British Petroleum Texas City Explosion

This paper discusses some of the technical flaws that happened after the 2005 explosion at the BP refinery in Texas. The details given here would be helpful to the boards of directors of BP and other oil refining firms. It is worth noting that the explosion at the BP refinery in Texas was triggered by a number of engineering flaws. First, after being found, broken devices were not fixed. The warning system, splitter level transmitter, control switches, and sight level glass were among the systems that crashed. The majority of these errors were disclosed to management, but no action was taken. The failure of these systems made it hard for the personnel to know the level of the fluid in the tower, leading to the overflow. Secondly, employees failed to follow stipulated protocol when carrying out the startup process. For instance, the personnel used to fill the bottom of the tower until the level transmitter reads 99 percent instead of the stipulated 50%. Another failure occurred due to inadequate communication. For instance, the handout notes lack information on the level of the tower. The consequences of all these failures was resulting overflow of fluid from the splitter chamber, which caused the explosion. To prevent such failures from occurring in the future, organizations need to be more proactive in assessing their safety measures. Moreover, individuals need to be held liable for their actions.

Background

On March 23th, 2005, a number of explosions occurred at the BP refinery in Texas City. The explosions led to the dead of fifteen people in the facility and several others injured. Many of the victims were in or near the work trailers that were located near an atmospheric vent stack. By then, BP refinery in Texas City was the third largest refinery in U.S. and it covered 1,200-acre tracts of land. The plant was mainly used to generate diesel and jet fuels as well as gasoline. The facility had the capacity to process 460,000 barrels of raw crude oil per day. According to the company, the fire started in its isomerization unit. The isomerization unit was used to produce components that were used to boost the level of octane in gasoline.

On the fateful day, BP employees and contract workers were re-starting a unit that had been down for repairs. The process of restarting the unit involved filling distillation chamber with gasoline and hydrocarbons. However, on that day the alarms which were meant to indicate the level of gasoline malfunctioned. As a result, the tower overflowed with gasoline. The excess gas flowed into the back-up units, which also overflowed. This sent a geyser of gasoline into the air, which formed thick fumes. A truck which had been left running ignited this highly flammable liquid, causing a large exploitation.

Looking at the incident, it is clear that some engineering failures played a role in the accident. First, the malfunctioning of several systems in the splitter tower coupled with individual errors were the main cause of the explosion. The first system that malfunctioned is the splitter level transmitter. The splitter level transmitter was meant to measure the level of fluid in the tower. However, on the fateful day, it never measured the level of the fluid, making it hard for the personnel to monitor.

Another system that malfunctioned is the alarm system. According to Chemical Safety and Hazard Investigation Board (CBS) report “the redundant hardwired high level alarm” (P. 50) failed to send signals on the level of fluid in the raffinate splitter tower. It is worth to note that the splitter had two alarms: one was to send signals when the transmitter reading reaches 72 percent and the other one, referred as redundant hardwired high level alarm, was to send a signal when the transmitter reading reaches 78 percent. The failure by the redundant hardwired high level alarm to sound made the personnel to continue filling the tower. This caused the overfilling of the tower. The level sight class were not clear, which made them impossible to use. Together, the failure by these systems contributed to the overflowing in the splitter tower, which later caused an explosion when ignited by a nearby running engine.

Despite noting these engineering failures, the company failed to repair them. There are several reasons why the company never repaired its defective equipment and instruments. Chief among them being the refusal by local engineers to do the safety upgrades in the facility due to hesitance by BP to meet the costs (Mac Sheoin, 2010).

Engineering Failure

Based on the findings of CBS (2007), major engineering failures resulted in the explosion of BP refinery in Texas City. Some of the engineering failures that occurred include: Failure to follow the stipulated safety procedures during start up, failure to repair malfunctioning equipment and instruments, and poor communication between personnel (Okoh & Haugen, 2013).

