities.

You must insist on tough standards.

You must understand and insist that your facilities use advanced root cause analysis and you must have measures of the effectiveness of the corrective actions they implement.

You must hold yourself accountable for the performance of those who report to you. If they let safety slide, it is YOUR FAULT. You can’t make excuses that you didn’t know.

The well being of every employee is your responsibility.

If a preventable fatality happens, you have failed.

Many may think these words are harsh. Some may say that I’m being too hard on BP. There were many managers at BP that should have acted from 1994 to 2005 so you can’t hold any one manager responsible. Some may say that the managers who just happened to be there when the explosion occurred are nothing more than scapegoats. They may be partially right.

But anyone who takes the big bucks to manage a high hazard facility needs to make sure that under their watch, they run a tight ship. They should be able to stand up and proudly say that they did everything they possibly could to keep people safe and prevent fatalities.

And I’m not speaking from ignorance.

I’m not bragging, but I put my career at risk by standing up to senior management on more than one occasion. So I know what it feels like to be pressured to not speak out. And I know the risk to your career when you do. But I stood in the breach and gambled my future when I saw decisions that could have cost lives. And I sleep well knowing that no one was killed on my watch.

After the damning information provided in the CSB press release quotes above, the senior managers who didn’t quit and leave in disgust from the Texas City Refinery from 1994 to 2005 – and by default, their senior corporate management – can’t say they did everything they could to safeguard the lives of those who worked for them. They let their workers down.


They should have known and they should have acted.

The 15 deaths are a result of their inaction (or their ineffective action). That’s why I get so mad when I read the CSB information. The billions of dollars of BP profits in 2005 are NOT worth those 15 lives.

Make no mistake. I believe what I wrote in the 2003 article “Stop the Sacrifices“. I wrote it for senior managers in the construction industry. But senior managers at BP should have read it. Perhaps the 21st century will be the new age where we stop sacrificing employees to maximize profits. It certainly is time for senior management to stop claiming that they just couldn’t see accidents coming. In BP’s case, the evidence was there for anyone who cared to look.

If you disagree or if you have an opposing view, please feel free to comment by clicking on the “Comments” link below.

And if you agree, please feel free to let me know by clicking on the “Comments” link below.

But no matter what your opinion of this article, TAKE ACTION to make your improvement program WORLD CLASS. Do everything you can to prevent accidents and save lives at your company. You won’t be sorry that you did.

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