1. BP TEXAS CITY REFINERY DISASTER
ACCIDENT & PREVENTION REPORT
Chinedu Charles Isiadinso
April 23, 2015
Contents
1 INTRODUCTION 2
2 KLETZ-TYPE PREVENTION TABLE 3
3 ANALYSIS 6
4 CONCLUSION 9
1

2. 1 INTRODUCTION
On Wednesday, March 23 2005, numerous explosions, and a fire, occurred at BP Texas City
refinery, Texas, USA. The explosions and fire occurred during start-up of an isomerization unit
at the refinery. The disaster resulted in 15 fatalities, over 150 injuries, and financial losses
exceeding $1.5 billion (USD)[1].
Details of the Accident
BP had begun a lengthy maintenance project at their Texas city refinery, which required over
1000 contractors on site along with employees. A number of trailers had been set up, close to
the blow-down stack (see figure 1), to serve as offices and meeting rooms for the contractors.
In the early hours of Wednesday, March 23 2005, workers began the start-up process of an
isomerization unit by pumping highly flammable liquid into to a raffinate splitter tower (see
figure 1), which would, normally, have ≈ 2m (6.5ft) of liquid at its base. Liquid height sensor
and two alarm systems, for heights of 2m, (6.5ft) and 3m, (10ft), were installed to measure
and report the height of liquid in the tower to operators, and raise alarms if the liquid reached
2m and 3m respectively. However, the sensor was designed to measure heights up to 3m, and
thus there was no way to tell the amount of liquid in the tower beyond that point. As workers
pumped liquid into the splitter tower, the liquid reached, and exceeded, the 3m mark, setting
off the 2m alarm but not the 3m. As the liquid feed exceeded 3m, when the feed was stopped,
and the height sensor reported 3m, while in actual fact, the tower is believed to have reached
4m, (13ft)[2].
Figure 1: Raffinate section of Isomerization unit[1]
Following a shift change, and very poor communication, operators recommenced the start-up
process, adding more liquid to the overfull splitter tower. While liquid was being pumped in,
no liquid was being pumped out, as specified in the start up procedure[5], due to a level control
valve being left closed. About 10 minutes later, as part of the normal process, operator lit
burners in the furnace to heat up the liquid being fed to the splitter tower. With the level
control valve still closed, the tower liquid level rose, and the heigh meter reported a height of
under 3m; however, calculations show that the liquid reached 42m[1].
At 1 pm, the level control valve was opened, following a high pressure alarm that caused a
manual relief valve to be opened; this stabilized liquid level. However, liquid leaving the tower
2

3. was at a very high temperature, and on exiting the heat exchanger (which was not designed to
cool down very hot liquid), induced a temperature rise (over 150o[1]) in liquid being fed to the
tower. This caused liquid in the tower to boil and expand causing the liquid level in the tower to
rise. Minutes later, the 52m, (170ft)[5], 586, 100l[7] capacity splitter tower was completely full,
and liquid flowed through a overhead pipe, down 45m, (148ft), and forced open all 3 safety relief
valves near the base of the tower; these valves redirected over 200, 000l of flammable liquid to
the blow-down drum of significantly lower capacity. Similar to the tower, the blow-down drum
was fitted with a liquid height sensor and an alarm, but when the drum overfilled, the alarm
failed to alert operators, who continued redirecting flow to the drum. Minutes later, there was
an eruption of very hot highly flammable liquid, from the top of the blow-down stack[3], which
fell to the ground creating a highly flammable vapour cloud that covered the entire refinery,
especially the trailers housing the contractors. Ignition of the cloud, by backfire from an idling
diesel truck at about 1:20 pm, caused a number explosions and fires, and sent shock-waves for
miles in all directions.