During its investigation, Chemical Safety and Hazard Investigation Board (CSB) found out that key procedurals requirements were not followed during the fateful day. First, the key splitter equipment and instruments were not repaired. It is worth noting that BP had established key safety procedures that needed to be followed during start-up. One of the procedures was to carryout pre-start up equipment checks. This procedure was followed during the fateful day. The pre-startup check revealed a couple of things including the malfunctioning of the splitter level transmitter, level sight glass, and the control valve. Despite this findings, the malfunctioning instruments were not repaired. Various reasons were given for not carrying out the repair. For instance, the supervisor deemed it unnecessary to repair the splitter level transmitter due to time constraints. Worse still some procedures were carried out, but were not completed. For instance, a functionality check of alarms were carried out, but were not completed. Again, the reason for not completing the procedures were attributed to time constraints.

Poor communication was also another engineering failure as the operators of various systems failed pass information among themselves. When the operators who were working on the night shift noticed that the system was nearly full of hydrocarbons, they stop the process. By stopping the process, the prevented overflow from occurring. However, inadequate handout notes failed to notify the day-time operators of the situation in the tower. In fact, the report by CSB found that the night personnel left the premises earlier than the stipulated time. This further contributed to miscommunication with the day-time personnel. Due to inadequate handout notes, the day-time personnel re-started the startup process. This then lead to the overflow of the fluid in the tower.

Ethical analysis

The ethical framework that I will use in this section is the duty framework. Duty framework looks into duties and obligations that one need to fulfill. According to this framework, ethical conduct of an individual is defined by fulfilling the stipulated duties and doing the right thing. The aim of individuals, according to the framework, is performing the correct action. This framework applies to the explosion at BP refinery in Texas City because the main problem was caused numerous ethical lapses.

First, the personnel of the company failed to follow the company’s protocols in operating the tower. It is worth to note that the company had established procedures that needed to be followed when operating the tower. These procedures took into the account the standard safety measures. However, the personnel of the company frequently diverted from these procedures. For instance, the startup procedure requires that the bottom of the tower is filled until the level transmitter reads 50 percent, but the personnel of the company used to fill it until the level transmitter reads 99 percent. With such amount, the risk of overflowing was very high. Diverting from the standard safety procedure expose individuals within the facility at high risk. As the employees of the company, the obligation of the personnel was just to stick to the set protocols. Diverting from this obligation amounted to immorality. If the personnel had followed the required procedures, probably the explosion could have been avoided. Since the personal choose to divert from their obligation, we can say that they were immoral. The results of their immorality was dead, injuries and destruction of property.

The supervisors were also involved in these ethical lapses. The supervisors either neglected their obligations or performed them unsatisfactory. From the findings by the CSB, the supervisors were informed severally about the malfunctioning of several systems. For instance, they were informed about the malfunctioning of one of the alarm and the splitter level transmitter. However, due to various reasons, they never took the initiatives to repair them. Instead they allowed the startup procedure to proceed. This was despite the fact that they were carrying a dangerous procedures, which required perfection. Was it morally upright for the supervisors to allow the process to continue while fully knowing that the key systems were not functional? Absolutely, it was not. As the supervisor, they had the moral authority to stop the process and allow for the repair of the fault systems. If the supervisors had fulfilled their obligations, probably the accident could have been avoided.

The company can also be blamed for the explosion that took place. It is worth noting that it is the moral obligation of the company to assure every employee and other person within their premises of his/ her safety. Did the company assure its employees of their safety? From the look of things, the company did not. In fact the company had turned down several proposals for safety upgrades. For instance, the CSB investigation found that proposals to remove the blowdown drums were not implemented due to “cost considerations” (p.114). Failure to maintain the facilities at BP refinery had been attributed to an initiative that was initiated by Amoco: the previous owner of the Texas refinery. The initiate was meant to enable the company cut on operation cost. Together with lack of investments, this cost-cutting initiative made the plant vulnerable to disasters. According to CSB, BP targeted to cuts its budgets by 25 percent in 1999 and in 2005. In addition to cutting its budgets, the company had downsized operator training and staffing. All of these actions were meant to enable the company maximize profit. Although it is one of the objectives of companies, was it moral for BP to pursue profits at the expense of safety? Probably, it was not. The company ought to put safety first in its premises. In state of targeting to cut cost, the company should have targeted to improve its safety standards. If the company had performed its obligation of assuring safety to its employees, probably the explosion could not have occurred.

