Seven Decades of Safety: Anatomy of a Tragedy

Time after time, those of us in the safety community read about workplace injuries and fatalities that were completely preventable. “Had Company X just followed basic workplace safety requirements,” the investigating agency often concludes, “this accident never would have happened.”

Tragically, the BP Texas City explosion — which took the lives of 15 workers and sparked the largest investigation in Chemical Safety and Hazard Investigation Board (CSB) history — was just such an accident.

Extensive Destruction

During a startup of the refinery's isomerization unit, operators pumped flammable liquid hydrocarbon into the raffinate splitter tower without allowing any liquid to drain from the bottom of the tower into storage tanks — which was contrary to startup procedures. The liquid overflowed into piping off the top of the tower, triggering emergency relief valves to open and channel liquid hydrocarbon into the blowdown drum at the other end of the isomerization unit.

The drum filled completely, and, consequently, liquid hydrocarbon spewed from the 113-foot tall blowdown stack like a geyser. The volatile liquid evaporated as it fell to the ground and created a large flammable vapor cloud, which spread quickly throughout the area. At 1:20 p.m. on March 23, 2005, the cloud ignited, likely after coming into contact with an idling diesel pickup truck parked about 25 feet away.

The 15 contract employees killed in the explosion were working in or near mobile trailers located too close to the blowdown drum. The explosion caused heavy damage within the isomerization unit, severely damaging the satellite control room and destroying the catalyst warehouse. The blast damaged or destroyed a number of vehicles and mobile trailers, damaged more than 50 large chemical storage tanks, broke windows, cracked masonry walls and damaged doors in surrounding refinery units and shattered windows in homes and businesses up to three-fourths of a mile away.

“Ripe for Human Error”

While BP's investigation report admitted that there was a complex set of “underlying reasons for the behaviors and actions during the incident,” the report clearly emphasized that workers and supervisors caused the accident by deviating from procedures. The BP investigation team asserted that one key mistake was the failure of BP personnel “to establish heavy raffinate rundown to tankage, while continuing to feed and heat the tower.”

CSB, however, contended that “safety system deficiencies created a workplace ripe for human error to occur.” According to the CSB report, the work environment at Texas City encouraged BP employees to deviate from procedures. Other latent conditions included a poorly designed computerized control system, inadequate operator training, a reduced training budget and more, CSB said.

“This is an event that has changed the company, and the commitment to safety has been reinvigorated,” said BP spokesman Neil Chapman.

Decade of the 00's


2000: OSHA issues ergo standard

2001: President George W. Bush repeals ergo standard

2001: Al-Qaeda terrorists attack United States

2003: American troops invade Iraq

2008: First viable female candidate runs in presidential primaries; Democrats nominate first black presidential candidate

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