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CUPB - Total Professeurs AssociйsCUPB - Total Professeurs Associйs University: MSTU Date: March 2012 Introduction to PETROCHEMICALS and INDUSTRIAL POLYMERIZATION From Refining to Polymers and Plastics MiniProject MAJOR ACCIDENT ANALYSIS Imagine that you work for an industrial company, ...

CUPB - Total Professeurs Associйs
CUPB - Total Professeurs Associйs University: MSTU Date: March 2012 Introduction to PETROCHEMICALS and INDUSTRIAL POLYMERIZATION From Refining to Polymers and Plastics MiniProject MAJOR ACCIDENT ANALYSIS Imagine that you work for an industrial company, not necessarily a petrochemical company. Through a recent discussion with colleagues, your big boss has learned about a catastrophe that occurred some years ago in a quite different company and he would like to know more about it. He has asked his assistant to search the literature for some pieces of information about: Group 1 - US Oil Refinery Explosion March 2005 However, after looking at what his assistant has quickly gathered from Internet, he realizes that he does not have the time necessary to go through all this information (you can also find other pieces of information by yourself**), eliminate the non-relevant documents, find out what occurred, sort out the most significant facts, analyze the root causes of the accident, and draw the major lessons which could be useful for his own company. So, because he is the boss, he simply asked your group to do the job for him. And because he is the big boss, you had better do that, and do it well! Please, jointly prepare a PowerPoint document which will summarize the results of your work and be ready to collectively present it to your boss, with some complementary oral comments. You know that your big boss is always in a hurry. So your PowerPoint document should be short: maximum 5 slides. You should strive to give only the most important pieces of information and not to bother your boss with non-significant details. If you have to present in front of him, do not read the slides: this makes your boss very, very nervous and unhappy! He is a fast reader and goes through your slide much faster than you can read it aloud. Also, he has the disagreeable habit of asking surprise questions to anyone in the group; so all members of your group should be prepared to give a collective answer at anytime during the presentation, on any part of it. If you have diverging views within the group, no problem! You simply need to "agree to disagree". But your boss should clearly feel that you have worked collectively. Please, hand out a paper copy + an electronic version (on a clean USB key!) of your group's PowerPoint presentation for Thursday March 15 afternoon. Selected teams will make a 15 minute oral presentation on Friday March 16 morning. Good luck! R.P. ** plenty of information available on the web. 1 Oil refinery explosion kills at least 14 Blast felt several miles from plant in Texas City, Texas Thursday, March 24, 2005 Posted: 1412 GMT (2212 HKT) TEXAS CITY, Texas (CNN) -- At least 14 people died and more than 70 others were injured in an explosion that ripped through a BP oil refinery in southeastern Texas on Wednesday, a company spokesman said. The fire sent huge plumes of smoke high into the air, and the blaze took nearly two hours to extinguish, Bill Stephen said. "We believe it's 14 people, but we will wait for official confirmation from the medical examiner," he told reporters. Stephen added that it was possible the number of dead could rise as emergency crews were continuing to search through the site. "We don't want to let anyone be overlooked," Stephen said. "We want to account for absolutely everyone." Plumes of smoke rise from the BP oil The explosion happened in the isomerization unit, where the octane of refinery plant in Texas City, Texas. gasoline is raised. The refinery is spread across 1,500 acres. It was not immediately clear how many of the 1,800 employees were at Image: the refinery in Texas City, 40 miles southeast of Houston, when the explosion happened at 1:30 p.m. (2.30 p.m. ET). Stephen said he hoped to know how many people were on the site by late Thursday morning. BP site director Don Parus said: "Our primary focus is really on the family and the people that were injured." Desperate rescues are For a short period, as a precautionary measure, Texas City residents followed by a solemn were ordered to stay inside, "but that was quickly pulled," Stephen said. moment. A spokeswoman said terrorism was not suspected in the blast, which PLAY VIDEO could be felt miles away. "It shook our building," said Mary Bonnett, a worker at Glass and Glazing Inc., less than a mile away. "It shook the whole city." A BP spokesman speaks of the A team of seven investigators from the U.S. Chemical Safety and Hazard refinery explosion. Investigation Board (CSB) was expected to arrive at the site late PLAY VIDEO Thursday morning. The refinery -- the country's third-largest -- produced 460,000 barrels of gasoline per day, 3 percent of the U.S. supply, said John Bresland, a CSB board member. The CSB is an independent federal agency that investigates industrial chemical accidents. The board does not issue citations or fines, but does • Explosions not uncommon in Texas make safety recommendations. city BP said the fire at the sprawling 1,200-acre facility was isolated to an • BP isomerization unit, used to upgrade gasoline quality. It said the rest of the refinery continued to operate normally although nearby secondary refining units were already idle for scheduled maintenance. After the explosion, U.S. gasoline prices reached an all-time high, according to Reuters, which reported that the price of gasoline on the New York Mercantile Exchange hit $1.6080 per gallon. Texas BP Plc Activateor CREATE YOUR OWN Manage alerts | What is this? 2 Texas City Blast May 18, 2005, 5:31PM BP blames staff for blast A probe finds workers were lax; the union says they're being made scapegoats By ANNE BELLI Copyright 2005 Houston Chronicle Email Get section feed Recommend Print Yahoo! Buzz Comments BP on Tuesday placed the lion's share of the blame for the deadly blast at its Texas City refinery at the feet of low- and mid-level workers who it said were lax in following written company procedures during one of the most dangerous times in refinery operations. Had the six operators and one supervisor