CSB's 335-page report – which is the culmination of its nearly 2-year investigation of the Texas City blast – also fingers OSHA for failing to enforce the workplace safety agency's process safety management standard (29 CFR 1910.119, Process Safety Management of Highly Hazardous Chemicals) at petrochemical facilities such as BP's Texas City refinery.
“OSHA’s national focus on inspecting facilities with high injury rates, while important, has resulted in reduced attention to preventing less-frequent but catastrophic process safety incidents such as the one at Texas City,” the report says.
In light of its findings, CSB is calling on OSHA to step up its inspection and enforcement at U.S. Oil refineries and chemicals plants and is urging OSHA to require oil and chemical companies “to evaluate the safety impact of mergers, reorganizations, downsizing and budget cuts.”
“Rules already on the books would likely have prevented the tragedy in Texas City,” CSB Chairwoman Carolyn Merritt said. “But if a company is not following those rules, year-in and year-out, it is ultimately the responsibility of the federal government to enforce good safety practices before more lives are lost. OSHA should obtain and dedicate whatever resources are necessary for inspecting and enforcing safety rules at oil and chemical plants. These facilities simply have too many potentially catastrophic hazards to be overlooked.”
BP Urged to Add Process Safety Expert to Board of Directors
With the release of its report, CSB is calling on BP to appoint to the company's board of directors an additional member who has expertise in process safety. The agency also is urging senior BP executives to establish an improved incident reporting program and to use new indicators to measure safety performance.
“It is my sincere hope and belief that our report and the recent Baker report will establish a new standard of care for corporate boards of directors and CEO’s throughout the world,” Merritt said. “Process safety programs to protect the lives of workers and the public deserve the same level of attention, investment and scrutiny as companies now dedicate to maintaining their financial controls. The boards of directors of oil and chemical companies should examine every detail of their process safety programs to ensure that no other terrible tragedy like the one at BP occurs.”
The report was to be presented and submitted to CSB's five presidentially appointed members for approval at a public meeting March 20 in Texas City.
Cost-Cutting Left Texas City “Vulnerable to a Catastrophe”
The CSB report notes that when BP acquired the Texas City refinery in 1999 as a result of its merger with Amoco, a top BP official ordered a 25 percent cut in fixed spending at the company's refineries. According to the report, “cost-cutting in the 1990s by Amoco and then BP left the Texas City refinery vulnerable to a catastrophe.”
BP has disputed CSB's assertions that budget cuts at BP hurt safety at Texas City. In a previous conversation with OccupationalHazards.com, BP spokesperson Neil Chapman noted that the company in its fatal accident investigation report did not identify funding and budget decisions as root causes of the accident.
However, CSB Chairwoman Carolyn Merritt told reporters at a March 20 press conference that cost-cutting directives – along with production pressures and a failure to invest in newer equipment at the Texas City refinery – were key factors in BP's “progressive deterioration in safety” that led to the 2005 incident.
“Beginning in 2002, BP commissioned a series of audits and studies that revealed serious safety problems at the Texas City refinery, including a lack of necessary preventative maintenance and training,” Merritt said. “These audits and studies were shared with BP executives in London, and were provided to at least one member of the executive board. BP’s response was too little and too late. Some additional investments were made, but they did not address the core problems in Texas City.”
According to Merritt, BP executives in 2004 “challenged their refineries to cut yet another 25 percent from their budgets for the following year.”
Asked whether the conclusions of the report could be distilled to BP's continued cost-cutting at the refinery despite continued red flags that a tragic accident was imminent, Merritt answered: “I think that summarizes it extremely well.”
“[BP] just did not recognize the warnings signs,” Merritt said. “They were fixed on lost-time incident rate and personal-injury rate as a measure of risk, and as we know and we've seen in other investigations, that is an indication of safety on the shop floor with regard to individuals, but it doesn't give you any indication whatsoever about what is going on with regard to deterioration [of safety] or increasing risk within a facility.”
Drum Released “Equivalent of a Full Tanker Truck of Gasoline”
According to CSB, the March 23, 2005, 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.
According to CSB, a diesel pickup truck that was idling nearby ignited the vapor, initiating a series of explosions and fires that swept through the unit and the surrounding area.
Fatalities and injuries occurred in and around occupied work trailers, which, CSB investigators have concluded, were placed too close to the ISOM unit and were not evacuated prior to the startup. The agency in October 2005 issued an urgent recommendation to the American Petroleum Institute to develop new guidance to prevent trailers from being sited near hazardous areas of refineries and chemical plants, where occupants could be injured or killed.
“The CSB was able to calculate that approximately 7,600 gallons of flammable liquid hydrocarbons – nearly the equivalent of a full tanker truck of gasoline – were release from the top of the blowdown drum stack in just under two minutes,” said CSB Investigator Mark Kaszniak, who led the CSB’s vapor and blast modeling effort. “The ejected liquid rapidly vaporized due to evaporation, wind dispersion and contact with the surface of nearby equipment. High over-pressures from the resulting vapor cloud explosion totally destroyed 13 trailers and damaged 27 others. People inside trailers were injured as far as 479 feet away from the blowdown drum, and trailers nearly 1,000 feet away sustained damage.”
Kaszniak added: “Industry trailer siting guidelines did not predict the level of trailer damage that we actually saw.”
“A human being is more likely to be injured or killed inside a trailer – which can shatter during an explosion – than if he is standing in the open air,” Kaszniak said. “For that reason, occupied trailers have no place near hazardous process areas of refineries and chemical plants.”
Operator Fatigue Likely Played a Role
According to CSB, the distillation tower overfilled because a valve allowing liquid to drain from the bottom of the tower into storage tanks was left closed for more 3 hours during the startup on the morning of March 23 – contrary to unit startup procedures. The CSB investigative team examined various conditions and human factors that led to this error.
The CSB team used an NTSB methodology to conclude that ISOM unit operators were likely fatigued when the startup occurred. By March 23, according to CSB, operators had been working 12-hour shifts for 29 or more consecutive days.
“Although errors and procedural deviations occurred during the startup, it is important to recognize that individuals do not plan to make mistakes,” said CSB investigator Cheryl MacKenzie, who led the human factors analysis. “They are doing what makes sense to them at the time, given the work environment, the organization’s goals and other job-related factors. Understanding and correcting these factors will help prevent future accidents at BP and throughout the industry.”
The report recommends that the American Petroleum Institute, along with the United Steelworkers International Union – the largest union representing refinery workers – develop a new consensus standard for fatigue prevention in the oil and chemical industry.