CSB Investigation of the Explosion and Fire at the BP Texas City Refinery on March 23, 2005
On March 23, 2005, at 1:20 p. m., the BP Texas City Refinery suffered one of the worst industrial disasters in recent U. S. history. Explosion and fire killed 15 people and injured another 180, alarmed the community, and resulted in financial losses exceeding 1.5 billion. The incident occurred during the startup of an isomerization (ISOM) process unit when a raffinate splitter tower was overfilled, resulting in a release of hydrocarbon to atmosphere. A flammable vapor cloud formed, found an ignition source, and exploded. The fifteen individuals killed were in and around trailers placed near the unit.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. Investigators analyzed the human factors issues, safety system deficiencies, and organizational culture of the refinery. And, due to the significance of the disaster, the CSB examined BPs safety performance beyond the Texas City refinery. This paper will present a summary of the CSBs findings regarding the underlying human factors issues and organizational causes of the incident and discuss some of the resulting recommendations issued by the CSB.Disclaimer: This paper has been prepared for general informational purposes only. It represents the individual views of the authors and all references, conclusions or other statements regarding CSB investigations are limited to information that is already in the public domain. Furthermore, this paper is not a product of the Board and its contents have not been reviewed, endorsed, or approved as an official CSB document. For specific and accurate information on completed investigations, please refer to the final published investigation report (no. CSB2005-04-I-TX), by going to the CSB website at www. csb. gov and clicking on the specific report desired under Completed Investigations. To the extent this paper includes statements about the conclusions, findings, or recommendations of the Board, such statements come under the general prohibition in 42 U. S. C. 7412 (r) (6) (G).
Organizational culture safety culture human factors process safety investigation explosion
Don Holmstrom Mark Kaszniak Cheryl MacKenzie
U. S. Chemical Safety and Hazard Investigation Board 2175 K Street, NW, Washington, DC 20037-United States
国际会议
The 1st International Conference on Risk Analysis and Crisis Response(首届风险分析与危机反应国际学术研讨会)
上海
英文
18-23
2007-09-25（万方平台首次上网日期，不代表论文的发表时间）