assigned to the start-up of the refinery's so-called isomerization unit been doing their jobs, the explosion would not have happened, 15 people would not have been killed and more than 170 would not have been injured, said Ross Pillari, president of BP Products North America. "The mistakes made during the start-up of this unit were surprising and deeply disturbing," Pillari said during a news conference in which BP released a 47-page interim report on its investigation. Workers, who the company said were experienced and well-trained, ignored start-up checklists, failed to communicate with each other during critical shift changes and inexplicably decided not to sound an evacuation alarm when they had a full six minutes to do so after the pressure relief valves opened before the March 23 blast, officials said. Even the unit's supervisor had left the plant in the middle of the start-up, they said. The start-up of a unit is considered one of the most dangerous times in the operations of a refinery. "The core issue here is people not following procedures," Pillari said. Seated at a table with two other BP executives at Texas City's Doyle Convention Center, Pillari said the company already has fired some workers and may fire others — from hourly workers to supervisors — but he declined to name them or give their specific titles. Plant manager Don Parus has been placed on leave — not as a part of any disciplinary action but to participate full-time in the ongoing investigation — and he has been replaced by Colin Maclean, who has managed refineries in Australia, Scotland and Whiting, Ind., Pillari said. The union's response 3 Union officials, victims and attorneys representing dozens of injured workers or the families of the deceased, said Pillari made scapegoats of the low-level refinery workers while sidestepping management's own responsibility. "Blaming workers doesn't solve the problem of unsafe conditions in that refinery," said Gary Beevers, Region 6 director of the United Steelworkers union. Glenn Alexander, whose wife, Lorena Cruz- Alexander, died in the explosion, said he also was dissatisfied with BP's statements. "I'm glad that they are admitting that it was their fault, but I am still very angry because it was a situation that could have been avoided," said Alexander, also a refinery worker who watched helplessly and in horror as the construction trailer in which his wife was working was consumed in a fireball. "The level that they are trying put blame on is too low. This is something that should be looked at higher up," Alexander said. Bill Hoyle, investigations manager with the U.S. Chemical Safety & Hazard Investigation Board, said it will continue to search for the root causes of the accident, "including management systems issues, design flaws and other problems." The Deer Park man who was the board operator in the control room did not return repeated phone calls. BP officials painted a picture of a careless group of workers who abandoned normal procedures while operating one of the most dangerous units at the refinery. They said that trouble began early in the morning when isom unit workers who had begun the start-up of the raffinate splitter during the night shift failed to fully brief day-shift workers and the supervisor. The splitter is used to produce chemicals used to boost the octane of gasoline. As the start-up continued early that morning, highly flammable hydrocarbons flowed into the splitter much more quickly and were heated much faster than normal, said Pat Gower, BP vice president of refining. What happened As the level of the fluids rose from 7 feet to a staggering 140 feet, three pressure-relief valves activated, allowing the materials to begin flowing into a blowdown drum nearby. After that filled, the materials then made their way up a vent stack, which overflowed. Liquids and vapors then flowed onto the plant grounds, where unsuspecting workers were driving vehicles, operating generators and doing other refinery work. A yet-to-be-identified ignition source then caused the massive blast, Gower said. He added that six minutes passed between the time the pressure relief valves opened and the explosion occurred, but none of the operators sounded the evacuation alarm. No call to evacuate "There was an opportunity to sound an emergency evacuation alarm so that people could get away, but they chose not to do it," Gower said. "There were quite a few things we didn't do right this day." Tim Holt, the BP senior executive who led the internal investigation, said the operators told investigators they had their hands full trying to correct the upset. "Their answers tended to be that there were a lot of things going on in that six-minute period," Holt said. The company's report says that some workers who saw the liquid and vapors flowing from the stack were able to save their lives by running for cover. Holt said that alarms did indeed sound in the control room, but that there was not a "flood of alarms." Gower said that although just one operator is assigned to the control room, which oversees the isom unit as well as two others, the company is not considering adding more. "Staffing was actually quite heavy," he said. Trailer's proximity at issue 4 Alexander and others still question why the trailer, where most of the dead were located, was allowed to be parked within 150 feet of the isom unit when the company's own guidelines suggest it should not. Pillari said a hazard review found that it was safe to place the doomed trailer and others so close to the unit and that they had been there for many years. Management did not "recognize the possibility that multiple failures by operations personnel" would cause such an accident. Likewise, Pillari defended the company's decision to continue to use a "blowdown stack" to contain overflow of flammable liquids and vapors from the isom unit. The refinery unit exploded after flammable liquid and vapors overflowed out of the stack and gathered onto the ground, where they were ignited. Federal investigators, safety experts and others have said that had the stack been equipped with a flare, the materials likely would have been safely burned away and the resulting explosion could have been avoided. Pillari said that while the company contemplated implementing a flare, and had opportunities to do so as part of other construction projects in 1995 and 2002, it decided not to do so. But he added