Updated BP Texas City Animation on the 15th Anniversary of the Explosion

Summary

Highlights

• The 2005 BP Texas City Refinery explosion is a case study in safety failures. ⚠️
• Improper communication and safety measure neglect led to 15 deaths and 180 injuries. 😔
• The CSB's new training initiative aims to prevent such disasters in the future. 🎓
• Revisions in safety protocols are crucial for preventing industrial accidents. 📝
• Interactive safety training can enhance safety awareness among workers. 🌐

Key Takeaways

• The BP Texas City explosion serves as a stark reminder of the importance of strict safety adherence in industrial operations. 🏭
• The lack of communication and proper safety measures led to the catastrophic incident at the refinery. 🚨
• The CSB is launching a training app to enhance understanding of OSHA's safety protocols using this incident as a case study. 📚
• Workers and supervisors need clear communication and precise operational directives to prevent accidents. 🔍
• The tragedy underscores the dire consequences of neglecting safety in hazardous environments. ⚠️

Overview

Chapters

• 00:00 - 00:30: Introduction to OSHA's PSM and BP Texas City as a Model The chapter introduces OSHA's Process Safety Management (PSM) and uses the BP Texas City incident as a model to understand its significance. It mentions that the US Chemical Safety Board is developing an interactive training application focusing on PSM regulations, particularly covering its 14 elements. The training aims to provide insights through historical incidents, like the 2005 explosion, to emphasize the importance of effective safety management practices.
• 00:30 - 01:00: Maintenance and Setup at BP Texas City In the chapter titled 'Maintenance and Setup at BP Texas City,' the discussion centers around the BP Refinery located in Texas City, Texas. The focus of this section is on the events of March 23, 2005, when the refinery had several of its units shut down for extended maintenance projects. This maintenance effort necessitated having nearly a thousand contractors present on site in addition to the BP employees. The chapter is part of a larger report available at CSB.gov, where the Texas City facility is examined as a model case.
• 01:00 - 01:30: Setup of Portable Trailers and Lack of Warning BP set up multiple portable trailers near process units to accommodate contractors and maintenance workers, particularly those servicing the ultra-cracker unit. Among these, a doublewide wood frame trailer with 11 offices was frequently used for meetings. Despite being situated near the isomerization (ISOM) unit, the workers in these trailers were not warned about ISOM unit risks.
• 01:30 - 02:00: Raffinate Splitter Tower Operations Begin Operations for the raffinate splitter tower began with the introduction of flammable hydrocarbons. Overnight operators started at 2:15 a.m. on March 23, aiming to distill and separate gasoline components. The tower was equipped with a single instrument near its base to measure the liquid level inside.
• 02:00 - 02:30: Instrument Limitations and Procedure Deviations The chapter discusses limitations of the level indicator instrument in a control system, which wasn't designed to measure liquid above 9 feet. However, during startups, operators often deviated from standard procedures, filling the tower beyond this limit.
• 02:30 - 03:00: High Level Alarm and Operator Actions The chapter discusses the activation of a high level alarm in a control room when a liquid level in a furnace tower nears a critical point. At 3:09 a.m., the alarm activates as the liquid approaches 8 feet, but a second alarm higher up the tower fails to sound. By 3:30 a.m., the indicator shows the liquid filled the bottom nine feet, prompting operators to halt the feed to prevent damage.
• 03:00 - 03:30: Operator and Shift Changes The lead operator was managing the startup from a satellite control room within the ISOM unit.
• 03:30 - 04:00: Confusion in Logbook Entries and Late Day Supervisor A board operator starts his 30th consecutive 12-hour shift and encounters confusion due to unclear logbook entries. The logbook lacks details about the existing liquid levels in the tower and equipment, as well as instructions for resuming startup and routing of liquid feed and products.
• 04:00 - 04:30: Recirculation and Overfilling of the Tower The chapter describes a lack of communication and documentation during a shift change at an ISOM unit. The control board operator only found a brief log entry about a task performed overnight, and because the dayshift supervisor arrived late, he did not receive a proper briefing from the outgoing nightshift personnel. This lack of information and oversight led to the operators resuming startup activities without full understanding of the current unit conditions.
• 04:30 - 05:00: Supervisor's Absence and Impact of Corporate Cuts The chapter discusses a scenario during which there was confusion due to conflicting instructions received by the board operator and others. This confusion was exacerbated by the supervisor's absence and the impact of corporate cuts, which could have included reduced training or staffing levels. These factors led to incorrect handling of the liquid levels in an overfilled tower. The failure to properly manage the liquid level control valve, which was mistakenly left closed, blocked the flow of liquid, potentially risking operational efficiency and safety.
