On the 23rd March 2005, a fire and explosion occurred at BP’s Texas City Refinery in Texas City, Texas, killing 15 workers and injuring more than 170 others. The accident was a catastrophic process failure.
The Texas City Refinery was the second-largest oil refinery in Texas and the third largest in the United States. The explosion occurred in a unit where light and heavy gasoline components were being separated, and octane was being added. Due to operator error, gasoline was forced in to a pressure release system called a blow down drum. The pressure was too much and overwhelmed it, resulting in liquids spilling out and accumulating on the ground, which created a highly flammable and combustible vapor cloud. The fuel-air vapour cloud was ignited by a pickup truck.
In January 2007 The Report of the BP Refineries Independent Safety Review Panel (aka “The Baker Report”) was published. The Panel concluded that BP had not emphasised process safety and had mistakenly interpreted improving personal injury rates at its US refineries as the key safety indicator. The Panel stated that, “BPS reliance on this data (personal safety), combined with an inadequate process safety understanding, created a false sense of confidence that BP was properly addressing process safety risks.”
The Panel further stated that, “While all of BP’s U.S. refineries have active programs to analyse process hazards, the system as a whole does not ensure adequate identification and rigorous analysis of those hazards. The Panel’s examination also indicates that the extent and recurring nature of this deficiency is not isolated, but systemic.”
In other words BP relied on one indicator of safety and failed to develop a holistic view of the vulnerabilities at its U.S. refineries. In dealing with complex systems it is essential to use as many indicators as possible and to fully assess the vulnerabilities in processes – this BP failed to do.