that BP did not think the unit was unsafe and management again did not predict such lax abandonment of company procedures. "Because the level of explosion risk associated with this operation was not fully recognized, no action was taken to change the configuration," he said. Culpability questioned Rob Ammons, an attorney representing dozens of injured workers, said Pillari's statements do not let the company off the hook. "It is good that the company has stated that they will accept responsibility but it appears they are only willing to do that on a very low level," he said. "Their own report suggests that decisions were made at a corporate level which were a cause of this explosion and needless tragedy ... I'm disappointed that they have not admitted the obvious concerning the flare system. My investigation leads me to believe it just wasn't in their budget." Another lawyer representing victims agreed. "I think their fault is so obvious they can't deny it, but they're trying to blame low-level employees," said David Perry. Pillari said BP has already begun widespread changes in the wake of the explosion. It is prohibiting the occupancy of trailers within 500 feet or more of blowdown stacks and flares, and it is removing all non-essential workers from process areas, he said. It also is equipping its blowdown stacks at its refineries in Texas City and Whiting, Ind., with flares or routing them to safer, so-called closed systems. And the company has commissioned a third party to conduct a process review of all operations in Texas City, Pillari said. As for the victims and their families, Pillari said BP has begun settlement talks with their attorneys in attempts to fairly compensate them for their losses. "We regret that our mistakes have caused so much suffering," he said. Staff writer Terri Langford contributed this report. anne.belli@chron.com 5 Chronicle June 29, 2005, 12:36PM Update on Chemical Safety Board's investigation This is the full text of a July 28, 2005, update on the investigation of the Texas City blast by the Chemical Safety Board: Good morning. I am Don Holmstrom, CSB lead investigator for the BP Texas City refinery investigation. Last week marked the third full month since the tragic explosions on March 23 that killed 15 workers and injured more than 100. The U.S. Chemical Safety Board has been continuing its independent, federal investigation to determine the root causes of this tragedy and make safety recommendations to save lives in the future. This morning we will be releasing some important new information in this investigation. Specifically, investigators from the U.S. Chemical Safety Board have found evidence that several key pieces of process instrumentation malfunctioned on the day of the accident. Alarms that should have warned operators of abnormal conditions in the isomerization unit did not go off. Before discussing these new findings, let me present some background information. The majority of our field investigation is now complete, and most of our field team has now returned to Washington, DC, where they are continuing to further the investigation. The team conducted approximately two hundred witness interviews, including re-interviews of key personnel. We have interviewed plant operators, contract workers, BP management staff, facility neighbors, and others. We have filed more than 20 separate document requests with BP, and we have received thousands of documents which we are now in the process of analyzing. We have also submitted written interrogatories to BP. The company has continued to be cooperative and has furnished documents on a voluntary basis. Our blast modeling experts have completed their field work and have left the site. They are now performing calculations to determine the precise nature of the explosions at the refinery. We have also retained several prominent experts in distillation technology who are assisting the team. Our team is also in possession of electronic process control records from the isomerization unit, which was the site of the explosions. Those electronic records are the source of much of the information I will present today. As most of you know, at approximately 1:20 p.m. on March 23, there was a sudden, geyser-like release of flammable hydrocarbon liquid and vapor from an atmospheric vent stack at the BP refinery’s isomerization unit. This release created a flammable vapor cloud, which ignited, causing as many as five explosions. There were multiple possible ignition sources on the ground, including vehicles, and the exact ignition source remains unknown and is not a principal focus of current work. Temporary work trailers were located 100 to 150 feet away from the vent stack. Workers who were in and around these trailers were killed or injured when the explosions occurred. I will now describe some of the key equipment involved in the accident, using the diagram here on the easel. This diagram is not drawn to exact scale, and it does not show all the equipment in the process. 6 On the morning of March 23, the raffinate splitter was being restarted after a maintenance turnaround. The raffinate splitter is the 164-foot tall distillation tower shown here on the left. This tower distills highly flammable hydrocarbons, such as pentane and hexane. When the tower is operating normally, vapor flows from the top of the tower into the condenser, condenses to a liquid, and is returned to the tower via a reflux drum, which is not shown. If tower experiences excess pressure above 40 pounds per square inch, there are three emergency pressure-relief valves designed to vent the pressure. Material vented through the pressure-relief valves flows to a blowdown drum – a vertical tank shown here. The blowdown drum vents directly to the atmosphere through a 114-foot-tall stack shown here. This vent system was of an antiquated design: it was originally installed in the 1950s, and it had never been tied in to a flare system to safely combust flammable vapors released from the process. As we reported back in April, the March 23rd start-up was abnormal, and the tower became flooded with liquid hydrocarbons. Our current estimate is that the liquid inside the tower ultimately reached a height of 120 feet or more. Normally this tower operates with less than 10 feet of liquid at the bottom. The flood of liquid inside the tower is shown here in blue. With the tower flooded, internal pressure rose