(230a) Bp Texas City: March 23rd 2005

Prepared for presentation at 40th Annual Loss Prevention Symposium AIChE 2006 Spring National Meeting

Don Holmstrom, Francisco Altamirano, Johnnie Banks, Giby Joseph, Mark Kaszniak and Cheryl MacKenzie

U. S. Chemical Safety and Hazard Investigation Board

2175 K Street, NW, Suite 400

Washington DC 20037

Telephone 202-261-7633

Fax 202-974-7633

At approximately 1:20 p.m. on Wednesday, March 23, a series of explosions occurred at the BP Texas City oil refinery during the startup of an isomerization process unit. Fifteen workers were killed and about 170 others were injured. Many of the victims were in or around work trailers located near a blowdown drum and stack open to the atmosphere. CSB found that there was a sudden, geyser-like release of flammable hydrocarbon liquid and vapor from the blowdown stack. This release created a flammable vapor cloud, which ignited, causing as many as five explosions. There were multiple possible ignition sources on the ground, including idling vehicles, and the exact ignition source remains unknown.

The U.S. Chemical Safety and Hazard Investigation Board (CSB) deployed a team of investigators to BP Texas City to conduct a root-cause investigation immediately after the incident. This team examined blast patterns to determine the explosion origin; reviewed the design of the isomerization unit equipment; and examined plant safety and operating procedures, past accidents, maintenance procedures, and oversight and inspection. Investigators also reviewed the adequacy of applicable regulations and industry standards for the placement of temporary structures such as trailers in refineries. This paper will present the preliminary findings from the CSB investigative team regarding the technical and underlying causes of the incident and discuss the two urgent recommendations issued by the CSB stemming from the BP incident.

This paper has not been approved by the Board and is published for general informational purposes only. Every effort has been made to accurately present the contents of any Board-approved report mentioned in this paper. Any material in the paper that did not originate in a Board-approved report is solely the responsibility of the authors and does not represent an official finding, conclusion, or position of the Board.

Don Holmstrom

Investigator

US Chemical Safety and Hazard Investigation Board

2175 K Street, NW, Suite 400

Washington DC 20037

202-261-7682 (w)

202-821-3068 (m)

202-974-7607 (fax)

Don.Holmstrom@csb.gov

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