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BP Texas City Refinery: The Inevitable Cost of an Incident

INCIDENT How long can management force a plant to produce without necessary resources before an incident occurs? This unfortunate incident is familiar to many working in process industries and especially in the United States where an extensive investigation and its associated report has been used to illustrate the importance of Process Safety Management. On March […]

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Instrumentation First Line of Defense

AREA OF ANALYSIS Field Instrumentation—The First Line of Defense The process control system and safety instrumented system (SIS) both depend on field instrumentation to monitor process conditions. Modern sensors are highly sophisticated and very reliable. When used in the context of a well thought out system, they watch for subtle changes in conditions that are […]

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Bayer Crop Sciences: Equipment Problems Share the Blame

Previous Next INCIDENT Equipment Problems Share the Blame: The Bayer Crop Science Incident For better or worse, the existing supporting piping and ancillary equipment was left in place. One element that had been a problem for some time was the vent condenser piping on top of the vessel. The decomposition reaction would generate flammable gas that […]

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When Operators Run without Training: The Bayer Crop Science Incident

Can operators be expected to learn a new control system by simply watching other units running a different processes? The cost of saving money by eliminating training. Prior to the 2008 incident, the methomyl unit at the Institute facility had been shut down for two major equipment upgrades: the DCS had been replaced and the […]

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Human Factors Elements

Technical and physical solutions are only part of the larger equation since human operators can have a huge impact on operational safety.  Research from the British regulatory body Health and Safety Executive (HSE ) has identified what it considers to be the top-ten factors involving people, primarily the ones working in the control room. Some […]

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Under Pressure to Start Production: The Bayer Crop Science Incident

Under pressure to get production going, the plant had to resume production without adequate preparation. One key omission leads to the explosion. Company procedures called for a PSSR (pre-startup safety review) to be run for the methomyl unit before it was restarted. This was a complex process that was supposed to prove that all the […]

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eGuides

When disasters like the Sayano–Shushenskaya hydroelectric power station collapse in Khakassia, Russia, occur, it is difficult to get past the overpowering tragedy of 75 people losing their lives and 40 other sustaining injuries. The only way to draw positiv… Having a safety plan in place is not enough to guarantee safety of manufacturing automation operations. […]

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eGuides

When disasters like the Sayano–Shushenskaya hydroelectric power station collapse in Khakassia, Russia, occur, it is difficult to get past the overpowering tragedy of 75 people losing their lives and 40 other sustaining injuries. The only way to draw positiv… Having a safety plan in place is not enough to guarantee safety of manufacturing automation operations. […]

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Williams Olefins Incident: Learning to Conduct a Proper Management of Change

It just seemed like a good idea. Instead of running two reboilers at the same time and shutting down the process when they fouled, why not operate one at a time and when one fouls, start up the other. Then you can perform maintenance on the off-line reboiler. In this way, the process can keep […]

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Normalization of Deviance: Carbide Industries Incident

When the EAF exploded at Carbide Industries, March 21, 2011, the two fatalities were operators working in the control room only 12 ft. from the lid of the furnace. The explosion was violent enough to throw chunks of debris and molten carbide through a window with dual-pane, half-inch thick glass and wire reinforcing. But this […]

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Having a safety plan in place is not enough to guarantee-Slide

INCIDENT Having A Safety Plan In Place Is Not Enough Of A Guarantee  Safety incidents rarely occur as the result of a singular independent occurrence, but rather result from a series of events and/or bad decisions that lead up to the accident. Over time, when small, overlooked detailed issues are addressed and/or fixed, accidents further […]

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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. How tightly does a flange have to be bolted to prevent vapor leaks on a condensate line pressurized to 650 psi? Most people that have been […]

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How Mechanical Failures and Procedure Misunderstandings: BP Texas City

The raffinate splitter tower had no functioning level sensors—overflow was the hazardous result. 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 […]

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Williams Olefins Incident: this is part 2 of a 4-part series

INCIDENT Williams Olefins Incident- The Day Multiple Safety Errors Led to a Major Chemical Plant Blast  Part 2: The errors that should have been avoided  On June 13, 2013, the Williams Olefins chemical plant in Geismar, Louisiana blew up, killing two workers and injuring 167. The main cause of the explosion was an inability to […]

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