U.S. C H E M I C AL S AF E T Y AN D H A Z AR D I N V E S T I G AT I O N B O AR D

INVESTIGATION REPORT

REFINERY EXPLOSION AND FIRE (15 Killed, 180 Injured)

KEY ISSUES: BP SAFETY CULTURE TEXAS CITY, TEXAS REGULATORY OVERSIGHT MARCH 23, 2005 PROCESS SAFETY METRICS HUMAN FACTORS

REPORT NO. 2005-04-I-TX MARCH 2007

Contents

FIGURES AND TABLES ..........................................................................................................................10 ACRONYMS AND ABBREVIATIONS ...................................................................................................13 1.0 EXECUTIVE SUMMARY ...........................................................................................................17 1.1 Incident synopsis ........................................................................................................................ 17 1.2 Scope of Investigation ................................................................................................................ 17 1.2.1 BP Group and Texas City ................................................................................................. 18 1.2.2 OSHA ............................................................................................................................... 20 1.3 Incident Description ................................................................................................................... 21 1.4 Conduct of the Investigation....................................................................................................... 22 1.5 Key Technical Findings.............................................................................................................. 22 1.6 Key Organizational Findings...................................................................................................... 25 1.7 Recommendations ...................................................................................................................... 26 1.7.1 New Recommendations .................................................................................................... 26 1.7.2 Previously Issued Recommendations ............................................................................... 27 1.8 Organization of the Report ......................................................................................................... 29 2.0 INCIDENT OVERVIEW ..............................................................................................................31 2.1 BP Corporate and Texas City Refinery Background.................................................................. 31 2.2 ISOM Unit Process ..................................................................................................................... 31 2.2.1 Raffinate Splitter Section.................................................................................................. 32 2.2.2 Raffinate Splitter Tower ................................................................................................... 33 2.2.3 Safety Relief Valves ......................................................................................................... 36 2.2.4 Disposal Header Collection Systems ................................................................................ 37 2.2.5 Blowdown Drum and Stack .............................................................................................. 37 2.2.6 ISOM Unit Sewer System................................................................................................. 40 2.3 Turnaround Activities................................................................................................................. 40 2.3.1 Ultracracker Unit and Aromatics Recovery Unit Turnaround.......................................... 40 2.3.2 Partial ISOM Unit Shutdown............................................................................................ 41 2.4 The Hazards of Unit Startup ....................................................................................................... 44 2.5 Incident Description ................................................................................................................... 44 2.5.1 Unit Staffing ..................................................................................................................... 45 2.5.2 Preparations for the ISOM Startup ................................................................................... 47 2.5.3 Initial Tower Filling and Shutdown.................................................................................. 49 2.5.4 Inadequate Shift Turnover ................................................................................................ 51 2.5.5 Raffinate Tower Startup.................................................................................................... 52 2.5.6 Tower Overfills................................................................................................................. 54 2.5.7 Tower Overflows .............................................................................................................. 58 2.5.8 Safety Relief Valves Open................................................................................................ 59 2.5.9 Hydrocarbon Liquid Flows Into Collection Header ......................................................... 61 2.5.10 Flammable Liquid Flow Into ISOM Sewer System.......................................................... 61 2.5.11 Flammable Liquid Flow Out of the Blowdown Stack ...................................................... 62 2.5.12 Flammable Vapor Cloud Formation and Fire ................................................................... 64 2.5.13 Ignition Source.................................................................................................................. 66 2.5.14 Blast Pressure.................................................................................................................... 66 2.5.15 Post-Explosion Fires ......................................................................................................... 67