sharply from about 20 pounds per square inch to about 60 pounds per square inch, causing the pressure-relief valves to open. The cause of this pressure spike remains under investigation. When the relief valves opened, a large volume of liquid and vapor flowed rapidly to the blowdown drum. Accumulating liquid in the blowdown drum is shown here in blue. As we noted at the last briefing, some hydrocarbon flowed through a so-called ―goose-neck‖ drain, shown here, and entered the process sewer, where it later caused a fire downstream. The blowdown drum was overwhelmed by the volume of liquid and vapor released from the raffinate splitter, and large quantities of flammable hydrocarbon were expelled from the top of the vent stack. The relief valves remained open for a period of just six minutes. I now draw your attention to some key instrumentation located on the tower and the blowdown drum. First, the raffinate splitter level indicator, shown here, is a sensor instrument that is supposed to measure the liquid level inside the tower. On our diagram, it is referred to as an LIC or level indicator control. The level indicator is tied in to the tower at a height from three to ten feet from the bottom. It transmits a percentage value to operators in the control room. If the instrument was functioning as intended, a 100% reading would indicate a liquid level of ten feet (or greater). A 0% reading would indicate a level of three feet or less. Under normal conditions, the reading from the level indicator should be 50%, meaning liquid is halfway between the three and ten foot points at the bottom of the tower. If the level rose too high in the tower an alarm would sound in the control room to alert operators to an abnormal condition. Because of the importance of maintaining an appropriate liquid level in the tower, the level indicator had a back-up or ―redundant‖ system in case of failure, with separate pipe connections. A high-level alarm or HLA switch was located just under ten feet up the tower. If functioning properly, when liquid rose above this point, another alarm would sound and also activate a separate display in the control room. By the same token, if the level sank below about three feet, a low-level alarm or LLA would sound. The blowdown drum was also equipped with a high-level alarm, shown here in the diagram. If functioning properly, this switch would trigger an emergency alarm if liquid approached the height of the goose-neck drain and was therefore in danger of draining into the sewer system. 7 This alarm would sound in the control room and alert operators to a potentially dangerous condition inside the blowdown drum. Based on the CSB investigative team’s examination of the computerized records from isom unit control system, we have made several determinations. We found that the alarm from the raffinate splitter level indicator did in fact go off at 3:05 in the morning on March 23. The reading on sensor was 72%, indicating a level approaching the ten-foot mark. Within a short time, the level reading increased to 100%. However, we also found that from 7:30 a.m. until the time of the incident at 1:20 in the afternoon, the readings from the level indicator actually drifted downward, from 100% to 79%. This downward trend would have erroneously indicated to operators that the liquid level in the tower was below 10 feet and was falling back toward a normal value. We now know that during this time period, the tower was actually flooding with liquid to a height of 120 feet or more. Second, process records indicate that although the redundant high-level alarm was enabled, at no time did it go off during the startup on March 23. That alarm should have sounded as soon as the liquid reached the ten foot mark, warning control room operators of the accumulating liquid in the tower, but in fact the alarm did not sound even as the liquid flooded to more than 12 times that height. Third, records indicate that the high-level alarm on the blowdown drum did not go off during the time the drum was flooding with liquid released from the splitter tower. Instrument readings from the oily water sewer indicate that the drum had indeed flooded, and liquid was flowing from the blowdown drum into the sewer. The high-level alarm did eventually sound, but only after the explosions had begun, likely as a result of the blast pressure. Had the alarm sounded properly as the blowdown drum was flooding, it could have alerted operators to the emergency situation. Because of these circumstances, we have extended our field investigation at the BP site and have begun an extensive program of equipment testing within the isom unit. The initial phase of the testing will examine over 30 different instruments and pieces of equipment. The testing will help us understand why the three instruments I just discussed evidently failed to operate as intended. We also have requested that BP produce its maintenance records for these and other pieces of equipment associated with the process. I emphasize that at this time, no root causes of the accident have been determined. Under federal law, no root cause will be assigned except by a vote of the full Chemical Safety Board. All possible causal factors including design flaws, additional equipment failures, and human performance remain under consideration. The investigation continues to focus on design issues involving the blowdown system as well as on the decision to site the trailers in proximity to a potentially hazardous process. We are also continuing to investigate the adequacy of the training, supervision, and oversight afforded to unit operators. Our objective is to understand why this tragedy occurred, and, we hope, to prevent similar occurrences in the future. Over the coming weeks and months, we will be gathering and analyzing the results of the equipment testing, the blast modeling work, and the modeling of the distillation tower. We will be also be studying the many thousands of pages of witness interviews and documentary evidence. Investigators will likely be returning frequently to Texas City for additional interviews and evidence collection. Early this fall, probably in September, the full Board will convene here in the Texas City area to review preliminary findings at a public meeting. We will be announcing an exact date and location in due course. 