"The CSB's investigation shows that BP's global management was aware of problems with maintenance, spending and infrastructure well-before March 2005," CSB Chairman Carolyn Merritt said. "BP did respond with a variety of measures aimed at improving safety. However, the focus of many of these initiatives was on improving procedural compliance and reducing occupational injury rates, while catastrophic safety risks remained. Unsafe and antiquated equipment designs were left in place, and unacceptable deficiencies in preventative maintenance were tolerated."
CSB noted that its conclusions are based on "preliminary findings" from its investigation into the March 23, 2005, explosions and fire at BP's Texas City, Texas, refinery that killed 15 workers, injured 180 and was the worst U.S. industrial accident in more than a decade.
Merritt pointed to earlier CSB findings that the equipment directly involved in the March 23 tragedy was of an obsolete design and was being phased out in most refineries and chemical plants, and that key pieces of instrumentation were either known to be not working or known to be unreliable by unit supervisors.
CSB has scheduled a news conference for Oct. 31 in Houston to discuss its new findings as well as more safety recommendations. Due to the complexity of the investigation, Merritt said that a final CSB report likely will not be issued until at least March 2007.
The release of CSB's preliminary findings was the first significant update in CSB's investigation since Oct. 27, 2005, when preliminary findings were issued at a public meeting in Texas City.
CSB: Previous Incidents at Texas City Uncovered
Investigators believe that the March 23 accident occurred during the startup of the 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.
Don Holmstrom, who is heading CSB's investigation, said that since last October CSB has uncovered additional previous incidents involving the same blowdown drum, which was designed in the 1950s.
Holmstrom said that his team has now documented the occurrence of eight previous instances in which flammable hydrocarbon vapors were discharged from the same blowdown drum between 1994 and 2004. In two of these incidents, the blowdown system caught fire, according to CSB.
CSB said that the eight incidents were not properly investigated, and appropriate corrective actions were not implemented.
The explosion on March 23, 2005, was not the only major accident the Texas City refinery had experienced, CSB investigators said. The history of major accidents and fatalities at the plant was summarized in a meeting held in November 2004 by the refinery manager for 100 supervisors. According to CSB, the refinery manager gave a sobering presentation entitled "Safety Reality" on the 23 deaths at the plant in the previous 30 years; on average, one worker had died every 16 months.
Texas City Management Believed Refinery "Had Turned the Corner"
Holmstrom noted that BP Texas City in 2004 had the lowest injury rate in its history. However, that same year the refinery experienced three major accidents that caused three fatalities.
"In late 2004, following these major accidents and other near-misses, the Texas City leadership was attempting to improve the refinery's safety performance," Holmstrom said. "Several years of audits and reports had identified serious safety system deficiencies. However, the safety initiatives that were undertaken focused largely on improving personnel safety - such as slips, trips and falls - rather than management systems, equipment design and preventative maintenance programs to help prevent the growing risk of major process accidents."
While refinery management believed improved personnel safety statistics meant Texas City "had turned the corner," in the words of Holmstrom, existing process safety metrics and the results of a safety culture survey indicated continuing serious problems with safety systems and concerns about another major accident, CSB said.
A health, safety and environment business plan presented on March 15, 2005 - just 8 days before the ISOM unit accident - identified as a key risk that the Texas City refinery "kills someone in the next 12 to 18 months."
Merritt also pointed to "stringent budget cuts" throughout BP as a major cause of "a progressive deterioration of safety at the Texas City refinery."
"Every successful corporation must contain its costs," Merritt said. "But at an aging facility like Texas City, it is not responsible to cut budgets related to safety and maintenance without thoroughly examining the impact on the risk of a catastrophic accident."
BP Still Blames Workers for Refinery Tragedy
BP spokesperson Neil Chapman said that BP agrees with CSB that Texas City "was a preventable tragedy," but he also indicated that the company takes issue with some of CSB's latest findings.
Responding to CSB's allegations that budget cuts at BP hurt safety at Texas City, Chapman noted that the company in its fatal accident investigation report - which BP released to the public in December - did not identify funding and budget decisions as root causes of the 2005 tragedy.
"The [Texas City refinery] budget for capital expenditures and operating expenditures increased steadily over the last 10 years," Chapman told Occupationalhazards.com.
Chapman added that BP will not comment on any specifics of CSB's latest findings until CSB produces "documentation explaining the basis of its statements."
Chapman also said that BP's fatal accident investigation report "clearly shows that while the problems that led up to [the Texas City tragedy] were complex," ultimately the incident was caused by "a failure to follow the procedures that were laid down."
"We've shared our report, as well as the documentation on what we found, with the general public, the industry and CSB," Chapman said. " … Whether there's any difference [between the BP report and the CSB report], we would be more than willing to hear why there are such differences."