Don Holstrom led the investigation for the Chemical Safety Board (CBS) into the causes for what occurred on March 23, 2005, at the BP Refinery Plant in Texas City. He summed up his findings into two categories: safety systems failures and human fatigue/communications between operators (USCSB). CSB board member William Wright said that this was the “worse industry accident in the United States in 15 years” (USCSB). The CSB concluded that BP had ignored the warning signs of a looming disaster and that as a “result of organizational and safety deficiencies at all levels of the company” (USCSB). BP is not the only company who ignores safety issues, so the first lesson that can be learned from this disaster is that this is something that can happen in any industry at any time, but especially to those industries who repeatedly ignore sound safety protocols in the interest of increasing profit margins.
The second lesson learned after investigating the explosion is that it is of the utmost importance to implement and follow written safety protocols as well as to increase communications between those involved in the daily operation of potentially life threatening manufacturing systems. The trailers that were being used to house temporary contractors were located to close to the isom unit, and the workers there were never informed of the dangers of the isom unit (USCSB). The isom tower was designed to only hold six and a half feet of liquid, and the design of the liquid indicator was flawed in that it would not measure above the nine foot mark (USCSB). Operators consistently ignored BP protocol and filled the tower above the six and a half foot mark due to the fact that the furnace would be damaged if the fluid level fell below six feet (USCSB). When the liquid reached the eight foot mark, the first alarm sounded but the second one failed, and when the liquid reached thirteen feet, it only measured as nine since the liquid indicator would only measure to nine feet (USCSB). Personnel failed to communicate efficiently with each other, and the lead operator in the satellite control room left one hour after his shift was over after he updated the one lone operator in the central control room (USCSB). The day operator arrived to work for the 30th day in a row for yet another twelve hour shift (USCSB). This operator was responsible for running three units including the isom unit which needed scrutinizing. A second necessary board operator had been cut due to budget restrictions (USCSB). The log book did not reflect how much liquid was in the tower. The day shift supervisor came in late and without any briefing from the night shift supervisor. Furthermore, the day shift supervisor left due to a family emergency which meant that no experienced supervisor was in attendance. This was counter to BP’s own protocol (USCSB). The board operator and others had conflicting information and instructions about the start up level, and, as a result, the auto level control valve was left shut (USCSB).
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The third important lesson to learn from this breakdown in systems is the importance of keeping equipment properly serviced and maintained. This includes testing alarms that serve as a primary indicator of equipment breakdown. The liquid had risen to 98 feet in the tower, but no one could know that since the liquid indicator was not calibrated correctly. The reading showed that the level was only at 8.4 feet and falling (USCSB). At 12:41 when the high pressure alarm sounded, the workers did not know where it was coming from, so they opened a chain valve to release gases to a 1950s designed blowdown drum which blew the gas into the air. They opened the valve to release liquid, now superheated, to the gasoline storage tanks (USCSB). When the boiling gas spilled down to the emergency valves at the base of the tower, the alarm failed to go off (USCSB). As a result, vapor and liquid spewed from the top of the stack and a vapor cloud rose and spread. Meanwhile an idling truck sparked the vapor cloud which resulted in the explosion and fire that burned for days (USCSB).
Going forward, three simple suggestions for BP could make the difference in whether they suffer another disaster such as this one. The first thing the company should do is to conduct monthly audits and drills to make sure that all BP and HSB safety protocols are being followed. In addition, safety audits from an outside company should be conducted to make sure that BP is testing all of its safety systems both mechanical and personal. This would make operators, supervisors, and other workers cognizant of what is required to ensure safety and what to do in the event of a catastrophic event.
The second suggestion would be to increase the budget to provide money to recruit and retain qualified experience personnel most specifically operators who are fluent in safety and personal safety systems. Since BP has had such a great turnover rate with regards to their leadership, they are left with few experienced operators. Paying those valued personnel a handsome salary with benefits would ensure that they have experienced people in place to maintain protocols.
The third suggestion would be that BP undergo weekly internal audits and monthly external audits of all work orders and work logs to ensure proper maintenance of equipment, alarms, etc. These audits would make the maintenance departments more accountable for completing all work in a timely manner and would ensure that all equipment is properly working, and if the equipment fails, then the alarms will properly function.
- USCSB, director. Anatomy of a Disaster. YouTube, YouTube, 2 June 2008, www.youtube.com/watch?v=XuJtdQOU_Z4&feature=youtu.be.