2.5.16 Fatalities and Injuries........................................................................................................ 68 2.5.17 Equipment and Facility Damage....................................................................................... 68 2.5.18 Offsite Damage ................................................................................................................. 70 2.5.19 Post-Incident Emergency Response.................................................................................. 70 3.0 SAFETY SYSTEM DEFICIENCIES IN UNIT STARTUP .........................................................71 3.1 Work Environment Encouraged Procedural Deviations............................................................. 72 3.1.1 Procedures Did Not Reflect Actual Practice..................................................................... 73 3.1.2 Procedural Changes Without Management of Change (MOC) ........................................ 76 3.1.3 Startup Procedure Lacked Sufficient Instructions ............................................................ 77 3.1.4 Summary........................................................................................................................... 78 3.2 Ineffective and Insufficient Communication Among Operations Personnel.............................. 79 3.3 Malfunctioning Instrumentation ................................................................................................. 81 3.4 Poor Computerized Control Board Display................................................................................ 83 3.5 Ineffective Supervisory Oversight and Technical Assistance During Unit Startup.................... 85 3.6 Insufficient Staffing During Start Up ......................................................................................... 86 3.6.1 Refining and Corporate Management Decisions Affected Staffing ................................. 88 3.7 Operator Fatigue ......................................................................................................................... 89 3.7.1 Fatigue Factors.................................................................................................................. 90 3.7.2 Operator Performance Impaired by Fatigue...................................................................... 91 3.7.3 Lack of a BP Fatigue Prevention Policy ........................................................................... 93 3.8 Inadequate Operator Training..................................................................................................... 94 3.8.1 Training for Abnormal Situation Management................................................................. 94 3.8.2 Verifying Operator Knowledge and Qualifications .......................................................... 96 3.8.3 Simulators Not Used to Train for Hazardous Scenarios ................................................... 96 3.8.4 Refinery and Corporate Management Decisions Affected Training................................. 98 3.9 Failure to Establish Effective Safe Operating Limits ............................................................... 100 3.10 Distraction Not a Factor ........................................................................................................... 101 3.11 Summary................................................................................................................................... 102 4.0 INCIDENT INVESTIGATION SYSTEM DEFICIENCIES ......................................................103 5.0 EQUIPMENT DESIGN...............................................................................................................105 5.1 Hazards of High Tower Level .................................................................................................. 105 5.2 Previous Tower Overfilling Incidents ...................................................................................... 105 5.3 Level Indication Design............................................................................................................ 106 5.4 Automatic Safety Controls ....................................................................................................... 107 5.5 Pressure Relief and Disposal System Design ........................................................................... 109 5.5.1 Safety and Engineering Standards .................................................................................. 110 5.5.2 Pressure Relief System Design Basis ............................................................................. 110 5.5.3 Blowdown System Design Basis .................................................................................... 111 5.5.4 Process Safety Standard No. 6 ........................................................................................ 111 5.5.5 Amoco Engineering Specification 49D-2....................................................................... 112 5.5.6 Amoco Engineering Specification A CV-PLT-DISP-E.................................................. 113 5.6 Previous Attempts to Remove Blowdown Drums.................................................................... 114 5.6.1 1991 Flare/Blowdown Strategy ...................................................................................... 114 5.6.2 1992 OSHA Citation....................................................................................................... 114 5.6.3 1993 Amoco Regulatory Cluster Project ........................................................................ 115 5.6.4 2002 NDU Flare line....................................................................................................... 115 5.6.5 2002 Clean Streams Project ............................................................................................ 116 5.7 API 521 Guidelines .................................................................................................................. 117

