Tool Test: The 5
What Went Wrong: Oil Refinery
When fuel spewed from the stack of a Gulf Coast facility in March, it
went looking for a spark. It found one.
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LOCATION: TEXAS CITY, TEXAS
EVENT: OIL REFINERY EXPLOSION
DATE: MARCH 23, 2005
For safety inspector Charles Ramirez, March 23 got off
to a good start. His team of specialized contractors
from Houston-based JE Merit had just polished off a
celebratory lunch held on the grounds of BP's massive
Texas City, Texas, refinery. The 1200-acre facility
processes up to 460,000 barrels of raw crude oil a day,
and the contractors had just wrapped up their part in its
complicated, nine-week "turnaround," or scheduled
maintenance cycle, accident-free. When the lunch hour
ended, Ramirez's colleagues returned to their offices in
temporary trailers while he left to run a final safety
What he didn't realize as he hustled across the yard
was that, just 100 ft. behind him, the huge steel
isomerization unit was being restarted after two weeks
spent offline. The "isom" unit, which boosts the octane
level of gasoline, was about to cause the deadliest U.S.
refinery disaster in a decade.
The most dangerous time for an oil refinery isn't when it
is running, but when it's in transition. During a refinery
turnaround, some 30,000 separate procedures are
performed. Dozens are required to move volatile
contents safely out of and into position when the isom
unit is coming back on line.
As workers restarted a component of the unit, abnormal
pressure built up in the production tower, and so three
relief valves opened to allow highly volatile gasoline
components to escape to the 10 x 20-ft. "blowdown"
drum. But so much fuel flooded into the drum that its
capacity was rapidly exceeded. Liquid and vapor shot
straight up the 113-ft. vent stack, into the open air.
Witnesses saw a cloud of vaporizing fuel geyser out of
the stack and cascade to the ground. One person
reported hearing a desperate call crackle over a
handheld radio. "What is this? Stop all hot work! Stop
all hot work!"
But too much equipment was running to shut it all
down. As vapors were sucked into its engine, an idling
pickup at the base of the tower began to rev up,
according to witnesses. A worker raced to turn it off, but
he was too late. Somewhere in the cloud of fumes,
perhaps in the truck's engine, a spark touched off the
gas and ignited a firestorm.
HOW A REFINERY WORKS
Refineries separate raw crude oil into its various
components, called fractions, by taking advantage of
the distinct boiling point of each. The process begins
with fractional distillation, when crude oil is heated to
about 720 F. Hot liquid and vapors enter a distillation
column where the vapors cool as they rise, condensing
on collection trays at different heights. These liquids,
such as naphtha and kerosene, may then be diverted to
other units for further processing. Each fuel is made of
a distinct chain of hydrocarbons, and manipulating
these molecules produces different petroleum products.
Cracking units and cokers break large chains into
smaller ones to create medium-weight and heavy fuels.
Alkylation units combine short chains, forming mainly
aviation gasoline. Isomerization units rearrange the
structure of molecules to turn naphtha into high-octane
Spring is typically when refineries buzz with
maintenance work to prepare for summer's heavy fuel
demand, and that morning workers from a variety of
contractors were in the vicinity of the isom unit. Across
the street, a contractor overhauling a turbine at a
cogeneration plant heard a pair of distinct explosions-one quiet, one loud. He instinctively checked for
shrapnel. "I looked up, and the sky was clear, so then I
looked over at the guys on the scaffolding," he says,
referring to men working near the isom unit. "They were
When a cloud of highly flammable material is ignited,
two events occur almost instantaneously, producing two
audible blasts. First, an initial flash consumes all
available oxygen, creating a giant vacuum. Once the
suction brings in fresh oxygen, the combustibles
explode into a well-fueled inferno that flings a shock
wave in front of it.
At close range, this supercompressed wall of air is
actually visible as it rockets outward at more than 1000
ft. per second. Ramirez says he saw it just before it
blew him to the ground. But his colleagues would have
had no warning before it slammed into the flimsy
frames of their trailer offices. Eleven of Ramirez's
teammates were killed instantly by the blunt force of the
shock wave. A fireball then rolled over the shattered
trailers and melted nearby porta-potties.
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Investigators now suspect there may have been as
many as five separate explosions, in rapid succession-including one directly beneath the trailer Ramirez had
Almost a mile from the explosion, BP retiree Shera
Shurley was watching TV in her mobile home when its
windows blew in. She ran outside to escape. Standing
in her driveway, she looked at the swirling black cloud
climbing into the sky. There was no sound, she
remembered later, not even a siren.
Texas City's emergency services crews began rolling
moments after the isom unit shattered. BP maintains its
own fire brigade, and has a mutual response plan with
the brigades of the other two Texas City oil refineries,
owned by Marathon Ashland Petroleum and Valero.
They get plenty of practice: According to Texas City
Fire Department chief Gerald Grimm, BP had 30 fire
alarms in 2003 and 27 in 2004, although he says this
was no more than other plants of a similar size.
