BP Texas City Refinery - process safety accident causation analysis

“On 23 March 2005, the US Chemical Safety and Hazard Investigation Board (CSB) found itself with a dilemma. The biggest explosion in 15 years had just occurred at the BP Refinery in Texas City, with multiple fatalities, missing and injured. All investigators were assigned to other important cases. The CSB management decision and will of the board chair was to put all other cases on hold and assemble a team to investigate this tragic incident in Texas City. This team would mount the most complicated and far-reaching investigation ever undertaken by the CSB since it was founded in the late 1990s.

As the team leaders returned from Texas City to Washington, they had many mechanical clues and facts to report as to what had caused this event. For months, I asked myself how this could have happened at a company like BP. I had been impressed with BP’s process safety professionals and had heard presentations touting their ideas about process safety values. The mechanical and human conditions that existed at the moment of the explosion certainly explained how it happened; how, but not why.

 Members of the team were already familiar with Andrew Hopkins’ book about the disaster at Longford. Then, shortly into the investigation, Hopkins published Safety, Culture and Risk. It became apparent that the situation at BP reflected a failure to learn and transfer lessons from what had occurred at Longford years earlier.

Impressed by his book Safety, Culture and Risk, we invited Hopkins to the CSB to discuss the cultural conditions and the facts of the BP event. He was instrumental in teaching our staff about the links between failure to learn, or even recognise, mistakes as part of the culture of risk prevention and safety.

During speaking engagements on the importance of culture and the BP lessons learned, I have recommended Hopkins’ books more than any others. Hopkins is a true teacher in the mode of all good teachers. He presents real situations and allows the reader to realise that mechanical or procedural failures are only the base of the problem. In actuality, there are a series of failures in management, budgetary priorities, and corporate values that set every stage preceding the unfolding of tragedy. Hopkins has become the pre-eminent voice in making the upward journey through the rubble of disaster to find those links with management decision-making that set the risk wheel in motion decades prior to an event.

Unfortunately, many companies, not just large multinational companies like BP, are either “risk blind” or in “risk denial” that devastating risk exists in their own operations. Maybe Hopkins’ masterful teaching will remove the blinders and disbelief as he presents this story of the tragedy at BP which took 15 lives, maimed countless others, and cost BP billions of dollars and much of its reputation as an industry process safety leader. The trick here is that executive managers must read the books and reports that will help to remove the blinders and restore their sight so that they may recognise their own failure to learn.”

Carolyn Merritt, Chair of the CSB at the time of the BP Texas City Refinery inquiry

Failure to Learn: the BP Texas City Refinery disaster