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CONTENTS
Accident Summary Change of Management Budget cut Human Errors Equipment Design Process Safety Regulations
Accident Summary
23 march 2005 Killed 15 people 180 injured US$1.5Biliion lost
Change of Management
Merger with Amoco in 1999 6 Business Unit Leaders changes in 5 years Checkbook mentality Leadership incompetence Basic HSE rules
Budget cuts
25% cost deduction Reduces operational cost Staff reduction
Human Error
Fatigue Training Procedure failure Communication
Equipment Design
Blow down stack Unsafe 50 years old Alarm failure Side glass dirty Computerized control system design Overwrite control valve