Figure 2: BP Texas City Refinery Layout[1]
2 KLETZ-TYPE PREVENTION TABLE
Table 1: Kletz-Type prevention table
Events Immediate Steps Avoiding Hazard Management System
Explosions and Fire Truck driver should
have turned engine off
after eruption
Idling diesel truck
backfires, ignites
vapour cloud
Do not idle truck a
few meters from haz-
ardous equipment
Create dedicated
parking space
Always know where
vehicles on plot are
Vapour Cloud forms
and expands across re-
finery
Sound alarm Install disaster alert
system
Train staff for dis-
asters, the CSB
report[1] showed
that staff where not
properly trained for
abnormal situations
3

4. Table 2: Kletz-Type prevention table
Events Immediate Steps Avoiding Hazard Management System
Blow-down stack over
fills and liquid erupts
Carry out disaster
protocol
Install blow-down
drum of equal capac-
ity as tower. Install
modern blow-down
stack, to eliminate
possibility of overflow
Train staff for
disasters[9]
Liquid in blow-down
drum reaches max.
capacity; high level
alarm does not sound
Tower is overfull, ex-
pect the drum alarm
to sound, and act if
there’s no sound
Emergency purge sys-
tem when drum over
fills
Regular equipment
inspection, due to
cost cutting tech-
niques, less money
was available to
inspect and repair
faulty equipment[1]
High pressure liquid
force open all 3 safety
relief valves; liquid
is redirected to the
blow-down drum
Turn off feed, and
purge systems
Install another set of
high pressure alarms
for the over head pipes
Tower overfills; liquid
flows through over-
head pipe towards re-
lief valves 45m below
Install overflow detec-
tor to shut down pro-
cess if tower overfills
Liquid fed to tower
causes boiling; liquid
level rises to 43m, sen-
sor shows decline
Design location based
temperature detector
Regular equipment in-
spection and repairs
Hot liquid, from tower
base, heats up tower
feed
Design system to mea-
sure temperature of
liquid in key areas
(e.g. tower outlet)
and alert operator of
problems
Operators worry
about lack of outflow,
level control valve is
open
The process had been
running for over 3
hours, check what
happened to liquid
fed
Design system to
show valve status
A supervisor must al-
ways be present
Tower high pressure
alarm sound; oper-
ators open manual
relief valve (auto-
matic emergency
valves failed)
Check information
about flow into and
out of tower and see
if there discrepancies.
Regular equipment in-
spection
Improperly calibrated
level indicator shows
liquid as 2.6m and
falling; liquid is at
30m
Show flow into and
out of tower on same
screen and work out
in tower volume based
on these
Equipment inspection
and repairs
4

5. Table 3: Kletz-Type prevention table
Events Immediate Steps Avoiding Hazard Management System
Supervisor leaves due
to family emergency,
there is no replace-
ment
Request replacement
supervisor
Enforce requirement
of at least one tech-
nical staff at all
times
Conflicting infor-
mation about level
control valve is re-
ceived by operator,
valve is left closed
Request clarification Design system to
show valve status
Start-up recom-
mences, more liquid
is added to already
overfull tower, liquid
level increases
Carry out pre-startup
procedure
Improve system to
allow operators see
flows in and out of
tower
Ensure pre-startup is
completed ans suc-
cessful
Night shift operator
leaves, day shift oper-
ator takes over; state
of start-up process is
badly communicated
Make better use of
logbooks
Enforce BP sign over
protocol, especially
during hazardous
processes
Sensor reads 3m (ac-
tual height is 4m),
feed is stopped
Improve sensor design
First tower high level
alarm sounds, second
fails
Stop after first alarm Regular equipment in-
spection
Operators ignore 2m
recommended height
and fill to 3m max.
height
Follow safety recom-
mendation
Enforce safety re-
quirements
Contract workers in
trailers are not in-
formed about start-up
process
Inform all personnel
about hazardous pro-
cesses
Ensure everyone is out
of harms way before
starting hazardous
processes
Isomerization start-up
begins, liquid is fed
into splitter tower
Evacuate all non-
essential staff
Ensure pre-startup is
completed
Safety culture
Lengthy maintenance
process; trailers are
set-up close to isomer-
ization unit
Setup trailers at safe
distance
Should have followed
CSB trailer citing rec-
ommendations
5

6. 3 ANALYSIS
The accident could be blamed on a wide range of failures, from mechanical to human to process,
however, the entire accident could be put down to human error. Starting at the very beginning
with the location of the trailers. From figure 3, it can be seen that the trailers where set up
in, potentially, the most dangerous part of the site. Trailers where setup between the catalyst
warehouse and the isomerization unit (close to the blow-down drum and staff), separated from
the unit by a rack of pipes carrying highly flammable liquid. Not only was this citing warned
against by safety experts[1], but from figure 2, it can be seen that permanent office structures
where erected reasonably far away from hazardous material and equipment, at the other end of
the refinery; no deaths occurred at these permanent structures. A reasonable location, for the
trailers, would have been next to the control room in the blue section of figure 2.