8 BP Issues Final Report on Fatal Explosion, Announces $1 billion Investment at Texas City Release date: 09 December 2005 HOUSTON -- BP Products North America Inc. today issued its final incident investigation report on the March 23, 2005 Texas City Refinery explosion and fire that claimed the lives of 15 workers and injured many more. The company is implementing the recommendations of the incident investigation team and a modernization program to secure the long term future of the refinery. The company expects to invest an estimated $1 billion dollars to improve and maintain the site over the next five years. “The report clearly describes the underlying causes and management system failures which contributed to the worst tragedy in BP’s recent history,” said Ross Pillari, president of BP Products North America Inc. “We accept the findings, and we are working to make Texas City a complex that attains the highest levels of safety, reliability and environmental performance.” Some of the actions recommended by the investigation team have been completed. Many are underway. Texas City site manager Colin Maclean has established a special project team to plan and drive execution of the improvement program. The company will install modern process control systems on major units, transition to a more powerful maintenance management system, improve worker training, remove blow down stacks and implement the other recommendations contained in the final report. The project team will also develop plans for reconfiguring and simplifying the operation of the Texas City refinery. “The result will be a safe, reliable and highly efficient refinery capable of producing clean fuels that consumers are demanding,” Maclean said. In anticipation of a recommendation contained in the final report, BP has strengthened and changed the focus of its internal audit program to provide greater assurance that operations at Texas City and the company’s four other U.S. refineries adhere to company standards. The investigation team “found no evidence of anyone consciously or intentionally taking actions or decisions that put others at risk.” However, “the team found many areas where procedures, policies and expected behaviors were not met.” According to the report, “the underlying reasons for the behaviors and actions displayed during the incident are complex and the team has spent much time trying to understand them…. It is evident that they had been many years in the making and will require concerted and committed actions to address.” The final report confirms the critical factors which led to the explosion and greatly increased its consequences. Those critical factors were identified in an interim report published May 17. The final report also identifies the following underlying causes: , Over the years, the working environment had eroded to one characterized by resistance to change, and lacking of trust, motivation, and a sense of purpose. Coupled with unclear expectations around supervisory and management behaviors this meant that rules were not consistently followed, rigor was lacking and individuals felt disempowered from suggesting or initiating improvements. , Process safety, operations performance and systematic risk reduction priorities had not been set and consistently reinforced by management. , Many changes in a complex organization had led to the lack of clear accountabilities and poor communication, which together resulted in confusion in the workforce over roles and responsibilities. , A poor level of hazard awareness and understanding of process safety on the site resulted in people accepting levels of risk that are considerably higher than comparable installations. One consequence was that temporary office trailers were placed within 150 feet of a blowdown stack which vented heavier than air hydrocarbons to the atmosphere without questioning the established industry practice. , Given the poor vertical communication and performance management process, there was neither adequate early warning system of problems, nor any independent means of understanding the deteriorating standards in the plant. 9 Prior to March 23, the leadership team at Texas City was working to address many of the problems later described in the final investigation report. A control of work program had been started to ensure maintenance activities were safely performed. Training for supervisors was being improved. A program to implement a “Just Culture” in which people are held accountable for their job performance was getting underway. The workplace injury rate had been reduced by more than 70 per cent. “We have recommended expansion, continuation and more rapid implementation of some initiatives already in progress at Texas City,” said John Mogford, who led the investigation team and who serves as senior group vice president for safety and operations. Maclean, who was named manager of the Texas City site May 17, has strengthened the leadership team at the refinery, bringing in new personnel from other locations in BP and reassigning others. He has simplified the organizational structure, clarified roles and responsibilities and put in place systems to improve communication and compliance with procedures. “We are creating an environment in which people know that what they say matters, that they know what is expected of them and that they will deliver what is expected of them,” Maclean said. “We must keep our promises to each other. It is the first step in rebuilding trust and the only way to earn the respect and obtain the commitment of a very skilled and very experienced workforce.” BP’s incident investigation was conducted by a team of BP operations, refining and safety experts and salaried and union employees of the Texas City refinery. The team was directed to determine the cause of the March 23 explosion and make recommendations for preventing similar incidents in the future. The final incident investigation report has been shared with government agencies investigating the incident and the findings and recommendations are being communicated across BP’s global operations. As promised, the report is available to the public and has been posted on the web at www.bpresponse.org www.bpresponse.org Notes to Editors , BP has accepted responsibility for the March 23rd explosion and for the management system failures and employee mistakes which contributed to or caused the explosion. , The company has set aside $700 million to compensate victims of the explosion and has