The US Chemical Safety and Hazard Investigation Board (CSB) concluded that the explosion and fire at the BP refinery in Texas City on March 23, 2005, was caused by organisational and safety deficiencies at all levels of the company.

Warning signs were present for years, but company officials did not intervene effectively to prevent it. The CSB began its investigation a day after the incident and reviewed more than 30,000 documents, conducted 370 interviews, tested instruments and assessed damage.

The report is divided into technical findings and organisational findings and, for the first time, the CSB conducted an examination of corporate safety culture. It adopted the model used by the Columbia Accident Investigation Board in the inquiry of the causes of the loss of the space shuttle Columbia in 2003, which sought to go beyond mechanical failures and human miscalculations.

The CSB report states: “Simply targeting the mistakes of BP’s operators and supervisors misses the underlying and significant cultural, human factors and organisational causes of the disaster that have a greater preventative impact.”

The accident happened when refinery personnel tried to start up the raffinate splitter tower in the refinery’s isomerisation unit (Isom) after a maintenance shutdown. Flammable hydrocarbons were pumped into the tower for three hours without any liquids being removed, contrary to proper procedure.

Alarms and instrumentation provided false indications. Unknown to the crew, the 170ft tower was overfilled and liquid was discharged into a drum with a stack (chimney) venting to the air. The drum and stack overfilled, leading to a geyser from the 113ft stack.

The report reads: “This blowdown system was an antiquated and unsafe design; it was originally installed in the 1950s and had never been connected to a flare system to safely contain liquids and combust flammable vapours released from the process.”

The liquid formed a vapour cloud and fell to the ground, where probably it was ignited by a backfire from an idling pick-up truck. The fire killed 15 people working in and around trailers parked near the blowdown drum.

The CSB found several technical failures that caused the accident, notably: the failure of the alarm system on the tower level indicator and the lack of any other indicators or automatic safety devices; an inadequate control board display; a lack of supervisory oversight and trained personnel; the fatigue of operators working in 12-hour shifts for 29 days; and the location of personnel trailers too close to a unit handling hazardous materials.

The board also found that BP had failed to replace blowdown drums and stacks with a flare, despite a series of incidents and a citation by the US Occupational Safety and Health Administration (Osha) that the drum and stack were unsafe. Eight serious releases of flammable material from the Isom had happened in the years before the incident. These events were not investigated.

The report adds: “In 2002 BP engineers proposed connecting the Isom blowdown drum system to a flare but BP chose a less expensive option.”

During project development for the construction of a naphtha desulphurisation unit (NDU), it was proposed that the Isom be connected to the NDU’s flare. There was discussion whether future environmental regulation might require linking the Isom to a flare to prevent hazardous emissions. The refinery manager ruled against the investment and stated in an e-mail: “Bank the savings in 99.999 per cent of the cases.”

In its organisation findings, the CSB report concludes: “Cost-cutting and budget pressures from BP Group executive managers impaired process safety performance at Texas City.”

The company relied on personal injury rate statistics that failed to provide a true picture of process safety and it exhibited a “check-the-box mentality”, in which personnel completed paperwork and checked off on safety policy and procedural requirements even when those requirements were not met.

The CSB said that BP lacked a learning culture and failed to respond to its own surveys and studies that had revealed deep-seated safety problems. The board cites a study conducted in August 2002 by the new site director — that was seen by BP executives in London — which found that the Texas City refinery infrastructure and equipment were “in complete decline”.

The study indicated that “there were serious concerns about the potential for a major site incident due to the large number of hydro-carbon releases [more than 80 in 2000-01]”.

The CSB also refers to a follow-up report in October 2002. The Texas City Refinery Retrospective Analysis linked the site’s deterioration with “the reduction in maintenance spending over the last decade”. Capital spending fell 84 per cent between 1992 and 2000. Fixed costs fell by half and maintenance spending was reduced by 41 per cent.

The 2002 study pointed to a target introduced by the chief executive of BP of a 25 per cent cut in fixed costs over 1999-2000. According to the CSB, one refinery manager refused to implement the target because he believed it to be unsafe. However, Texas City came close to reaching the target.

The CSB report states: “Items cut included turn-arounds, safety committee meetings . . . plant maintenance and training courses. Safety and maintenance expenditures were a significant portion of the cuts.”

In October 2002 the BP group refining vice-president warned refinery managers that the financial condition of refining was much worse than expected and that, from a financial perspective, refining was in “crisis mode”.

The Texas City West plant manager, responsible for the Isom unit involved in the 2005 disaster, instructed further expenditure cuts, including training courses. In September 2003 an audit titled Getting Health, Safety and Environment Right found that the condition of assets and infrastructure at Texas City was poor and identifed a “chequebook mentality” as problematic.

This meant that budgets were not large enough to address identified risks. An internal presentation about safety conducted in November 2004 included a slide show titled Texas City is Not a Safe Place to Work that displayed photos of 23 workers killed at the site since 1974.

The CSB also cites a report from the Telos Group, a safety culture consultancy, which surveyed 1,080 workers and interviewed 112, including plant leaders and supervisors, in 2004. Telos said that it had never seen such “intensity of worry” about the occurrence of catastrophic events by those “closest to the valve”. The CSB states that in 2004 BP ordered a 25 per cent budget reduction “challenge” for 2005. The Texas City management asked for more funds, but initially the group management denied the request.

The plant manager negotiated a restoration of half the cut, but the news affected workforce morale. The CSB report reveals that a BP health, safety, security and environment (HSSE) business plan, published on March 15, 2005 — eight days before the disaster — gave warning that the refinery would “kill someone in the next 12-18 months”.

Concern about the risk of fatality was expressed by an HSSE manager in an e-mail sent in February 2005, referring to a catastrophic incident. It read: “I truly believe that we are on the verge of something bigger happening.”

Texas countdown

March 23, 2005 Explosion at BP’s Texas City refinery kills 15 workers and injures 170

July 28 Process-related hydrogen fire at Texas City

August 10 Incident involving gas oil hydrometer at Texas City

August 17 US Chemical Safety and Hazard Investigation Board issues urgent safety recommendation to BP to form an independent panel “to assess and report on the effectiveness of BP North America’s corporate oversight of safety management systems at its refineries and its corporate safety culture”

October 24The formation of the BP US refineries independent safety review panel announced

October 27 Chemical Safety Board issues preliminary findings

November 10 First meeting of independent panel

December 9 BP issues final report on explosion, saying that it will invest $1 billion at Texas City

December 22 Review panel public meeting in Texas City

April 4, 2006 Panel holds public meeting in Oregon, Ohio, near BP's Toledo refinery

January 16, 2007 Panel issues its final report in Houston, Texas

March 20 Chemical Safety Board publishes final report

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