Figure 3: Trailer area and adjacent Isomerization unit[1]
Second, employees, and maintenance workers knew how hazardous the isomerization start-up
process was, but no alerted the contracts (who where in the trailers) about the start-up, as such
contracts where unaware of of what was happening until the eruption and explosion. Deaths
could have easily been prevented if trailer staff where informed, or better still, removed from
harmsway until the start-up process was complete; there was a safety meeting that day, over
300 people (employees and contractors) where in attendance and nothing was said about the
startup about to begin[3].
While immediately it would not have been possible for the night shift operator to have know
the second alarm had failed, a better logbook entry could have been left for the day shift operator
to work on. The logbook entry gave no indication of previous pumping level and alarm sound,
instead it read ”ISOM brought in so raff to unit, to pack raff with”[1].
Operators usually neglected key safety requirements, like the pre-startup checks, which would
have confirmed the position of the level control valve, removed non-essential personnel from the
6

7. site, and potentially noticed, and dealt with, the idling truck. It could have also alerted staff
to the faulty alarms and indicator, as it required manual liquid level confirmation, via a sight
glass at the base of the tower; it is worth noting, that the sight glass had not been cleaned for
longer than recommended and as such dark liquid had covered the glass making it unuseable.
Poor communication saw the situation on the ground being badly transmitted from ground
operators to board staff, which lead to a one of the most obvious causes of the disaster, the level
valve was left closed for over 3 hours while liquid as fed. The valve was later opened, but staff
should have instigated the location of hours of pumped liquid; if there was no liquid outflow,
then there must have been a build up of liquid in the tower, this would have brought the faulty
indicator (which read 2.6m and falling instead of 30m), to their attention and they could have
stopped the feed and drained the tower. Following the departure of the only technically trained
staff on site that day, due to a family emergency, and contrary to BP standard procedure,
there was no replacement supervisor assigned to over see the startup process; this left one low
experience operator (not qualified to run an entire refinery without supervision) alone to manage
all 3 units at the refinery, including the iszomerizaion unit.
On one end of Kletz’s spectrum, we have ways of preventing the hazard. In this case, the
hazard could have been prevented had the level indicator had been designed to accommodate
the full 52m height of the tower. Looking at it from the point of view of what is necessary,
the level was never meant to exceed 3m, however, if operators did not stop the feed exactly
when the 3m alarm was heard, they would overshoot and not know how much by. The system
could have been fool-proofed by designing an automatic system that shut off liquid feed when
the level reached 3m instead of just an alarm. A similar system in the blow-down drum could
automatically open the sewer block valve (see figure 4) to drain the drum if it overfills; these
would help prevent any instances where there’s human failure.
Figure 4: Blow-down drum and gooseneck[1]
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8. A similar system was already operational in the emergency relief valve, which failed to open on
operator’s command, but opened when pressure exceeded maximum allowed, and this prevented
a different accident of a burst pipe.
In figure 3, cars can be seen parked around very dangerous equipment, there where more
suitable locations for a car park than between a catalyst warehouse and a rack of pipes.
Also, the CSB’s report noted poor operator display designs. The control unit did have display
for amount of liquid flowing into and out of the tower, but these when on different screens, and
thus meant that unless the operator suspected discrepancies in the flow, they would not check
to see if the number matched. A better design would have been to have both flows on the
same screen, but also to workout the different the alert the operator, or trigger an automatics
protection system, if the difference exceeds an acceptable tolerance range.
On the other end of Kletz’s spectrum, failures of the management, such as lack of regular
equipment inspection and repairs, lead to key safety devices and instruments, level indicators,
alarms and even the emergency pressure relief systems, failing to alert operators of danger; these
piece of equipment where know by management to be faulty but nothing was done to repair or
replace them[3]. Staff where not adequately trained and protections where not put in place to
prevent catastrophic failures, the likes of which, had bee predicted as early as 1992[9]. There
where no real automatic systems that would act immediately in and emergency, all systems
required the intervention of an operator, and while BP required operators to work in pairs and
always have one person in the control room at all times, cases of desertion where very common;
on the day of the accident, an operator deserted his post hours before his replacement arrived.
Management had also consistently failed to address re-occurring unsafe practices, e.g. startup
without fully completed pre-startup checks, that had previously (on February 12, 1994) lead
to a similar situation where the tower was overfilled. Also, reports show management failed
to invest in hazard prevention and safeguard. Furthermore, huge cost cutting tactics saw the
isomerization unit grossly under staffed during startup.