• 05:00 - 05:30: Liquid Level Misreading and Contractors' Lunch Break Operators started heating the feed by lighting the furnace burners as part of the startup process. The day supervisor, however, left unexpectedly due to a family emergency, leaving no experienced supervisor in charge. This resulted in only one control board operator being present without supervision, which was against BP's procedures.
• 05:30 - 06:00: Alarm Activation and Emergency Relief Actions The chapter discusses the operation of three refinery units, emphasizing the ISOM unit that required careful monitoring. It highlights the impact of corporate budget cuts following BP's acquisition of Amoco in 1999, which led to the elimination of a board operator position. During the startup process, the liquid level in a tower unexpectedly rose to 98 feet, significantly exceeding the normal level.
• 06:00 - 06:30: High Pressure Actions and Heat Exchanger Impact The chapter discusses issues with the calibration of a level indicator which misguides operators by showing incorrect liquid levels. The control panel's configuration further complicates the situation by failing to adequately warn operators or display critical flow data. Additionally, it touches on the maintenance contractors who are not a part of the ISOM unit operations.
• 06:30 - 07:00: Hot Feed Impact and Contractors' Return Chapter title: Hot Feed Impact and Contractors' Return. Summary: The chapter describes an incident occurring during a company lunch, marking a month without a lost time injury. At 12:41 p.m., an alarm was triggered due to rising liquid compressing gases at the top of a tower, which caused a high-pressure situation. Operators, unable to determine the pressure source, opened a manual valve leading gases to an outdated emergency relief system.
• 07:00 - 07:30: Boiling Liquid and Overflow into Vapor Line In the chapter titled "Boiling Liquid and Overflow into Vapor Line," the main focus is on the critical situation in a processing tower. Operators attempted to manage the pressure by venting vapor into the atmosphere and turning off two furnace burners to lower the internal temperature. Despite these efforts, the operators were unaware that the tower was dangerously overfilled. Their concern grew due to the lack of outflow from the tower, leading them to open a valve to transfer the extremely hot liquid from the bottom of the tower to storage tanks. This action signifies a response to an imminent hazard, although the operators were attempting to mitigate a perceived pressure threat without realizing the true risk of overflow.
• 07:30 - 08:00: Emergency Valves and Blow Down Drum Incident The chapter discusses an incident involving emergency valves and a blow down drum. It begins with a sudden 141-degree Fahrenheit increase in temperature as liquid flowed through a heat exchanger into the tower. Around this time, contract workers, unaware of the startup and potential danger, returned from lunch and started a meeting in a doublewide trailer near the blow down drum. The chapter sets the stage for the unfolding incident as hot feed continues to enter the tower.
• 08:00 - 08:30: Overfill and Geyser Formation The chapter "Overfill and Geyser Formation" describes an incident where a liquid inside a tower started to boil and swell, leading to overfilling and exerting pressure on emergency relief valves situated 150 feet below. At 1:14 p.m., three emergency valves opened, releasing approximately 52,000 gallons of flammable liquid to a blow down drum located at the other end of the ISOM unit. Subsequently, the liquid level rose inside the blow down drum and overflowed into a process sewer.
• 08:30 - 09:00: Formation and Ignition of Vapor Cloud Alarms sound in the control room as hydrocarbons overfill the blowdown drum, but the high-level alarm fails to activate. Unaware of the unfolding disaster in the ISOM unit, operators witness a geyser of liquid and vapor erupting from the stack. A tanker truck's worth of hot gasoline spills to the ground, creating a large flammable vapor cloud.
• 09:00 - 09:30: Explosions, Destruction, and Fatalities The chapter 'Explosions, Destruction, and Fatalities' details a catastrophic event where a vapor cloud rapidly expanded within 90 seconds, consuming the surrounding area, including a unit and trailers occupied by workers. Two workers seated in a pickup truck nearby experienced their diesel engine racing uncontrollably as flammable vapor entered the air intake. Upon fleeing the vehicle, they were unable to stop the engine, leading to the truck backfiring shortly after, as witnessed by observers.
• 09:30 - 10:00: Injuries, Rescue Efforts, and Damage Assessment A vapor cloud in the ISOM unit was ignited, leading to powerful explosions and a pressure wave that caused extensive destruction and fires. The blasts resulted in the deaths of 12 out of 20 occupants in a doublewide trailer and three workers in a nearby trailer. The fires persisted for hours as rescue efforts and damage assessment commenced.
• 10:00 - 10:30: CSB Investigation Conclusion The chapter describes the harrowing aftermath of an explosion at BP's Texas City facility, where 180 workers sustained injuries ranging from serious burns to fractures and other traumatic conditions. The explosions also obliterated trailers made of wood and metal. Firefighters faced significant challenges in rescuing and treating the injured while also tending to the deceased. Additionally, 50 large chemical storage tanks suffered damage, and the ISOM unit was inoperative for over two years. The disaster is noted as the most severe.