worked to resolve claims arising from the incident. Settlements have been achieved with the families of most of the workers who died and with many workers who suffered serious injuries. , BP has entered a settlement with the U.S. Occupational Safety and Health Administration resolving more than 300 separate alleged violations of OSHA safety regulations. BP paid a fine of $21.3 million. The company agreed to a number of corrective actions, including the hiring and placement of process safety and organizational experts at the refinery. Under the agreement, BP does not admit the alleged violations or agree with the way OSHA has characterized them. , BP continues to cooperate with the U.S. Chemical Safety and Hazard Investigation Board (CSB), the U.S. Environmental Protection Agency and the Texas Commission on Environmental Quality regarding the Texas City explosion and related concerns. , On the recommendation of the CSB, BP has voluntarily appointed an independent panel to assess and make recommendations for improvement of safety management and safety culture at the company’s five U.S. refineries. Former U.S. Secretary of State James A. Baker is chairman of the panel. , BP has endorsed a CSB recommendation urging the industry to revisit existing standards for the use of temporary buildings inside refineries and other processing plants. BP has established a new standard for its refining operations and plans to share it with others in industry. , The Texas City refinery is owned and operated by BP Products North AmericaInc. It is BP’s largest and most complex refinery with a rated capacity of 460,000 barrels per day and an ability to produce up to 11 million gallons of gasoline per day. 10 , The Isomerization (ISOM) unit is used to convert raffinate, a low octane blending feed, into higher octane components for unleaded regular gasoline. The unit has four sections including a splitter which takes raffinate and fractionates it into light and heavy components. The splitter consists of a surge drum, fired heater reboiler and a fractionating column 164 feet tall. Description of incident The explosion and fire occurred after personnel responsible for the startup greatly overfilled the raffinate splitter tower and overheated its contents, which resulted in over pressuring of its relief valves. Liquid was pumped into the tower for almost three hours without any liquid being removed or any action taken to achieve the lower liquid level mandated by the startup procedure. The liquid level in the tower just prior to the loss of containment was at least 20 times higher than it should have been. Activation of the automatic liquid level control, as mandated in the startup procedure, would have prevented this occurring. A decision late in the start up to begin removing liquid from the tower exacerbated the incident. Rapid heat exchange between the over heated liquid being removed from the bottom of the tower and the liquid feed continuing to flow into the tower (the two streams pass through a heat exchanger) caused significant vapor generation as the feed entered the tower. Vaporization of the liquid feed low in the tower pushed liquid up the tower and out of the unit, over pressuring the relief valves and ultimately overwhelming the adjacent blow down unit. Based on process modeling, the investigation team estimates that about 1,100 barrels of liquid was discharged to the blow down unit which has a capacity of 390 barrels. Most of the liquid was released into the petroleum sewer system. An estimated 50 barrels overflowed the tower and led to the formation of a hydrocarbon vapor cloud at ground level. Based on inspection of the sewer system and process and explosion modeling, the investigation team concluded that the sewers were not the primary route for the formation of the hydrocarbon vapor cloud that subsequently exploded. The damage observed to the sewer system was the result of secondary fires caused by the main explosion. The source of ignition is not known. Unit supervisors were absent from the scene during critical parts of the startup and unit operators failed to take effective action to control the process upset or to sound evacuation alarms after the pressure relief valves opened. Critical factors The final report confirms the critical factors which led to the explosion and greatly increased its consequences. Those critical factors, which were described in the interim investigation report issued May 17 are: , The failure to follow procedures, leading to greatly overfilling the raffinate splitter tower , Venting of liquids caused by overfilling and over heating of the liquid in the tower leading to a liquid relief to atmosphere and the subsequent explosion , The location of many people too close to the source of relief (a blow down unit), congregated in and around temporary trailers which were inappropriately sited , The continued use of a blow down unit for light-end hydrocarbon use when inherently safer options were available and could have been installed. Further information: Name: Ronnie Chappell Office: BP Press Office Location: BP Houston Phone : +1 (281) 366-5174 11 CSB Investigation Continues as Texas City urge all oil and chemical companies to consider Marks First Anniversary of BP Refinery similar actions, if they have not already done so. Explosion Everywhere I go, I am encouraged to see that many companies are sincerely trying to learn from what happened." For more information, go to: BP Investigation Information Page The CSB investigative team has conducted over 350 witness interviews, collected tens of thousands of Washington, DC, March 23, 2006 - On the first documents, and expended almost $2 million in the anniversary of the refinery explosion at BP Texas City costliest and most complex investigation in the that killed 15 people and injured 170 others, the U.S. agency's eight-year history. Chemical Safety and Hazard Investigation Board (CSB) is continuing to investigate many aspects of the disaster. Recently, the CSB has retained an expert in human The Board expects to issue its final report on the accident, factors safety to assist in the investigation. On including a determination of root causes and new safety November 10, the CSB noted that some operators recommendations, at a public meeting in Texas City in involved in the startup operation had been working late 2006. long hours for more than 30 consecutive days, and that