Updated BP Texas City Animation on the 15th Anniversary of the Explosion

USCSB

23 Mar 202011:05

Summary

TLDRThe US Chemical Safety Board is developing an interactive training app based on OSHA's PSM regulation, using the 2005 BP Texas City Refinery explosion as a case study. The tragedy, caused by a combination of human error, inadequate safety measures, and equipment malfunction, resulted in 15 deaths and over 180 injuries. The incident underscores the critical need for robust process safety management in industrial settings.

Takeaways

🔥 The BP Texas City Refinery explosion in 2005 was a catastrophic event that resulted in 15 fatalities and over 170 injuries.
🛠 Maintenance and startup procedures at the refinery were not followed correctly, leading to a series of operational errors.
🏢 BP had placed trailers close to process units for contractor use without warning them of the potential hazards.
📈 The level indicator in the raffinate splitter tower was not designed to measure liquid levels above 9 feet, but the tower was overfilled to 13 feet.
⏰ Operators routinely deviated from written procedures during startups, which contributed to the unsafe conditions.
🛑 A high-level alarm activated, but a second alarm failed to go off, indicating a failure in the safety systems.
📝 Communication and logbook entries were inadequate, leading to a lack of clear instructions and understanding of the startup process.
👷‍♂️ The absence of experienced supervision and the elimination of a second board operator position due to budget cuts compromised safety.
🚫 Operators were unaware of the actual liquid levels and the growing danger due to improper calibration of the level indicator.
🌀 A flammable vapor cloud formed and was ignited by a pickup truck, leading to a series of powerful explosions and fires.
🏗️ The disaster resulted in significant damage to the ISOM unit and surrounding areas, with the unit being shut down for over two years.

Q & A

What is the purpose of the new interactive training application being developed by the US Chemical Safety Board?
-The new interactive training application is focused on OSHA's Process Safety Management (PSM) regulation, aiming to educate and train on the 14 elements of PSM using the 2005 explosion at BP's Texas City Refinery as a model.
What was the situation at BP's Texas City Refinery on March 23, 2005?
-Several units at the refinery had been shut down for lengthy maintenance projects, which required nearly a thousand contractors and BP employees to be onsite. BP had positioned portable trailers close to process units for the use of contractors and other maintenance workers.
Why were the trailers located near the isomerization unit potentially hazardous?
-The trailers were located near the isomerization unit, but the occupants were not warned when the ISOM unit was about to start up, which is a potentially hazardous operation.
What was the issue with the level indicator at the base of the raffinate splitter tower?
-The level indicator was not designed to measure liquid above the 9-foot mark, which led to operators being unable to know the actual level during startups when the tower was routinely filled above the 9-foot mark.
Why did operators deviate from written procedures during startups?
-Operators routinely deviated from written procedures and filled the tower above the 9-foot mark because they were concerned that if the liquid level fluctuated too low, it would cause costly damage to the furnace.
What happened at 1:14 p.m. that led to the disaster?
-At 1:14 p.m., the three emergency valves opened, sending nearly 52,000 gallons of flammable liquid to the blow down drum, which overflowed into a process sewer and created a huge flammable vapor cloud that eventually ignited.
What was the role of the control board operator in the lead-up to the explosion?
-The control board operator, who had been working a 12-hour shift for 30 days in a row, was left without a qualified supervisor to run three refinery units, including the ISOM unit, due to budget cuts and a last-minute family medical emergency of the day supervisor.
How did the ignition of the vapor cloud occur?
-The ignition occurred when flammable vapor entered the air intake of a pickup truck parked near the base of the blow down drum, causing the diesel engine to race and backfire, which ignited the vapor cloud.
What were the consequences of the explosion for the workers and the facility?
-The explosion resulted in the deaths of 15 workers, injuries to 180 others, and significant damage to the facility, including the destruction of trailers and damage to 50 large chemical storage tanks. The ISOM unit remained shut down for more than two years.
What was the significance of the BP Texas City disaster in terms of refinery accidents?
-The disaster at BP Texas City was the most serious refinery accident ever investigated by the CSB, highlighting the importance of proper safety management and adherence to procedures in the chemical industry.