Updated BP Texas City Animation on the 15th Anniversary of the Explosion Transcription

• 00:00 - 00:30 Voiceover: The US Chemical Safety Board is developing a new interactive training application focused on OSHA's Process Safety Management or PSM regulation. The training will cover the 14 elements of PSM using the 2005 explosion
• 00:30 - 01:00 at BP's Texas City Refinery as a model. Look for it soon at CSB.gov. March 23, 2005, the BP Refinery in Texas City, Texas. Several units at the refinery had been shut down for lengthy maintenance projects which required nearly a thousand contractors to be onsite along with BP employees.
• 01:00 - 01:30 BP had positioned a number of portable trailers close to process units for the use of contractors and other maintenance workers. Over a period of months, BP had located 10 trailers for workers servicing the ultra-cracker unit including a doublewide wood frame trailer that contained 11 offices and was regularly used for meetings. Though these trailers were located near the isomerization unit, the occupants were not warned the ISOM unit
• 01:30 - 02:00 was about to start up, a potentially hazardous operation. At 2:15 a.m. on March 23 overnight operators began introducing flammable liquid hydrocarbons known as raffinate into a 170-foot tall raffinate splitter tower used to distill and separate gasoline components. Near the base of the tower, there was a single instrument that measured how much liquid was inside.
• 02:00 - 02:30 It transmitted this information to both a satellite control room and a central control room located away from the ISOM unit. But this level indicator was not designed to measure liquid above the 9-foot mark. During normal operation, the tower was only supposed to contain about six and one-half feet of liquid. But during startups, operators routinely deviated from written procedures and filled the tower above the 9-foot mark,
• 02:30 - 03:00 concerned that if the liquid level fluctuated too low it would cause costly damage to the furnace. At 3:09 a.m. as the liquid neared the 8-foot mark, a high level alarm activated and sounded in the control rooms. But as second high level alarm slightly further up the tower failed to go off. By 3:30 a.m. the level indicator showed that liquid had filled the bottom nine feet of the tower, and the feed was stopped.
• 03:00 - 03:30 The CSB later estimate that the liquid was in fact at a height of 13 feet, but operators could not know the actual level because the indicator only measured up to nine feet. The lead operator had been overseeing the startup from a satellite control room within the ISOM unit. At 5:00 a.m. he briefly updated the night board operator in the central control room about the startup activities. The lead operator then left the refinery early, an hour before the end of the shift.
• 03:30 - 04:00 A new board operator arrived in the control room around 6:00 a.m. to start his 30th day in a row working a 12-hour shift. He spoke briefly with the departing nightshift operator and then read the logbook to prepare for the startup. But the logbook did not clearly indicate how much liquid was already in the tower and equipment. And it left no instructions on routing of the liquid feed and products when the startup resumed.
• 04:00 - 04:30 Instead the control board operator only found a one-line logbook entry that said, ISOM brought in some raff to unit to pack raff with. At 7:15 a.m. the dayshift supervisor arrived. Because he was more than an hour late, he received no formal briefing from personnel on the nightshift about conditions in the ISOM unit. At 9:51 a.m. operators resumed the startup.
• 04:30 - 05:00 They began recirculating the liquid feed and adding more liquid to the already overfilled tower. As new feed was added, startup procedures called for regulating the liquid level in the tower using the automatic level control valve. But the board operator and others had received conflicting instructions on routing the product. As a result, this critical valve was left closed for several hours, blocking the flow of liquid from the tower.
• 05:00 - 05:30 A few minutes later operators lit burners on the furnace to begin heating up the feed, part of the normal startup process. While the startup was underway, the day supervisor left the refinery on short notice just before 11:00 a.m. to attend to a family medical emergency. Contrary to BP's own procedures, no experienced supervisor was assigned to replace him. This left a single control board operator now without a qualified supervisor