Soon 75 local, regional and industrial emergency
response units surrounded the site, where walls of
water erupted from "monitors"--strategically located
water cannons, each capable of hurling up to 1500 gal.
per minute. The thwack of rotors could be heard
pounding through the thick smoke overhead. First on
scene were news choppers, followed by a Life Flight
helicopter from Memorial Hermann Hospital in Houston.
Just 20 minutes after the accident, the airspace had
become so crowded that the Federal Aviation
Administration declared a no-fly zone 3000 ft. high and
3 miles wide.
At the end of 1 hour, the fire had been contained, and
within 2 it was nearly out. Only then did the tally sink in:
15 dead, over 100 injured. Of the fatalities, more than
two-thirds worked for Ramirez's team, and had nothing
to do with the unit that exploded.
HOW THE ACCIDENT HAPPENED
According to the Chemical Safety Board, computerized
records from the control system equipment indicate
pressure inside the production tower (1) rose rapidly
from 20 psi to 60 psi. This triggered three pressurerelief valves (2) to open for 6 minutes, discharging
enough fuel into the blowdown drum (3) to overwhelm
the system. Petroleum could not be recycled back
through the refinery (4) quickly enough, forcing liquid
and vapors up the 120-ft. stack (5). As fuel settled to
the ground, it ignited in a blast strong enough to rip the
roof off a benzene storage tank 300 yards away.
Investigators discovered that a 6-in. drain leading to the
plant sewer (6) had been chained open. Fumes
traveling under the refinery may have fueled one of
what is believed to have been five explosions.
Texas City knows industrial facilities and their dangers.
Often referred to as "Toxic City," it is home to four
chemical plants and three refineries. The sprawling BP
complex, built in 1934, is the third largest of 149
petroleum refineries nationwide. At night it glows like a
forested landscape of steel Christmas trees, strung with
flickering safety lights. Since records were kept in 1971,
there have been at least nine other accidents at the
refinery that injured or killed workers, but the explosion
on March 23 was by far the most destructive.
In the weeks following the accident, BP's operations
came under intense scrutiny. Blowdown drums are a
common feature at refineries, as are towers used to
release evaporating gases. Most tower vents, however,
include a flare system--a sort of pilot light that ignites
potentially hazardous vapors as they funnel out. In
1992, the Occupational Safety and Health
Administration (OSHA) mandated that the Texas
refinery switch to a flare system. Amoco, which merged
with BP in 1998, appealed and OSHA withdrew the
request. The refinery continued to use stacks that
allowed gases to escape.
Former BP employee Wydell Dixon says she has seen
lightning ignite vapors wafting out of the isom stack.
Whether a flare would have ultimately prevented the
explosion is questionable given the quantity of liquid as
well as vapor involved, says Don Holmstrom, an
investigator with the U.S. Chemical Safety and Hazard
Investigation Board (CSB), but "a flare does provide an
extra layer of safety."
The location of the temporary trailers also has been
questioned. BP rules allowed trailers within 350 ft. of
refining units--at least two were within 150 ft.--provided
they receive site-specific analysis. (BP has since
mandated trailers be located at least 500 ft. away.)
Some other refiners take the additional precaution of
requiring nonessential personnel to be evacuated when
units like the isom are being brought on line. According
to BP spokesman Hugh Depland, BP has no such
OSHA and CSB are both conducting investigations.
According to Holmstrom, the CSB is looking into such
factors as whether the fuel was heated too quickly,
which may have led to the pressure spike in the tower,
and whether all outflow valves had been working
properly. An official report isn't expected for up to a
year. BP is also conducting an investigation. Says
Depland, "It would be inappropriate to comment on an
investigation that's ongoing."
Ramirez, who survived the explosion, was left
wondering if an evacuation order that might have saved
his colleagues was ever passed along. His boss,
Eugene White, might have known, but he died when his
trailer office was demolished by the shock wave.
A week after the accident, workers wearing a who's
who of petro industry caps gathered between shifts in
the Texas Tavern. One said a buddy had quit; he'd
been having lunch with his wife in a minivan when the
plant blew right in front of them. Someone else noted
the date: exactly a year since an explosion in another
unit at the plant. Soon the bar grew crowded with men
drinking longneck Buds and shooting pool. Down the
street at the refinery, skeletal cranes, shrouded in fog,
continued to pick over the rubble.
Tom Price is a freelance writer.
T.J. Aulds is an editor for the Galveston County Daily
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Anatomy of Disaster
By Jim Malewitz, Mark Collette and Lise Olsen | March 22, 2015
10 years later, the blood lessons of Texas City haven’t taken hold at refineries.
! " “Our policies and procedures are written in blood.” After Texas City blast, are refineries
The geyser of toxic, highly flammable chemicals accidentally unloosed at the BP refinery in Texas
City on March 23, 2005, would later be estimated at 7,600 gallons. All it took was a spark from a
passing truck to trigger one of the worst oil refinery tragedies in U.S. history.
A chain of explosions obliterated nearby office trailers, killing 15 people inside. About 180 others
were burned, maimed or otherwise injured.
