CSB Issues 'Urgent' Safety Recommendation to BP Global Board

Aug. 17, 2005
For the first time in its history, the U.S. Chemical Safety and Hazard Investigation Board, (CSB) issued an "urgent" safety recommendation on August 17, calling on the BP Global Executive Board of Directors to commission an independent panel to review a range of safety management and culture issues in the wake of recent chemical accidents at BP's south Texas facilities.

BP plans to appoint an independent panel to review the safety management systems and corporate safety culture of BP Products North America Inc., the subsidiary responsible for its U.S. refining operations.

Responding to the recommendation made today by the CSB, which is investigating the March 23 explosion at the company's Texas City refinery, BP Group chief executive John Browne said the panel would be headed by an external chairperson and would include outside safety experts and BP staff representatives.

"The Texas City explosion was the worst tragedy in the recent history of BP, and we will do everything possible to ensure nothing like it happens again. Today's recommendation from the CSB is a welcome development and we take it seriously," said Browne. "We will move speedily to appoint an independent panel and offer it every help to do its job. When it reports, we will act with equal speed to deal with its recommendations."

Browne said the panel's findings would be made public.

Ross Pillari, president of BP Products North America Inc., said he had discussed the recommendation with the CSB on Monday and pledged that "the membership and mission of the independent panel will be consistent with the recommendation of the CSB.

"We have made use of a number of outside experts in our investigation of the March 23 explosion. This additional step, which will take in all five of BP's U.S refineries, is entirely consistent with how we have proceeded to date," Pillari said. "We see value in this approach, and we look forward to working with the CSB and the panel towards our common goal of making our refineries as safe as they can be."

The independent panel would focus on BP's oversight of its five North American refineries in Texas City, Texas; Carson, Calif.; Whiting, Ind.; Cherry Point, Wash.; and Toledo, Ohio. Four of the refineries were acquired through BP's mergers with the former Amoco and ARCO corporations.

The CSB is currently investigating an explosion and fire which occurred at BP's Texas City refinery on March 23, 2005, killing 15 workers and causing about 170 injuries. It is the first safety recommendation in the agency's 8-year history that has been designated as "urgent" and issued in advance of a completed investigation. In voting to adopt the recommendation, the board said that identified safety management lapses pose an issue that "is considered to be an imminent hazard and has the potential to cause serious harm unless rectified in a short time frame."

Citing a series of serious safety incidents at the Texas City facility over the past 2 years, the board recommended that BP commission and fund a diverse panel of experts, including employee representatives. The panel would review corporate safety oversight, safe management of refineries obtained through mergers and acquisitions, corporate safety culture, and management systems such as near-miss reporting and mechanical integrity programs.

BP has fully cooperated with the CSB, the U.S. Occupational Safety and Health Administration, the U.S. Environmental Protection Agency and the Texas Commission on Environmental Quality. The company continues to make corrective actions recommended in the May 17 CSB report, including appointing a new refinery manager, a new health, safety and environment manager, a new compliance manager and a new maintenance manager. The organization has been simplified, to ensure everyone involved in maintenance and operation of the refinery knows what they are accountable for and to whom they are accountable. Roles, responsibilities and expectations around start-up, operating, maintenance and evacuation procedures have been clarified. Action has been taken to ensure procedures are followed across the site.

CSB Chairman Carolyn Merritt announced the CSB's action at a news conference in Houston, near the Texas City refinery, which experienced two fatal safety incidents last year and has had two additional serious incidents since the fatal March explosion, including a hydrogen fire and a gas release. She also praised BP's recent commitments to relocate nonessential personnel from its Texas City refinery and to eliminate hazardous atmospheric vents at its refineries in Texas City and Whiting.

"Today, the Chemical Safety Board is issuing an urgent safety recommendation to BP America and BP's Global Board of Directors," Merritt said. "This is the first urgent safety recommendation in the board's 8-year history. The Chemical Safety Board recommends that BP immediately convene an independent panel of experts to examine BP's corporate safety management systems, safety culture, and corporate oversight of its refineries. The panel should report its findings and recommendations to the BP workforce and the public."

Merritt said the work of the panel would dovetail with CSB's investigation of the March 23 tragedy, which will continue to focus on uncovering the specific root causes of the incidents as well as generate recommendations for national changes to prevent a recurrence.

The panel should include safety experts from a wide variety of sectors, such as aviation, space exploration, nuclear energy and the undersea navy, as well as the process industries. The panel must be independent from BP and have an external chairperson as well as labor representation.

Merritt cited the Columbia Accident Investigation Board, which investigated in the 2003 Space Shuttle reentry disaster, as one of the models for the independent panel. She said the CSB was requesting that BP develop an implementation plan for the recommendation within 30 days and complete all work within 6 to 12 months. The CSB will not serve on the panel but will track and evaluate progress in implementing the recommendation, with periodic reporting to the public.

The March 23 incident involved a sudden release of flammable hydrocarbon liquid and vapor from an atmospheric vent stack in the refinery's isomerization, or isom, unit. Workers in nearby trailers were killed and injured in the subsequent explosions.

The 114-foot tall stack, which dated from the 1950s and was not tied in to a safety flare system, was overfilled with hydrocarbons during the startup of a raffinate splitter tower, a 164-foot tall distillation column that became flooded with at least 120 vertical feet of liquid. Normal operating levels in the tower are less than 10 vertical feet. The flooded tower experienced a sudden pressure increase, opening relief valves and venting hydrocarbon liquid and vapor that overwhelmed the vent stack and its associated blowdown drum.

The urgent safety recommendation was accompanied by new and more detailed CSB findings that were reported at the news conference. The findings included:

Key alarms and a level transmitter failed to operate properly and to warn operators of unsafe and abnormal conditions within the tower and the blowdown drum.

The startup of the raffinate splitter was authorized on March 23 despite known problems with the tower level transmitter and the high-level alarms on both the tower and the blowdown drum; for example, a work order dated March 10 and signed by management officials, acknowledged that the level transmitter needed repairs but indicated that these repairs would be deferred until after startup.

The majority of 17 startups of the raffinate splitter tower from April 2000 to March 2005 exhibited abnormally high internal pressures and liquid levels including several occasions where pressure-relief valves likely opened but the abnormal startups were not investigated as near-misses and the adequacy of the tower's design, instrumentation, and process controls were not re-evaluated.

Written startup procedures for the raffinate splitter were incomplete and directed operators to use the so-called "3-lb." vent system to control tower pressure, even though the pressure-control valve did not function in pre-startup equipment checks and also failed to operate effectively during post-accident testing.

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