The BP Texas City Accident Report

Thanks to Larry O'Brien of ARC for sending me this link: US Chemical Safety Board's animation of the events that led to the explosion at BP's Texas City refinery It is about 6 minutes long, and sometimes it loads slowly. Persevere. It is worth it. This video takes you from the start to the end of the incident, and clearly explains what caused it. It appears to be a combination of bad control system design, poor instrument maintenance, multiple operator errors, and if you work around refineries, you know how easy it is for something like this to happen. There are lots of questions generated by the report of the CSB...they come up repeatedly in the video:

*Why did they use a level gauge that only measured up to 10 feet and could not indicate overcharging? *Why did the High High level alarm fail? *Why was there not a Safety Instrumented System on this tower and the entire ISOM unit? If there was, why did it fail? *Why did all the automatic systems fail? *Why did the operators do the things they did?

There is no way this accident should have happened. Stuff happens. Instruments fail. Valves fail. But what happened here is that the operators had a "headspace" failure. They didn't follow the book, and everything they did appears to have been in panic mode. If they had stopped the process at any time during the leadup to the liquid vent, it is likely that they would not have died. You wonder if operators who were intimately involved with their process for years and years, and who were highly trained and resourceful (the kind of operators we used to have in the 70s and 80s) would have done the sensible thing and shut it down. But that didn't happen then either. The excuse doesn't wash anymore that they panicked and it just happened. We have had a generation of investigation and new learning since Bhopal. We know how to prevent an accident like this. Why didn't we? Walt