Texas City Refinery: Importance of Safety Mangement

On March 23, 2005 at the Texas City refinery, a geyser of flammable hydrocarbon liquid and vapor erupted from a blowdown stack, which ignited creating a huge fire. The result: 15 fatalities and 180 injuries. All the individuals who died were in or around a gro…

Mechanical Failures and Human Factors

On March 23, 2005, the raffinate splitter process was being restarted after a turndown. The unit had been shut down February 21 so that the tower could be drained, purged, and steam cleaned to remove residues. Apparently nothing had been done to check level se…

Texas City Safety Culture

When the corporate culture ignores safety, what do you think about going to work each day? Looking at the 2005 Texas City refinery fire with the benefit of nearly 10 years of reflection and much discussion of what was going on at the facility, it is difficult …

Three Human Factor Patterns in Safety Incidents

Virtually every safety incident has a human element in one form or another. They follow three basic patterns: Design Decisions, Operator Training, Maintenance Practices and Human Factors.

Piper Alpha: A Maintenance Process Hazard Analysis

Among the physical causes of the initial process safety incident, maintenance should be at the top of the list. That basic safety management failure struck the first match.

Piper Alpha: Maintaining a safe work environment

Operator and supervisor errors escalated a process safety incident into a disaster. Could people better trained in oil and gas safety procedures have prevented it, or stopped the process safety incident once the fire stated?

The Rocky Relationship between Safety and Security

Best practices for avoiding common cause failure and preventing cyber security attacks in Safety Systems.

Common Denominator of Economic Effect

The common denominators of most major process safety disasters is that they seem to happen in facilities where people are not well trained and they work in units where equipment and systems are not always in the best condition. Much of that is probably cost dr…

Examining the Buncefield Layers of Protection

Buncefield: Neglecting Layers of Protection In a facility that generally runs with a high degree of stability, layers of protection that don’t get used can form holes, both figuratively and literally. Examining the Buncefield fire in 2005 could be a te…

Buncefield: Operator Overload

Operators didn’t see the tank overfilling. Part of the problem was mechanical, but part was inattention. How much can we expect from individual operators? The Buncefield fuel depot fire was somewhat akin to leaving the tub filling in the upstairs bathroom, …
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