Texas City Explosion Happened on March 23 at 1:20 PM
It is still unknown why an operator started filling (with raffinate) an already full (98% full on his display) column.
And he continued to fill the column for a couple of hours longer than it would have taken to fill it if it was empty.
Perhaps is was the level indicator that had never been calibrated in the past 10 years and indicated that level was slightly decreasing while he continued to overfill the tank (many maintenance items had been backlogged for a long time).
Perhaps it was the operators’ practice of making sure that they were at the upper end of the indicating level before starting up (a practice that was counter to the operating procedure that nobody followed).
Perhaps it was that the top of the operating range of the level indicator was only 15% up the column and there was no accurate level indication if you exceeded that level.
Perhaps it was that the second high level alarm failed to sound.
Perhaps it was the fatigue that slowly slips up on an operator when they work weeks upon weeks without a day off and with extensive overtime (12 hours days and 7 day weeks).
Perhaps it was that he received no turnover on the plant status at the start of the shift and the log book only had a cryptic note about “packing” the column with “raf.”
Maybe it was all these combined.
Then, as he tried to start up the unit for the first time (he had never done a startup on this “simple” unit before) without a supervisor (who went to check on one of his kid with a broken arm) and without a relief for the other three plants he was already running (the relief was required by procedures but they were short on staff), while they also ran a safety meeting in his control room, he couldn’t understand why the process behaved strangely … Why pressure stayed too high … Why venting (using an alternate path because the normal path was out of service) didn’t work. Even talking to the supervisor on his cell didn’t give him any good ideas.
Then, when he tried to take fluid out of the column, he actually made the problem worse by causing rapid boiling of the raffinate and a huge overflow into a knock-out drum that was never sized for this type of overflow.
The result? Hot, flammable raffinate spewed forth from a stack (not a flare) and formed a large vapor cloud that reached an ignition source and caused a large explosion and fire.
This would have been less disastrous if some temporary, non-blast hardened trailers had not been located close to the stack. They were flattened. The majority of the 15 people killed in the blast and fire were killed in these trailers. Why was the waiver for these temporary trailers approved? Shouldn’t they have at least been “blast-proof”? The company’s risk assessment said this was a low risk area and that a large release of hydrocarbons was impossible (or at least highly unlikely).
And it all happened on this day in March of 2005 – five years ago.
People are already starting to forget the lessons learned (if they were learned) from this sad explosion and fire. But if you would like to review materials to keep the accident fresh in your memory, here is a wealth of information including reports and links to previous blog postings…
Baker Panel Report: Baker_panel_report.pdf
BP Press Conference Call About Baker Panel Report: BakerPanelConfCall.pdf
Bonse (Discipline) Report: Bonse Main Report.pdf
BP Accident Report (Mogford Report): Link to report
Telos Report: Link to report
Brown gets It Movie … (Quicktime .mov format – click below to play) …
Extensive evidence from Texas City Lawsuits: Link to web site
US CSB Report and Information: Link to CSB web site
Early e-Newsletter Articles: Link
Lessons Learned Talk by John Mogford: Link
Mark Gets Mad After Interim CSB Report: Link
Cost of US CSB Investigation: Link
BP Annual Report Note Story in Blog: Link
Interesting Deposition Videos: Link
Deposition Shows How Hard it is to Justify Performance After an Accident (Whole Deposition in Written Form from Don Paris): Link
Blog Post About Instrumentation Problems: Link
Blog Post on Cost Cutting Controversy: Link
Blog Post on Fatigued Operators: Link
Blog Post About BP Pleading Guilty to Felony: Link
Blog Post on BP Texas City Accident Cost: Link
Blog Post About BP CEO Admitting that He Never Read the US CSB Report: Link
Blog Post on EPA Fine: Link
Blog Post on $87 Million OSHA Fine for Missing Corrective Action Deadlines: Link
That should give you plenty to read to help you learn all there is to learn from the BP Texas City Refinery Explosion.
Now let’s take a few minutes to remember those who died to teach us these lessons.