Working in the largest trailer, David Leining heard a weird sort of banging and went to look out
the door. An explosion pushed him to the ground. A fireball swept over the building as Leining
lay trapped under a pile of rubble and an unconscious co-worker. Able to move the fingers of his
left hand, he tapped his communicator to issue a distress signal. “I’m still here,” he said into his
Mayra Beltran, © Houston Chronicle
Dave Leining, who was badly injured in the 2005 BP refinery explosion, stands outside of the refinery. Watch
our interview with Leining.
Safety is often purchased through death and injury. For years afterward, the Texas City explosion
was scrutinized, producing volumes of findings and recommendations on how best to prevent
more men and women from dying in oil refineries.
But 10 years later, there is little evidence that the 15 lives lost on that March day bought much of
anything: The death toll at U.S. refineries has barely slowed, evidence assembled in a joint Texas
Tribune/Houston Chronicle investigation shows.
At least 64 energy company employees and contractors were killed in the decade before the 2005
Texas City blast. At least 58 have died in the 10 years since, according to data compiled from
newspaper archives, Occupational Safety and Health Administration records, lawsuits and union
The Department of Energy has tracked nearly 350 fires at refineries in the last eight years —
almost one every week. Refinery workers have gone on strike demanding, among other issues, an
increased emphasis on safety.
And in what some see as the insult added to injury, last year temporary tents and trailers were
again erected at the Texas City plant close by the unit that leaked in 2005, on the very ground
where people died.
In an inherently dangerous industry where money and time can sometimes trump safety, the
blood lessons of Texas City have not fully taken hold.
###“Vulnerable to Catastrophe”
All 15 contractors killed that warm afternoon were working with Leining and other BP employees
in or near the group of office trailers that BP had placed on refinery grounds to house workers
during a turnaround — industry lingo for shutdowns, maintenance and startups — the most
dangerous time at a refinery.
Most had just returned from a safety lunch elsewhere at the refinery. Without warning, operators
tried to restart a nearby unit that boosts the octane of gasoline. A stream of flammable liquids
shot from an obsolete vent stack, triggering a series of massive explosions that ripped apart the
refinery’s 1,200 acres and shook nearby homes.
In its two-year investigation, the U.S. Chemical Safety and Hazard Investigation Board (CSB), an
independent government watchdog, traced the disaster’s beginnings to decisions made long
before the orange-red flames towered above the neighborhoods of Texas City.
CSB Safety Video Anatomy of a Disaster
In its investigation of the accident, CSB created this animation depicting what went wrong that caused the
explosion in Texas City.
“Simply targeting the mistakes of BP’s operators and supervisors misses the underlying and
significant cultural, human factors, and organizational causes of the disaster,” said the
introduction of the 2007 final report.
Years of cost-cutting, poor worker training and a safety culture with “serious deficiencies” left the
plant “vulnerable to catastrophe,” but company leaders ignored the warning signs, the report
The board, and experts involved in a slew of other studies, aimed their recommendations at BP
and the industry at large. They wanted refineries to stop putting people in harm’s way
unnecessarily, specifically by keeping occupied trailers and temporary tents or buildings away
from dangerous areas.
They said plants needed to upgrade or replace outdated technology, like the stacks that
overflowed. They also recommended developing ways to identify “leading and lagging indicators”
of industry safety. And the CSB urged companies to start getting workers more involved in safety
panels to identify small problems before they turned catastrophic.
Taken together, the recommendations were supposed to save lives.
In the decade since the Texas City disaster, the problems that triggered it continue to pop up in
probes of subsequent accidents, said Daniel M. Horowitz, a longtime top CSB official.
Tesoro’s Puget Sound refinery, just north of Seattle, saw the deadliest accident of the past decade.
On April 2, 2010, a damaged heat exchanger ruptured, spewing 500-degree gases that engulfed
the unit in a toxic orange cloud that killed seven workers. The death toll was so high, the CSB
concluded, in part because a supervisor failed to evacuate unneeded staff during the hazardous
maintenance procedure. Though just one operator could do the job, the supervisor standing near
the equipment asked five others to help.
The investigation also found “several indications of process safety culture deficiencies” at the
refinery. “Refinery management had normalized the occurrences of hazardous conditions,”
including frequent leaks from the heat exchangers.
A similar scenario played out two years later at a Chevron refinery in Richmond, Calif. There, 19
people were “all too close to the hot zone” of an active refinery unit, Horowitz said, when it leaked
flammable gas oil that vaporized into a cloud surrounding the workers. Eighteen people escaped
before the cloud burst into flames. The other — a firefighter donning a protective suit — later
trudged through the flames to safety. The toxic cloud eventually spread to surrounding
neighborhoods in the suburban county near San Francisco.
The CSB concluded that Chevron failed to properly maintain its equipment and that its “decision
making encourages continued operation of a unit despite hazardous leaks.”
Despite those deaths and near-disasters, industry regulators say the industry has taken major
strides toward safety amid increased scrutiny ...
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