5.7.1 Tower overfilling scenario.............................................................................................. 118 5.7.2 Selection of disposal systems.......................................................................................... 118 5.7.3 Sizing the knockout drum ............................................................................................... 119 5.7.4 Inherently safer approaches ............................................................................................ 119 5.8 Conclusion ................................................................................................................................ 120 6.0 TRAILERS .................................................................................................................................. 122 6.1 Placement of Temporary Structures ......................................................................................... 122 6.2 History of Trailers in the Area.................................................................................................. 122 6.2.1 2005 Turnaround............................................................................................................. 123 6.3 BP Texas City Facility Siting Practices.................................................................................... 123 6.3.1 Amoco Facility Siting Screening Workbook................................................................... 124 6.3.2 MOC Procedures for Facility Siting ............................................................................... 125 6.3.3 What If/Checklist Methodology ..................................................................................... 125 6.3.4 MOC Implementation Problems with Trailer Siting....................................................... 126 6.4 API 752 Guidelines .................................................................................................................. 127 6.5 BP Actions After the Explosion ............................................................................................... 129 7.0 MECHANICAL INTEGRITY.....................................................................................................130 7.1 Instrumentation Failures ........................................................................................................... 130 7.2 Mechanical Integrity Management System Deficiencies ......................................................... 132 7.2.1 Process Safety Information ............................................................................................. 132 7.2.2 Maintenance Procedures and Training............................................................................ 133 7.2.3 Process Hazard Analysis (PHA) ..................................................................................... 133 7.2.4 Deficiency Management: The SAP Maintenance Program ............................................ 134 7.3 Summary................................................................................................................................... 134 8.0 OTHER SAFETY SYSTEM PROBLEMS .................................................................................136 8.1 Process Hazard Analysis (PHA)............................................................................................... 136 8.2 Management of Change (MOC) ............................................................................................... 137 8.3 Auditing .................................................................................................................................... 138 8.3.1 Compliance Audits ......................................................................................................... 138 8.3.2 PSM Audits..................................................................................................................... 138 8.3.3 2001 PSM Audit ............................................................................................................. 139 8.3.4 2004 PSM Audit ............................................................................................................. 139 8.4 Controlling Vehicle Traffic and People During Startup........................................................... 140 8.4.1 Traffic Safety Policy ....................................................................................................... 140 8.4.2 Failure to Remove Non-Essential Personnel .................................................................. 141 9.0 BP’S SAFETY CULTURE..........................................................................................................142 9.1 BP Texas City Explosion: An Organizational Accident........................................................... 142 9.2 Grangemouth Lessons—Focus on PSM................................................................................... 144 9.3 BP’s Approach to Safety—Lack of PSM Focus....................................................................... 146 9.3.1 Changes in the Safety Organization................................................................................ 146 9.3.2 BP Group’s HSE Management System .......................................................................... 147 9.3.3 Group Major Hazard Safety Standard............................................................................. 150 9.3.4 BP Management Framework .......................................................................................... 150 9.3.5 Texas City Process Safety Group ................................................................................... 152 9.3.6 Other Factors Impacting BP’s Safety Management........................................................ 153 9.3.7 Summary......................................................................................................................... 155 9.4 Ineffective BP Response to Reports of Serious Safety Problems 2002-2005 .......................... 155

9.4.1 2002 Study Provides Warnings of Impending Major Site Incident ................................ 155 9.4.2 Study Follow-up: Lack of Investment Compromised Safety.......................................... 157 9.4.3 1999 – 2000 Significant Budget Cuts ............................................................................. 158 9.4.4 2002 Financial Crisis Mode ............................................................................................ 159 9.4.5 2003 Maintenance Gap Assessment ............................................................................... 160 9.4.6 The SHIFT Program ....................................................................................................... 160 9.4.7 2003 GHSER Audit—“The condition of infrastructure and assets is poor”................... 161 9.4.8 1,000 Day Goals ............................................................................................................. 163 9.4.9 The Texas City Repositioning Project ............................................................................ 163 9.4.10 The Ultraformer #4 (UU4) Incident................................................................................ 164 9.4.11 Ultraformer #3 (UU3) Incident....................................................................................... 165 9.4.12 2004 BP Group GHSER Audit Review—“Systemic Underlying Issues” ...................... 166 9.4.13 BP’s Golden Rules of Safety .......................................................................................... 167 9.4.14 Process Safety Performance Declines Further in 2004................................................... 171 9.4.15 “Texas City is not a Safe Place to Work” ....................................................................... 172 9.4.16 Telos Survey ................................................................................................................... 173 9.4.17 2005 Budget Cuts............................................................................................................ 176 9.4.18 2005 Key Risk—“Texas City kills someone”................................................................. 177 9.4.19 Summary......................................................................................................................... 177 10.0 ANALYSIS OF BP’S SAFETY CULTURE...............................................................................179 10.1 Lack of Reporting, Learning Culture........................................................................................ 179 10.1.1 Reporting Culture ........................................................................................................... 180 10.1.2 Learning Culture ............................................................................................................. 182 10.2 Lack of Focus on Controlling Major Hazard Risk ................................................................... 184 10.2.1 Focus on personal safety rather than process safety ....................................................... 184 10.2.2 “Check the box”.............................................................................................................. 186 10.2.3 Oversimplification .......................................................................................................... 186 10.2.4 Ineffective corporate leadership and oversight ............................................................... 187 10.3 Safety Implications of Organizational Change......................................................................... 191 10.3.1 BP mergers...................................................................................................................... 191 10.3.2 Organizational Changes at Texas City............................................................................ 192 10.3.3 Budget Cuts..................................................................................................................... 194 10.3.4 Good Practice Guidelines ............................................................................................... 194 11.0 REGULATORY ANALYSIS......................................................................................................196 11.1 OSHA’s Process Safety Management Regulation.................................................................... 196 11.1.1 Background Information................................................................................................. 196 11.1.2 PSM Standard Elements ................................................................................................. 196 11.1.3 Other Models for Process Safety Inspections ................................................................. 204 11.1.4 Summary and Discussion................................................................................................ 206 11.2 EPA’s Risk Management Plan (RMP) Rule............................................................................. 207 11.2.1 Comparison to PSM........................................................................................................ 208 11.2.2 RMP Rule Enforcement.................................................................................................. 209 12.0 ROOT AND CONTRIBUTING CAUSES..................................................................................210 12.1 Root Causes .............................................................................................................................. 210 12.2 Contributing Causes ................................................................................................................. 211 13.0 RECOMMENDATIONS.............................................................................................................212 American Petroleum Institute (API) and United Steelworkers International Union (USW).................... 212

