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The US Chemical Safety Board posted an updated video of the explosion and fire at the BP Texas City Refinery that occurred 15 years ago. Watch it below…
Have you solved all these types of human performance problems at your facility?
Perhaps you need help. Try reading Stopping Human Error or attend our course coming up on September 15-16, 2020 in Knoxville, TN. You get the book with the course.
What’s left out of the video? These are the things I remember from the multiple investigations that were performed…
1) Multiple procedures that didn’t agree and none of which were accurate or being followed.
2) The local level indicator (a sight glass) was darkened and not readable.
3) The lone operator left in charge (who was “qualified”) had never performed an ISOM startup before.
4) Hazop recommendations to review the blowdown system for adequacy and replace it if necessary had not been implemented in 10 years.
5) Blowdown drum did not meet Amaco’s or BP’s engineering standards.
6) A project to replace the inadequate relief system (remove the blowdown drum and hook process into an adequate flare system) was canceled to save $100,000.
Mark
In relation To human performance:
-Safety Critical Communication -Shift Handover did not work
-Performance Shaping Factors – Managing Fatigue and shift work did not work,
-Organisational learning- They had similar incident few years back, they did not learn