training resources had been reduced from 1998 CSB Chairman Carolyn W. Merritt said, "Not a day goes to 2005 even as workload increased for the control by that we do not think of the 15 people who died and the board operator position. The CSB team has also many more who must now live with their injuries and been studying how widespread is the use of their grief. At the CSB, we have not moved on to other blowdown drums instead of flare systems for things; the accident one year ago remains a central focus handling hydrocarbon releases at oil refineries. of our daily work. This solemn anniversary reminds us all of the need to prevent such accidents from happening On August 17, 2005, the Board called on BP to anywhere else through positive change. There is a urgently convene an independent panel to examine heightened need for corporate responsibility, sound safety practices and culture at its five North operating practices and equipment, and vigorous American refineries, including Texas City. BP enforcement of good and needed regulations such as the named former U.S. Secretary of State James A. Process Safety Management standard and the Risk Baker III to head the 11-member independent panel Management Program rule." Those regulations, in October, and the panel has since conducted three promulgated by the U.S. Occupational Safety and Health public hearings at BP refinery locations. Administration (OSHA) and the U.S. Environmental Protection Agency during the 1990s, require good safety Also in October 2005, the Board made an urgent and engineering practices at oil refineries, chemical recommendation to the American Petroleum plants, and other facilities that handle hazardous Institute (API) to develop a new safety guidance substances. document to help prevent the placement of occupied trailers close to hazardous process units. The API, a The accident occurred during the startup of the leading trade organization of U.S petroleum isomerization unit, when a distillation tower was producers, develops safety practices that are widely overfilled, flooding a nearby blowdown drum with followed in the industry. flammable liquid. The resulting geyser-like release from an atmospheric vent stack led to a series of explosions The CSB is an independent federal agency charged that killed and injured workers in nearby trailers. The with investigating industrial chemical accidents. CSB issued an extensive set of preliminary findings about The agency's board members are appointed by the the accident at a public meeting on October 28 in Texas president and confirmed by the Senate. CSB City, including a detailed description of the physical investigations look into all aspects of chemical causes of the release. accidents, including physical causes such as equipment failure as well as inadequacies in safety Chairman Merritt said, "We commend BP for committing management systems. to remove antiquated blowdown drums from all its U.S. refineries and for developing an improved siting policy The Board does not issue citations or fines but does for trailers. These measures will contribute to improved make safety recommendations to plants, industry safety at the Texas City refinery and other locations, and I 12 organizations, labor groups, and regulatory agencies such as OSHA and EPA. Please visit our website, www.csb.gov. For more information, contact Daniel Horowitz, CSB Director of Public Affairs, at (202) 261-7613 / (202) 441-6074 cell or Lindsey Heyl, Public Affairs Specialist, at (202) 261-3614 / (202) 725-2204 cell. 13 CSB Calls on Oil Industry to Eliminate Atmospheric Blowdown Drums Similar to Equipment at BP Texas City Refinery; Urges New OSHA "Emphasis Program" throughout U.S. For more information, go to: Text of CSB's Safety Recommendations on Blowdown Drums to the American Petroleum Institute and OSHA Houston, Texas, October 31, 2006 - On a unanimous vote of 5 to 0, the U.S. Chemical Safety Board (CSB) today issued new safety recommendations calling on the U.S. oil industry to improve safety practices for refinery pressure relief systems, eliminating the type of atmospheric vent that caused the hydrocarbon release and explosions that killed 15 workers and injured 180 at the BP Texas City refinery on March 23, 2005. The accident occurred during the startup of the refinery's octane-boosting isomerization (ISOM) unit, when a distillation tower and attached blowdown drum were overfilled with highly flammable liquid hydrocarbons. Because the blowdown drum vented directly to the atmosphere, there was a geyser-like release of highly flammable liquid and vapor onto the grounds of the refinery, causing a series of explosions and fires that killed workers in and around nearby trailers. The announcement followed by one day the release of new preliminary findings in the CSB's ongoing, independent federal investigation of the accident. The Board's final report is expected in March 2007. The first recommendation calls on the American Petroleum Institute (API), a leading oil industry trade association that develops widely used safety practices, to change its Recommended Practice 521, Guide for Pressure Relieving and Depressuring Systems. The revised guidance should warn against using blowdown drums similar to those in Texas City, urge the use of inherently safer flare systems, and ensure companies plan effectively for large-scale flammable liquid releases from process equipment. Further recommendations call on the U.S. Occupational Safety and Health Administration (OSHA) to establish a national emphasis program promoting the elimination of unsafe blowdown systems in favor of safer alternatives such as flare systems. OSHA should also emphasize the need for companies to conduct accurate relief valves studies and use appropriate equipment for containing liquid releases, the Board said. A national emphasis program results in a concerted inspection and enforcement effort around a specific safety hazard. CSB Chairman Carolyn W. Merritt said, "Unfortunately, the weaknesses in design, equipment, programs, and safety investment that were identified in Texas City are not unique either to that refinery or to BP. Federal regulators and the industry itself should take prompt action to make sure that similar unsafe conditions do not exist elsewhere. Taken as a package, the new CSB safety recommendations we issued today will provide for effective guidance, outreach, and regulatory enforcement to reduce the risk of similar tragedies in the future." Lead Investigator Don Holmstrom noted that the ISOM unit blowdown drum at the BP Texas City refinery had a number of safety problems. "This drum simply wasn't large enough to hold all the liquid released from the distillation tower if it flooded. Not only could the blowdown drum not hold enough liquid, but it could not assure safe dispersion of flammable vapors through the vent stack," Mr. Holmstrom said. He added that safe dispersion of flammable vapors would require a high exit velocity that could never be guaranteed when handling multiple discharges through a complex piping system. 