• 05:30 - 06:00 to run three refinery units including the ISOM unit which needed close attention. The refinery had eliminated a second board operator position following corporate budget cuts in 1999 after BP acquired Amoco. As the startup continued, the tower steadily filled with liquid, reaching a height of 98 feet shortly before noon, more than 15 times the normal level.
• 06:00 - 06:30 But the improperly calibrated level indicator told operators in the control room that the liquid was at 8.4 feet and gradually falling. Furthermore the control panel was not configured to clearly warn operators of the growing danger. It did not display flows into and out of the tower on the same screen, nor did it calculate the total liquid in the tower. Meanwhile the maintenance contractors who were not involved in the operation of the ISOM unit
• 06:30 - 07:00 left their work trailers to attend a company lunch, celebrating a month without a lost time injury. At 12:41 p.m. an alarm activated as the rising liquid compressed the gases remaining in the top of the tower. Unable to understand the source of the high pressure, operators opened a manual chain valve that sent gases to the unit's emergency relief system, a 1950's era blow down drum
• 07:00 - 07:30 that vented vapor directly into the atmosphere. Operators also turned off two burners in the furnace to lower the temperature inside the tower, believing this would reduce the pressure. Nobody knew the tower was dangerously full. The operators did become concerned about the lack of flow out of the tower and began opening the valve to send liquid from the bottom of the tower to storage tanks. But this liquid was very hot.
• 07:30 - 08:00 As it flowed through the heat exchanger, it suddenly raised the temperature of the liquid entering high up the tower by 141 degrees Fahrenheit. It was now about 1:00 p.m. Contract workers unaware of the startup and the looming danger, returned from lunch and began a meeting in the doublewide trailer in the corner room closest to the blow down drum. Over the next few minutes, the hot feed entering the tower
• 08:00 - 08:30 caused the liquid inside to start to boil and swell. Liquid filled the tower completely and began spilling into the overhead vapor line, exerting great pressure on the emergency relief valves 150 feet below. At 1:14 p.m. the three emergency valves opened, sending nearly 52,000 gallons of flammable liquid to the blow down drum at the other end of the ISOM unit. Liquid rose inside the blow down drum and overflowed into a process sewer,
• 08:30 - 09:00 setting off alarms in the control room. But the high level alarm on the blow down drum would fail to go off. None of the operators knew of the catastrophe unfolding in the ISOM unit. As flammable hydrocarbons overfilled the blow down drum, operators nearby saw a geyser of liquid and vapor erupt from the top of the stack. The equivalent of nearly a tanker truck full of hot gasoline fell to the ground and began forming a huge flammable vapor cloud.
• 09:00 - 09:30 The vapor cloud expanded in just 90 seconds, engulfing the unit and the nearby trailers full of workers. About 25 feet from the base of the blow down drum, two workers were parked in a pickup truck with the engine idling. As flammable vapor entered the air intake, the diesel engine began to race. The two workers fled, unable to shut off the engine. Moments later witnesses saw the truck backfire
• 09:30 - 10:00 and ignite the vapor cloud. Powerful explosions swept through the area. The blast pressure wave accelerated through the ISOM unit causing heavy destruction and igniting fires. The workers inside the trailers were right in the path of the explosions. The fires continued to burn for hours. 12 of the 20 occupants of the doublewide trailer were killed along with three workers in a trailer nearby.
• 10:00 - 10:30 180 workers were injured, many with serious burns, fractures or other traumatic injuries. The wood and metal frame trailers were blown apart by the blasts. Firefighters struggled to rescue the injured and recover the victims. 50 large chemical storage tanks were damaged, and the ISOM unit remained shut down for more than two years. The disaster at BP Texas City was the most serious
• 10:30 - 11:00 refinery accident ever investigated by the CSB.