Occupational Safety and Health Administration (OSHA)........................................................................ 213 Center for Chemical Process Safety (CCPS)............................................................................................ 214 BP Board of Directors .............................................................................................................................. 214 BP Texas City Refinery............................................................................................................................ 215 United Steelworkers International Union and Local 13-1 ........................................................................ 216 APPENDIX A: TEXAS CITY TIMELINE 1950S – MARCH 23, 2005 .................................................218 APPENDIX B: LOGIC TREE..................................................................................................................222 APPENDIX C: PREVIOUSLY ISSUED RECOMMENDATIONS........................................................236 C.1 Safety Culture Recommendation.............................................................................................. 236 C.2 Trailer Siting Recommendation................................................................................................ 241 American Petroleum Institute ...................................................................................................... 243 American Petroleum Institute & the National Petrochemical and Refiners Association............. 244 C.3 Blowdown Drum & Stack Recommendation ........................................................................... 244 American Petroleum Institute ...................................................................................................... 247 Occupational Safety and Health Administration (OSHA) ........................................................... 248 APPENDIX D: BP CORPORATE AND TEXAS CITY REFINERY BACKGROUND........................249 D.1 BP- Amoco Merger .................................................................................................................. 249 D.2 BP South Houston Integrated Site ............................................................................................ 249 D.3 BP Texas City Refinery ............................................................................................................ 250 APPENDIX E: ISOM UNIT - HISTORY, EQUIPMENT, AND OPERATION .....................................251 E.1 Raffinate Splitter Section.......................................................................................................... 251 E.2 Blowdown Drum and Stack...................................................................................................... 252 APPENDIX F: TRAILERS FOR TURNAROUND ACTIVITIES..........................................................255 F.1 BP Internal Guidelines Compared To Good Practice Guidelines............................................. 256 F.1.1 Occupancy Criteria ......................................................................................................... 257 APPENDIX G: PROCESS MODELING .................................................................................................258 G.1 Modeling Approach .................................................................................................................. 258 G.2 Raffinate Splitter Column Overfill ........................................................................................... 260 G.3 Blowdown Stack Hydrocarbon Liquid Overflow..................................................................... 261 G.3.1 Methodology................................................................................................................... 261 G.3.2 Computer Inputs and Assumptions................................................................................. 262 G.3.3 Computer Simulation Results ......................................................................................... 263 APPENDIX H: BLAST DAMAGE ANALYSIS, VAPOR CLOUD AND EXPLOSION MODELING 265 H.1 Surveys of Blast Damage.......................................................................................................... 265 H.2 Blast Damage Analysis............................................................................................................. 266 H.3 Intense Blast Regions ............................................................................................................... 266 H.4 Trailer Damage ......................................................................................................................... 269 H.5 ISOM Satellite Control Room Building ................................................................................... 270 H.6 Catalyst Warehouse .................................................................................................................. 271 H.7 Storage Tanks ........................................................................................................................... 271 H.8 Off-Site Buildings..................................................................................................................... 272 H.9 Vapor Cloud Dispersion Modeling........................................................................................... 272 H.10 Methodology............................................................................................................................. 273 H.10.1 Wind Effects ................................................................................................................... 273 H.10.2 Source Term.................................................................................................................... 274 H.11 PHAST Modeling ..................................................................................................................... 275