Outlines

00:00

🚨 BP Texas City Refinery Disaster: Prelude to the Explosion

The US Chemical Safety Board was developing an interactive training application based on OSHA's Process Safety Management (PSM) regulation, using the 2005 BP Texas City Refinery explosion as a case study. The incident began with the refinery undergoing maintenance, involving nearly a thousand contractors and BP employees. Portable trailers were placed near process units for workers' use. A doublewide wood frame trailer served as an office and meeting space. On the night of March 23, 2005, operators started the isomerization unit without warning the occupants of the trailers nearby. They began introducing flammable hydrocarbons into a raffinate splitter tower, which was not equipped with a level indicator capable of measuring above the 9-foot mark. Despite a high-level alarm at 3:09 a.m., the tower was overfilled, and the lead operator left early, leaving a new board operator to manage the startup without clear instructions. The dayshift supervisor arrived late and received no formal briefing, leading to a series of miscommunications and procedural deviations that set the stage for a catastrophic event.

05:01

🔥 The Catastrophic Explosion at BP Texas City Refinery

The morning of the explosion, operators resumed the startup process, adding more liquid to the already overfilled tower. The automatic level control valve, critical for managing the liquid level, was left closed due to conflicting instructions. The control panel failed to warn operators of the rising danger, as it did not display flows into and out of the tower or calculate the total liquid. The day supervisor left abruptly for a family emergency, and no experienced supervisor replaced him, leaving a single control board operator to manage three refinery units. The tower filled to an unprecedented 98 feet with liquid, while the level indicator incorrectly showed 8.4 feet. Operators, unaware of the severity, attempted to relieve pressure by opening a manual valve and turning off furnace burners. The hot liquid caused a temperature spike in the tower, leading to boiling and swelling of the liquid. The emergency relief valves failed, and a massive amount of flammable liquid overflowed into a process sewer, creating a huge vapor cloud. A pickup truck's idling engine ignited the vapor, triggering a series of powerful explosions that devastated the ISOM unit and the nearby trailers, resulting in fatalities and serious injuries among the workers.

10:03

🏗️ Aftermath of the BP Texas City Refinery Tragedy

The disaster at BP Texas City Refinery resulted in the deaths of 15 workers and injuries to 180 others, making it the most serious refinery accident ever investigated by the Chemical Safety Board. The explosions destroyed the trailers, damaged 50 large chemical storage tanks, and shut down the ISOM unit for over two years. The aftermath highlighted the tragic consequences of inadequate safety measures, procedural failures, and a lack of effective communication during a critical startup process.

Mindmap

Keywords

💡Chemical Safety Board (CSB)

The Chemical Safety Board is an independent federal agency in the United States that investigates and reports on the causes of major chemical incidents. In the context of the video, the CSB is developing a new interactive training application focused on OSHA's Process Safety Management (PSM) regulation, using the 2005 BP Texas City Refinery explosion as a case study. This highlights the CSB's role in promoting safety and learning from past incidents to prevent future ones.

💡Process Safety Management (PSM)

Process Safety Management is a set of regulations and procedures designed to prevent or mitigate the impact of catastrophic releases of toxic, reactive, flammable, or explosive chemicals. The video script mentions that the CSB's training will cover the 14 elements of PSM, emphasizing its comprehensive nature and the importance of adhering to these guidelines to ensure safety in chemical processes.

💡BP Texas City Refinery

The BP Texas City Refinery is a petroleum refinery located in Texas City, Texas. The video script uses the 2005 explosion at this refinery as a model for the training application. This incident is a critical example of the consequences of not following proper safety protocols and serves as a cautionary tale in the training material.

💡Raffinate Splitter Tower

The raffinate splitter tower is a piece of equipment used in the BP Texas City Refinery to distill and separate gasoline components. The video script describes how operators introduced flammable liquid hydrocarbons into this tower, which was a key factor in the explosion. This highlights the importance of proper operation and monitoring of such equipment in PSM.

