The Baker Panel Report - ABSA

(3) The raffinate splitter tower had a history of abnormal start-ups that included recurrent high liquid levels and pressures.(4) On March 23, 2005, the blowdown drum on the isomerization unit vented highly flammable material directly into the atmosphere.Since its construction in the 1950s, the drum had never been connected to a flare. Amoco, the previous owner of the refinery, hadreplaced the blowdown drum and stack in 1997 with identical equipment. Amoco refinery safety standards recommended connectingthe drum to a flare when such major changes were undertaken, but the drum was never connected to a flare system.(5) Between 1995 and March 23, 2005, there were four other serious releases of flammable material from the isomerization unit’sblowdown drum and stack that led to ground-level vapor clouds. Fortunately, none ignited.(6) In 1992, OSHA cited a similar blowdown drum and stack at the refinery as unsafe because it vented flammable material directly intothe atmosphere. However, OSHA dropped the citation, and the drum was never connected to a flare system.C. OSHA’S Investigation of the Texas City AccidentOSHA, the federal agency that oversees workplace safety, investigated the Texas City accident. On September 22, 2005, BP agreed to a record$21 million fine to settle more than 300 violations that OSHA identified. Under the terms of the settlement agreement, BP also agreed toreinforce health and safety training given to refinery workers, to hire both a process safety management expert and an organizational expert toreview conditions at the refinery, and to make recommendations for correcting deficiencies.D. BP’S Investigation of the Texas City Accident—the Mogford ReportBP formed a fatality investigation team shortly after the Texas City accident. The team consisted of both BP employees and contractors,including a BP Group executive (John Mogford) who led the team, three salaried employees from the Texas City refinery, three hourly workersfrom the Texas City refinery, and three persons from other BP businesses.The team’s tasks were to investigate the circumstances surrounding the accident, determine the root causes, make recommendations toprevent a recurrence, and identify lessons learned. During its investigation, the team used the BP root cause methodology supplemented withguidance from the CCPS.On May 17, 2005, the BP team issued its interim report, which presented an analysis of the events leading up to the accident, identifiedprovisional critical factors for the accident, and made early recommendations to prevent a recurrence until a root cause analysis could becompleted. After more than six additional months of gathering, researching, and analyzing other evidence and information, the team issued itsfinal report—the Mogford Report—on December 9, 2005.According to the Mogford Report, the accident would not have happened, or would have had a significantly lower impact, but for four criticalfactors:(1) loss of containment,(2) raffinate splitter start-up procedures and application of knowledge and skills,(3) control of work and trailer siting, and(4) design and engineering of the blowdown stack.Precipitating Events for the Panel’s Assessment and Report C 18