H.12 Pool Evaporation ...................................................................................................................... 276 H.13 FLACS Vapor Dispersion Modeling ........................................................................................ 277 H.13.1 Results............................................................................................................................. 278 H.14 Explosion Modeling Methodology ........................................................................................... 279 H.15 Vapor Cloud Formation............................................................................................................ 279 H.16 Ignition Locations.................................................................................................................... 281 H.17 Additional Explosion Modeling ............................................................................................... 283 H.17.1 Results............................................................................................................................. 283 APPENDIX I: HISTORICAL DATA ON 19 RAFFINATE UNIT STARTUPS ....................................285 APPENDIX J: INEFFECTIVE AND INSUFFICIENT COMMUNICATION........................................286 J.1 What is Effective Communication?.......................................................................................... 286 J.2 BP Grangemouth Refinery Study on Effective Communication.............................................. 287 J.3 Summary................................................................................................................................... 288 APPENDIX K: DESIGN OF THE AU2/ISOM/NDU CONTROL BOARD ...........................................289 APPENDIX L: STAFFING CONCERNS ................................................................................................291 APPENDIX M: FATIGUE AND PERFORMANCE ...............................................................................293 M.1 Research on the Performance Effects of the 12-Hour Shift...................................................... 293 M.2 BP’s Fatigue Policy .................................................................................................................. 295 APPENDIX N: COMPARISON OF HOURS-FOR-SERVICE REGULATIONS ..................................296 APPENDIX O: OPERATOR TRAINING ...............................................................................................300 O.1 BP Board Operator Training..................................................................................................... 300 O.1.1 Five-Week Basic Operator Training............................................................................... 300 O.1.2 Two-Day Troubleshooting Course ................................................................................. 300 O.1.3 On-The-Job Training ...................................................................................................... 301 O.1.4 Computerized Training Program .................................................................................... 301 O.2 Training Certifications.............................................................................................................. 302 APPENDIX P: DISTRACTION NOT A CONTRIBUTING FACTOR ..................................................304 P.1 Possible Distraction Due to Understaffing ............................................................................... 305 APPENDIX Q: PRIOR INCIDENTS .......................................................................................................306 Q.1 Texas City Blowdown System Incidents .................................................................................. 307 Q.2 Raffinate Splitter Tower Upsets During Startup....................................................................... 311 APPENDIX R: EMERGENCY RELIEF SYSTEM DESIGN ANALYSIS.............................................313 APPENDIX S: RAFFINATE SPLITTER AND BLOWDOWN DRUM INSTRUMENT HISTORY, TESTING, INSPECTION, AND ANALYSIS .........................................................................................319 S.1 Instruments Involved ................................................................................................................ 319 S.2 Physical Failure Causes ............................................................................................................ 319 S.2.1 Description of Instrument Testing .................................................................................. 320 S.2.2 Raffinate Splitter Level Transmitter LT-5100 ................................................................ 320 S.2.3 Raffinate Splitter Sight Glass LG-1002A/B ................................................................... 323 S.2.4 Raffinate Splitter High Level Alarm LSH-5102............................................................. 323 S.2.5 Blowdown Drum High Level Alarm LSH-5020............................................................. 324 S.2.6 Raffinate splitter 3-pound vent valve PCV-5002............................................................ 325 S.3 Instrument Inspection and Testing............................................................................................ 326 S.4 Test Results and Instrument Failure Analysis .......................................................................... 327

S.5 Photographic Evidence ............................................................................................................. 329 APPENDIX T: BP MANAGEMENT-OF-CHANGE (MOC) POLICY ..................................................332 APPENDIX U: BP TURNAROUNDS TRAFFIC CONTROL MAP* ....................................................334 REFERENCES .........................................................................................................................................335