14 That design weakness resulted in unsafe conditions in Texas City prior to the March 23, 2005, accident. The CSB documented eight previous releases of vapor from the same blowdown drum from 1994 to 2004. In six cases, dangerous flammable vapor clouds formed at ground level but did not ignite; in two other cases, the blowdown stack caught fire. Prior to the 2005 accident, BP operated 17 blowdown drums for disposal of flammable materials at its five U.S. refineries. BP has since pledged to eliminate all the drums and use safer alternatives, such as flare systems. A properly designed flare system includes an adequately sized vessel for containing liquids and a stack with a flame for safely burning flammable vapors, preventing an uncontrolled fire or explosion near personnel. Flares are the most commonly used disposal system for flammable releases in refineries. In 1992, the Texas City refinery, then owned by Amoco Corporation, was cited by OSHA for operating an unsafe blowdown drum. However, Amoco succeeded in having the citation and fine withdrawn, asserting that the drum complied with accepted industry standards embodied in API Recommended Practice 521. Today's recommendation from the CSB would strengthen that guidance document so that it would explicitly warn against such unsafe blowdown systems. The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in safety management systems. The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Please visit our website, www.CSB.gov. For more information, contact Daniel Horowitz at (202) 441-6074 cell (Houston) or Sandy Gilmour at (202) 261-7613 / (202) 251-5496 cell. 15 Sept. 7, 2007, 4:46PM BP nixed $150,000 project that might have prevented blast By BRAD HEM Copyright 2007 Houston Chronicle Email Get section feed Recommend Print Yahoo! Buzz Comments (21) BP executives rejected a $150,000 budget request in 2002 that would have piped flammable hydrocarbons to a flare instead of the blowdown drum, which could have prevented the 2005 explosion that killed 15 people and injured many others, according to documents and testimony Friday morning in the trial of a lawsuit filed by four workers. The explosion occurred after a piece of equipment overfilled with flammable liquid hydrocarbons, and vented vapor ignited during startup of a unit that boosts octane in gasoline. Investigations into the blast have said a flare, a more modern and safer alternative to the blowdown drum, could have burned off the fluid which could have prevented or limited the explosion. In an e-mail presented as evidence, a BP engineer recommended against the expense because flares were not mandated by the government and he estimated there was only an 80 percent chance the law would require flares within the next five years. Emails presented at the trial showed other officials supported the decision not to spend the money. Don Parus, the former head of BP's Texas City refinery, stopped short of testifying that installing a flare would have prevented the explosion. "The outcome would have been different," said Parus, who also testified the Texas City refinery was making profits of more than $1 billion a year. The trial involves four contractors who are suing BP for injuries and emotional distress inflicted by the blast. BP says their claims are weak and they are using the blast to seek big payoffs. Struggling with safety In his second day on the witness stand, Parus talked about long-standing struggles to make safety a higher priority and to get the oil giant to spend money on safety equipment and training. During the afternoon session, Coon presented documents to bolster his argument that BP officials had what one document described as a "checkbook mentality," ignoring repeated warnings about shortfalls at the refinery for the sake of saving money. He introduced a 2001 safety assessment of BP's South Houston area operations, which included Texas City. These operations have "the potential for events which could result in multiple deaths, property damage, business interruptions and damage to the BP brand reputation." An August 2002 memo between an executive in London and another BP official said it would be good if Texas City could return to its 1995 form when it was considered "the Amoco jewel." 16 He blamed the deteriorating condition first on a lack of spending by Amoco, before that company was acquired by BP, and then on BP's 1999 order to cut budgets across the company by 25 percent. An October 2002 BP document presented as evidence said Texas City had the second highest number of hydrocarbon leaks of all BP refineries and was overdue on more than 1,000 inspections. The document said $297 million was needed to fix the infrastructure. Struggles with worker morale There were also problems with worker morale because of BP decisions to cut retiree health benefits for new hires, and feelings that management was not concerned about safety. With Parus on the stand, Brent Coon, the attorney representing the workers, produced several examples where BP had cut spending for various safety training and equipment, including fire-proof blankets and steel-toed boots. Even after a damning workplace survey at the refinery that found many workers feared they might die on the job, cuts continued, further damaging Parus' efforts to improve relations between management and workers, he said. "People still felt nothing had changed," Parus said. Parus, who is among four senior executives targeted to be fired in an internal BP investigation completed in February, has been on paid leave from the company since May 2005. He testified Thursday that he still draws a $279,000 annual salary. His testimony is expected to take the remainder of Friday. brad.hem@chron.com 17
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