BP Texas City Refinery

Explosion
Wednesday afternoon, March 23
At approximately 1:20 p.m. on Wednesday, March
23, a series of explosions occurred at the BP Texas
City refinery during the restarting of a hydrocarbon
isomerization unit. Fifteen workers were killed and
about 170 others were injured. Many of the victims
were in or around work trailers located near an
atmospheric vent stack. CSB investigators have
reported that the explosions occurred when a
distillation tower flooded with hydrocarbons and was
overpressurized, causing a geyser-like release from
the vent stack.

BP Texas City Video Clip

 CSB Investigation
• Trailers sited in unsafe location
(occupied, adjacent operating unit)
• Raffinate splitter should not have been
started up because of existing
malfunctions to the level indicator, level
alarm and control valve
• Raffinate splitter had a history of
abnormal startups that included
recurrent high liquid levels and
pressures.
 CSB Investigation
• In March 2005, the blowdown drum vented
highly flammable material directly into the
atmosphere. Since its construction in the
1950’s the drum had never been connected
to the flare. Amoco, the previous owner,
replaced the blowdown drum and stack in
1997 with identical equipment. Amoco safety
standards recommended connecting the
drum to a flare when such major changes
were undertaken.
 CSB Investigation
• Between 1995 and 2005 there were 4 other
serious releases of flammable material from
the unit blowdown drum and stack that led to
ground level vapor clouds, fortunately none
ignited.
• In 1992, OSHA cited a similar blowdown
drum and stack at the refinery because it
vented flammable materials directly to the
atmosphere. However, OSHA dropped the
citation and the drum was never connected to
a flare system.
 Baker Panel Review
• “The passing of time without a process
accident is not necessarily an indication that
all is well and may contribute to a dangerous
a growing sense of complacency”
• “When people lose an appreciation for how
their safety systems were intended to work,
safety systems and controls can deteriorate,
lessons can be forgotten, and hazards and
deviations from safe operating procedures
can be accepted.”
 Baker Panel - Culture
• “BP has emphasized personnel safety
in recent years and has achieved
significant improvement in personnel
safety performance, but BP did not
emphasize process safety. BP
mistakenly interpreted improving
personal injury rates as an indication of
acceptable process safety performance
at its U.S. refineries”
 Baker Panel – Culture
• “A good process safety culture requires a
positive, trusting and open environment with
effective lines of communication between
management and the workforce, including
employee representatives”
• “At Texas City, Toledo, and Whiting, BP has
not established a positive, trusting and open
environment with effective lines of
communication”
 Sunoco
• Sunoco was working on improvement
opportunities in the area Risk Management
before the Texas City Explosion and will
continue to do so.
• BP Texas City has reaffirmed and provided an
urgency in our efforts to effectively manage risks
that are inherent to our facilities. It has also
provided valuable reminders and lessons not
only Sunoco, but for our industry.
 Sunoco Risk Management
• Sunoco Risk Methodology Standard
– Defined Risk Criteria (Qualitative and Quantitative)
– Risk Based Decision Making
• Layers of Protection Analysis (LOPA)
– Single Scenario Analysis
• Initiating event frequency and consequence, evaluated against
independent layers of protection = RISK
– PHA integration/interlock evaluations
– Identifies what systems are critical and what isn’t
• Safety Instrumented Systems (SIS) Analysis (ISA 84)
– Evaluation of current Safety Instrumented Systems (Detect,
Decide, Deflect) with regard to redundancy and
independence with assigned testing and inspection
frequencies.
 Sunoco Facility Siting
• Baker Risk Analysis of all sites
– OSHA recognized (BP Texas City)
• Sunoco Portable Building and
Alternative Enclosure Standard
– Approved Trailer Lots
– MOC and risk review inside “Restricted
Areas”
– Clearing of “non-essentials” during start-up
 Process Safety Auditing
• Corporate PSM Audit every three years
for each site (independent)
– Management Systems Evaluated
• Trending/Lessons (across the
company)
– PSM Forum/Chemicals PSMTT
• BP Texas City Gap Assessment
• Sunoco PSM Audits
Sunoco Management Commitment
• Safety Culture
– Positive, Trusting, Open
– Effective Communication
• Effective Risk Management
– Facility Siting
– PHA/LOPA/QRAs
– SIL
– Reliability/Mechanical Integrity
– OD/MWP = Operating Excellence
• Root Cause Analysis
– Level 2 and 3 Events
– Trending across the business (internally and externally)
Sunoco Employee Engagement
• Total Event Reporting (TERs)
– Stating block for effective risk management
• Hazard Recognition
– Quality PHAs, Incident Investigations, inspections
– Quality Safe Plan of Action (SPAs)
• Personal Hazard Review
– Quality Observation Processes
• 3rd Party Hazard Review
• JSC and local Safety Committee
– Safety Action that targets Risk Reduction, not jackets
• Challenge Our Assumptions