The U.S. Chemical Safety and Hazard Investigation Board, (CSB) recently issued an urgent recommendation calling on the BP Global Executive Board of Directors to commission an independent panel that would review a range of safety management and culture issues in the wake of recent chemical accidents at BP’s south Texas facilities.
The independent panel would focus on BP’s oversight of its five North American refineries in Texas City, Texas; Carson, Calif.; Whiting, Ind.; Cherry Point, Wash.; and Toledo, Ohio. Four of the refineries were acquired through BP’s mergers with the former Amoco and ARCO corporations.
The CSB is currently investigating an explosion and fire which occurred at BP’s Texas City refinery on Mar. 23, 2005, killing 15 workers and causing about 170 injuries. It is the first safety recommendation in the agency’s eight-year history that has been designated as “urgent” and issued in advance of a completed investigation. In voting to adopt the recommendation, the Board said that identified safety management lapses pose an issue that “is considered to be an imminent hazard and has the potential to cause serious harm unless rectified in a short time frame.”
Citing a series of serious safety incidents at the Texas City facility over the past two years, the Board recommended that BP commission and fund a diverse panel of experts, including employee representatives. The panel would review corporate safety oversight, safe management of refineries obtained through mergers and acquisitions, corporate safety culture, and management systems such as near-miss reporting and mechanical integrity programs.
CSB Chairman Carolyn Merritt announced the action at a news conference in Houston, near the Texas City refinery, which experienced two fatal safety incidents last year and has had two additional serious incidents since the fatal March explosion, including a hydrogen fire and a gas release. She also praised BP’s recent commitments to relocate nonessential personnel from its Texas City refinery and to eliminate hazardous atmospheric vents at its refineries in Texas City and Whiting.
Merritt said the work of the panel would dovetail with CSB’s investigation of the March 23 tragedy, which will continue to focus on uncovering the specific root causes of the incidents as well as generate recommendations for national changes to prevent a recurrence.
The panel should include safety experts from a wide variety of sectors, such as aviation, space exploration, nuclear energy, and the undersea navy, as well as the process industries. The panel must be independent from BP and have an external chairperson as well as labor representation.
Chairman Merritt cited the Columbia Accident Investigation Board, which investigated in the 2003 Space Shuttle reentry disaster, as one of the models for the independent panel. She said the CSB was requesting that BP develop an implementation plan for the recommendation within 30 days and complete all work within six to twelve months. The CSB will not serve on the panel but will track and evaluate progress in implementing the recommendation, with periodic reporting to the public.
The March 23 incident involved a sudden release of flammable hydrocarbon liquid and vapor from an atmospheric vent stack in the refinery’s isomerization, or isom, unit. Workers in nearby trailers were killed and injured in the subsequent explosions. The 114-foot tall stack, which dated from the 1950s and was not tied in to a safety flare system, was overfilled with hydrocarbons during the startup of a raffinate splitter tower, a 164-foot tall distillation column that became flooded with at least 120 vertical feet of liquid. Normal operating levels in the tower are less than 10 vertical feet. The flooded tower experienced a sudden pressure increase, opening relief valves and venting hydrocarbon liquid and vapor that overwhelmed the vent stack and its associated blowdown drum.
The urgent safety recommendation was accompanied by new and more detailed CSB findings that were reported at the news conference. The findings included:
• Key alarms and a level transmitter failed to operate properly and to warn operators of unsafe and abnormal conditions within the tower and the blowdown drum.
• The startup of the raffinate splitter was authorized on March 23 despite known problems with the tower level transmitter and the high-level alarms on both the tower and the blowdown drum; for example, a work order dated March 10 and signed by management officials, acknowledged that the level transmitter needed repairs but indicated that these repairs would be deferred until after startup.
• The majority of 17 startups of the raffinate splitter tower from April 2000 to March 2005 exhibited abnormally high internal pressures and liquid levels – including several occasions where pressure-relief valves likely opened – but the abnormal startups were not investigated as near-misses and the adequacy of the tower’s design, instrumentation, and process controls were not re-evaluated.
• Written startup procedures for the raffinate splitter were incomplete and directed operators to use the so-called “3-lb.” vent system to control tower pressure, even though the pressure-control valve did not function in pre-startup equipment checks and also failed to operate effectively during post-accident testing.
The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in safety management systems.
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