Recommendation

To avoid calamities such as the one that occurred at the BP refinery plant in Texas, it is recommended that everyone performs his or her duties. In the case, the calamity that struck BP refinery was mainly caused by failure by individuals to fulfill their obligations. Organizations also need to focus on safety measures within their premises. From the case, BP had not upgraded its safety systems for long. Moreover, maintenance of systems need to be taken seriously.

The engineering failures that resulted in the tragedy at BP refinery could have been avoided. First, the supervisors should have stopped the startup process once they have been informed about the malfunctioning of several systems. Their decision to allow the process to continue led to the overflow at the splitter tower. One of the main reason why the supervisors allowed the process to continue was due to the tight schedule they were working on. From the case, it appears that the supervisors were required to complete their duties within a specified period. In the future, the supervisors need to be given flexible work schedule, where they can adjust any activities. The organizational management need to increase the powers of supervisors to include the power to adjust schedules. If the work schedule was not tight, probably the supervisors could have postponed the process to a later period. The advantage of this is that it allows room for mistakes to be corrected. However, giving supervisors flexible work schedule would slow down the work in the company.

Maintenance of systems, instruments and equipment need to be carried out more frequently. Most of the systems that malfunctioned during startup process was mainly due to lack of maintenance. Organizations need to have a department, whose specific role is to check on the functionality of equipment. In case of a malfunctioning system, this department would carry out maintenance and repair work. For the department to be functional, it must be provided with enough resources including personnel and budgets. The advantage of having a department that is only concerned with maintenance is that it would reduce the number of malfunctioning systems and equipment. The disadvantage, is however, increased operational costs as additional budget will be required to run the department.

Safety upgrade procedures need to be mandatory for organizations. Authorities need to enact laws that makes it mandatory for organizations to carry out safety upgrades. For instance, laws can be enacted that forces companies to carry out safety upgrades annual. Companies that fail to abide by such laws need to be punished severely including withdrawal of their operational license. In the case, BP refused to carry out safety upgrade due to cost consideration. Making safety upgrades a mandatory would force companies to carry out the procedures no matter the costs. The advantage of this would be increased safety level in all organizations. However, enforcing such a law may be detrimental to investors as it increases the cost of operating a business.

Conclusion

There are many lessons that can be drawn from the case. First, individual errors, though small, are costly. The engineering failure at BP refinery in Texas was mainly caused by individual errors and negligence. Glaring mistakes were made throughout the startup process. Failure to address these mistakes resulted into the calamity that claimed the lives of 15 individuals while injuring a dozen others. From the case, one thing is clear: even the smallest mistake may turn to be costly. This then calls for individuals to be extra vigilant when dealing with such errors.

Another thing that is clear from the case is the importance of effective communication. Most of the problems in the case can be attributed to lack of effective communication. For instance, the night supervisor left the premises before properly describing the condition of the tower to the day-time supervisors. This lack of communication caused the day-time supervisors to restart the startup, although it had been stopped by the night-time supervisor due to overfilling.

Another lesson that can be obtained from the case study is the importance of companies fulfilling their corporate responsibilities. BP failed to fulfill one of its social responsibilities of providing safety to its employees. The employees working in their premises were constantly exposed to dangers. Yet, the company never took any initiative to address them. After the incident, the company swung into action. It has since implemented a lot of safety measures that are meant to protect individuals within the organization.

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