Figures and Tables

Figures Figure 1. Raffinate section of the ISOM..................................................................................................... 34

Figure 2. Disposal collection header system............................................................................................... 37

Figure 3. Blowdown drum and gooseneck.................................................................................................. 39

Figure 4. Left: Gooseneck piping and manual block valve (chained-locked open) Right:: Close-up of manual block valve ............................................................................................................................. 40

Figure 5. Refinery layout of the area surrounding the ISOM unit .............................................................. 42

Figure 6. At 1:04 p.m. the liquid level in the tower was 158 feet (48 m), but the computerized control system indicated to operators that the level was at 78 percent of the level transmitter (7.9 feet, or 2.4 m, of liquid in the tower). ................................................................................................................... 57

Figure 7. Heating of feed in the splitter tower ............................................................................................ 58

Figure 8. Hydrostatic head of liquid in overhead piping leads to the three relief valves opening.............. 60

Figure 9. Tower overfills and blowdown drum releases hydrocarbons ...................................................... 63

Figure 10. The darkened areas in and around the ISOM unit had the heaviest fire damage; the red arrow points to the top of the blowdown stack ............................................................................................. 65

Figure 11. Idling diesel pickup truck at north end of ISOM unit................................................................ 66

Figure 12. Blast overpressure map depicting the areas of highest blast pressure (10+, 5+, and 2.5+ psi) . 67

Figure 13. Destroyed trailers west of the blowdown drum (red arrow in upper left of the figure)............. 69

Figure 14. The Board Operator viewed this screen, which provides information on raffinate product leaving the unit but not the liquid being added to the unit.................................................................. 84

Figure 15. Trailer area and adjacent ISOM unit ....................................................................................... 124

Figure 16. Comparison of explosion damage based on API and BP Texas City criteria.......................... 129

Figure 17. Simplified organizational chart of BP at the time of the March 23, 2005 incident. Some positions are not included ................................................................................................................. 148

Figure 18. Organizational changes affecting the Texas City refinery....................................................... 192

Figure G- 1. Experimental boiling (bubble) point data (Fauske & Associates, 2005).............................. 260

Figure H- 1. Intense blast regions in the ISOM unit ................................................................................. 268

Figure H- 2. Blast overpressure map ........................................................................................................ 269

Figure H- 3. Cloud extent comparing field observations (red line) to dispersion modeling..................... 278

Figure K- 1 The computerized control system for the AU2/ISOM/NDU complex.................................. 289

Figure S- 1. Calculated LT-5100 flooded reading versus specific gravity ............................................... 321

Figure S- 2. Calculated raffinate splitter feed specific gravity as a function of temperature.................... 322

Figure S- 3. LT-5100 cabinet showing calibration set for 0.8 specific gravity......................................... 329

Figure S- 4. LSH-5102 internal components ............................................................................................ 329

Figure S- 5. Internal components of LSH-5020 blowdown drum high level alarm.................................. 330

Figure S- 6. Close-up of LSH-5020 float, showing corrosion and hole.................................................... 330

Figure S- 7. PCV-5002 shop testing ......................................................................................................... 331

Tables

Table 1. Timeline of events from ISOM unit shutdown to March 23 incident........................................... 43

Table 2. Individuals involved in the March 23, 2005, startup .................................................................... 46

Table 3. Safeguard reliability (CCPS, 1996b) .......................................................................................... 108

Table 4. Instrumentation that failed to operate properly on March 23, 2005 ........................................... 131

Table 5. Upper management job position descriptions............................................................................. 147

Table G- 1. Raffinate splitter column simplified composition model (Fisher, 2006)............................... 259

Table G-2: Safety relief valve characteristics ........................................................................................... 262

Table G-3: Overall mass balance of hydrocarbon flow from the raffinate splitter ................................... 264

Table H- 1. Trailer damage ....................................................................................................................... 270

Table H- 2. Source term release and material property data..................................................................... 275

Table H- 3. PHAST input parameters....................................................................................................... 275

Table H- 4. PHAST model results ............................................................................................................ 276