Management had a responsibility to ensure a safe working environment for everyone on site,
but years of limited funding and a growing unsafe culture saw mandated processes being ig-
nored, and near misses being left uninvestigated. The main cause of the disaster was a lack of
properly implemented pre-emptive measures, which would have completely prevented not only
this incidence, but future ones as well.
Lessons Learned
The following lessons could be drawn and generalized from is disaster;
1. Follow recommend procedure: Operators should not deviate from their training, but also,
managers, and supervisors should ensure protocol is strictly adhered to.
2. Alert people of potential danger: Contractors and uninvolved staff, e.g. the two in the
idling truck, where not aware of the hazardous process that was going on very close to
them. This could also be extended to members of the public, for example, construction
site must tell, not only their employees about dangers, but passers-by that could be hurt
as well.
3. Check design by Hazop: Safety equipment, in the refinery, where not designed to eliminate
hazard, rather they where designed to alert of potentially dangerous situations, and thus
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9. where highly susceptible to human error. Safety devices should be designed to make it
almost impossible to hurt yourself and others, e.g. automatic speed limiters on high speed
trains (Santiago de Compostela rail disaster)[11].
4 CONCLUSION
In conclusion, the disaster at Texas City was completely preventable. Key immediate steps by
operators on the day could have prevented the accident, however, the key cause of the disaster
was a continuous failure to learn from near misses, an absence of safety culture, and persistent
absence of hazard prevention by management staff, even after numerous near misses on numer-
ous machines. Also misplaced priorities could be blamed for the disaster, as investments in
safety and hazard prevention where not made following BP’s acquisition of Amoco’s outdated
(even at the time of acquisition) refinery, instead job cuts and poor maintenance culture, which
saved BP hundreds of thousands of dollars, where priority.
References
[1] U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD. INVESTIGA-
TION REPORT REFINERY EXPLOSION AND FIRE. Rep. no. 2005-04-I-TX. Texas City:
U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD, 2007. Print.
[2] U.S. CHEMICAL SAFETY BOARD. ”Anatomy of a Disaster.” csb.gov. U.S. Chemical
Safety Board, 11 Jan. 2008. Web. 11 Mar. 2015.
[3] Schorn, Daniel. ”The Explosion At Texas City.” CBSNews. CBS Interactive, 26 Oct. 2006.
Web. 11 Mar. 2015.
[4] Broadribb, Mike. ”Lessons from Texas City.” Lessons from Texas City (2008): 1-26.
hse.gov.uk. Bp, 8 May 2008. Web. 12 Mar. 2015.
[5] Michael, Jo-Anne. ”Texas City Incident Human Factor Aspects.” Hse.gov.uk. Health and
Safety Executive, n.d. Web. 12 Mar. 2015.
[6] Wikipedia contributors. ”Texas City Refinery explosion.” Wikipedia, The Free Encyclope-
dia. Wikipedia, The Free Encyclopedia, 1 Mar. 2015. Web. 12 Mar. 2015.
[7] Kalantarnia, Maryam, Faisal Khan, and Kelly Hawboldt. ”Modelling of BP Texas City
Refinery Accident Using Dynamic Risk Assessment Approach.” Process Safety and Environ-
mental Protection 88.3 (2010): 191-99. ScienceDirect. ELSEVIER, 1 Feb. 2010. Web. 12 Mar.
2015.
[8] Dean, L. E., H. R. Harris, D. H. Belden, and Vladimir Haensel. ”The Penex Process for
Pentane Isimerisation.” Platinum Metals Review 3.1 (1959): 9-11. Print.
[9] Cappiello, Dina, and Anne Belli. ”OSHA Warned Refinery about Danger in 1992.” Houston
Chronicle. Houston Chronicle, 8 Apr. 2005. Web. 12 Mar. 2015.
[10] Hopkins, Andrew. Failure to Learn: The BP Texas City Refinery Disaster. Sydney, N.S.W.:
CCH Australia, 2008. Print.
[11] Wikipedia contributors. ”Santiago de Compostela rail disaster.” Wikipedia, The Free En-
cyclopedia. Wikipedia, The Free Encyclopedia, 5 Mar. 2015. Web. 13 Mar. 2015.
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