April 11, 2007 | Mark Paradies

Instrumentation Failures at BP Texas City

After reading the final Chemical Safety Board report on the BP Texas City Refinery explosion, it is obvious that there were almost too many problems to count. Management problems, a non-existent safety culture, procedural non-compliance… the list goes on and on. Take a look at everything we teach and emphasize during a 5-Day course, and none of that was done.

Just trying to get your arms around the problems is tough. I decided to take a subset of the problems and take a look at only the issues related to instrumentation and equipment malfunction. Even this had an enormous amount of data involved, and trying to perform an accurate, comprehensive root cause analysis with the information presented in the report is not possible. However, it is obvious that equipment problems made up a large number of causal factors in this accident.

This incident is an extreme example of allowing equipment failures to run your facility or business. Many of the actions taken by operators, supervisors, and the management team were dictated by the operational state of the equipment and instrumentation. Procedures were changed on the fly because the entire process did not work as it was initially designed. Actions were taken by operators and supervisors based on faulty indications. Some actions were not taken at all because some indications were never present. Work orders were not generated for known problems, and known problems were accepted as normal.

Many of the equipment problems were actually minor in nature. Fixing some of them would have been easy, but many reasons were given for allowing them to exist:

  • Not enough money
  • Not enough time (schedule pressure)
  • People were too busy
  • Work-arounds were already in place
  • Work order system was ineffective

Yet, none of these were that difficult to fix. They were allowed to happen, with full knowledge of the issues at all levels, from the operators up through senior management.

At the TapRooT® Summit later this month, I will be giving a presentation on how “Minor Mechanical Failures Lead to Major Accidents.” A good portion of this discussion will pull examples from the BP refinery explosion. Join in the discussion, and see how easy it is to get yourself into these types of situations. Even better, see how easy it can be to keep yourself out of these situations.

Root Cause Analysis
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