Table R- 1. Specifications of safety relief valves installed on the raffinate splitter tower ....................... 316

Table R- 2. Flow from the safety relief valves on the raffinate splitter .................................................... 316

Table S- 1. Field and Shop Testing and Inspection Summary.................................................................. 326

Table S- 2. Test results and analysis summary ......................................................................................... 327

Acronyms and Abbreviations

ACC American Chemistry Council

AIChE American Institute of Chemical Engineers

API American Petroleum Institute

ARPD Amoco Refining Planning Department

ARU Aromatics Recovery Unit

AU2 Aromatics Unit #2

BOT Basic Operator Training

BPSH BP South Houston

bpd barrels per day

BUL Business Unit Leader

CAIB Columbia Accident Investigation Board

CDP Compliance Delivery Process

CFHU Cat Feed Hydrotreating Unit

CCPS Center for Chemical Process Safety

CMMS Computerized Maintenance Management Software

CSB U.S. Chemical Safety and Hazard Investigation Board

CVP Capital Value Process

DIERS Design Institute for Emergency Relief Systems

DIH Deisohexanizer

EHS Environment, Health and Safety

EPA Environmental Protection Agency

GHSER Getting Health, Safety, and Environment Right

gph gallons per hour

HAZOP Hazard and Operability Study

HC1 Hydrogen Chloride

HRO High Reliability Organization

HSE Health, Safety & Environment

HSSE Health, Safety, Security, & Environment

HUF Heavy Ultraformate Fractionator

IH Industrial Hygiene

IMAS Industrial Mutual Aid System

ISBL Inside Battery Limits

ISOM Isomerization unit

kPa kilopascal

KPI Key Performance Indicators

L&D Learning and Development

MAR Major Accident Risk

MAWP Maximum Allowable Working Pressure

MDL Manufacturing Delivery Leader

MOA Memorandum of Agreement

MOC Management of Change

mscf million standard cubic feet

NDU Naptha Desulfurization Unit

NESHAP National Emissions Standard for Hazardous Air Pollutants

NPRA National Petrochemical and Refiners Association

NPS Nominal Pipe Size

NTSB National Transportation Safety Board

OSBL Outside Battery Limits

OCAM Operator Competency Assurance Model

OSHA Occupational Safety and Health Administration

P&ID Piping and Instrumentation Diagram

PHA Process Hazard Analysis

PIP Piping Integrity Program

pph pounds per hour

PPS Amoco Petroleum Products Sector

psi pounds per square inch

PSM Process Safety Management

PSS Process Safety Standard

PSSR Pre-Startup Safety Review

PT Process Technician

QA/QC Quality Assurance/Quality Control

R&M Refining and Marketing

RCFA Root Cause Failure Analysis

RHU Resid Hydrotreating Unit

RIF Recordable Injury Frequency

RMP Risk Management Program

SAP Systems Applications and Products

SEP Special Emphasis Program

SHIFT South Houston Infrastructure for Tomorrow

SIS Safety Instrumented System

SOI Standard Operating Instructions

SOPs Standard Operating Procedures

SPU Strategic Performance Unit

TCEQ Texas Commission on Environmental Quality

TCR Texas City Refinery

TCS Texas City Site

TSP Traffic Safety Policy

UK United Kingdom

ULC Ultracracker unit

UOP Universal Oil Products

USW United Steelworkers

UU3 Ultraformer Unit # 3

UU4 Ultraformer Unit #4

VOC Volatile Organic Compounds

VPP Variable Pay Plan

1.0 EXECUTIVE SUMMARY

1.1 Incident synopsis

On March 23, 2005, at 1:20 p.m., the BP Texas City Refinery suffered one of the worst industrial

disasters in recent U.S. history. Explosions and fires killed 15 people and injured another 180, alarmed the

community, and resulted in financial losses exceeding $1.5 billion. The incident occurred during the

startup of an isomerization 1 (ISOM) unit when a raffinate splitter tower 2 was overfilled; pressure relief

devices opened, resulting in a flammable liquid geyser from a blowdown stack that was not equipped with

a flare. The release of flammables led to an explosion and fire. All of the fatalities occurred in or near