Articles

How Mechanical Failures and Procedure Misunderstandings: BP Texas City Refinery

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…

Focusing on the Wrong Safety Metrics: BP Texas City Refinery

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 …

A Maintenance Process Hazard Analysis: Piper Alpha Incident

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.

A Process Hazard Analysis of the Human Factor: Piper Alpha Incident

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?

Neglecting Layers of Protection: Buncefield Incident

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…

How Many Units Can Operators Monitor on One Screen?: Buncefield Incident

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, …

Failure of Process Safety Management on Every Level: Piper Alpha Incident

Part of the problem of trying to examine this event is its complexity. The specific series of events that turned a simple process safety incident into a disaster began with a decision to change the mode of production on the platform. A mix of maintenance issue…
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