💡Level Indicator

A level indicator is a device that measures the amount of liquid inside a container, such as a tower. In the video, the level indicator in the raffinate splitter tower was not designed to measure liquid above the 9-foot mark, leading to a misjudgment of the actual liquid level. This example underscores the need for accurate and reliable measurement tools in process safety.

💡Control Room

The control room is a central location from which operators monitor and control industrial processes. The video script mentions a satellite control room and a central control room, both of which received information from the level indicator. The miscommunication and lack of clear instructions from these control rooms contributed to the disaster, emphasizing the critical role of effective communication in PSM.

💡High Level Alarm

A high level alarm is a safety device designed to alert operators when the liquid level in a container reaches a dangerous height. In the video, the high level alarm activated but was not heeded properly, and a second alarm failed to go off, demonstrating the importance of reliable alarm systems and operator response in preventing accidents.

💡Emergency Relief System

The emergency relief system is a safety mechanism designed to relieve pressure by releasing gases or liquids when a system becomes over-pressurized. The video script describes how operators opened a manual chain valve to send gases to the unit's emergency relief system, which ultimately failed to contain the situation, leading to the explosion. This illustrates the necessity of well-maintained and effective emergency relief systems.

💡Blow Down Drum

A blow down drum is a component of an emergency relief system that vents vapor directly into the atmosphere. The video script mentions a 1950's era blow down drum that was overwhelmed by the volume of flammable liquid, leading to the formation of a massive vapor cloud and subsequent explosion. This highlights the importance of having up-to-date and capable emergency relief equipment.

💡Flammable Vapor Cloud

A flammable vapor cloud is a mixture of flammable gases or vapors in the air, which can ignite and cause an explosion. The video script describes the formation of a huge flammable vapor cloud that engulfed the unit and nearby trailers, leading to a catastrophic explosion. This term is central to understanding the cause of the disaster and the potential hazards of uncontrolled releases of flammable substances.

💡Safety Procedures

Safety procedures are the established guidelines and protocols that must be followed to ensure the safe operation of industrial processes. The video script details multiple instances where safety procedures were not followed, such as operators deviating from written procedures and the absence of qualified supervision. These breaches of safety procedures were directly linked to the accident, emphasizing their critical importance in preventing such incidents.

Highlights

Development of a new interactive training application by the US Chemical Safety Board focused on OSHA's PSM regulation.

Training to cover the 14 elements of PSM, using the 2005 BP Texas City Refinery explosion as a model.

Several units at the refinery were shut down for lengthy maintenance projects.

Portable trailers were positioned close to process units for contractor use without proper hazard warnings.

Operators began introducing flammable liquid hydrocarbons into a raffinate splitter tower with a flawed level indicator.

High level alarm activated but a second alarm failed, indicating a lack of proper safety measures.

Operators could not know the actual liquid level in the tower due to the level indicator's limitations.

Lead operator left the refinery early, leaving the startup process without proper oversight.

Logbook did not clearly indicate the liquid level in the tower or provide instructions for startup procedures.

Operators resumed the startup process with conflicting instructions on product routing.

Critical automatic level control valve was left closed, blocking liquid flow from the tower.

Day supervisor left the refinery due to a family emergency, leaving a single control board operator in charge.

Refinery had eliminated a second board operator position due to budget cuts, increasing operational risk.

Tower filled with liquid to an unsafe level, contrary to normal operation standards.

Improperly calibrated level indicator misled operators about the actual liquid level in the tower.

Operators opened a manual chain valve, releasing gases into the atmosphere without understanding the high pressure source.

Flammable vapor ignited by a pickup truck backfire, leading to powerful explosions and fires.

12 workers were killed and 180 injured in the explosions, marking a significant loss of life and injury.

The disaster resulted in the ISOM unit being shut down for more than two years and extensive damage to the facility.