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 to imagine how anybody working there could have had any sense of personal security. Those individuals who spend most of their waking hours surrounded […]

INCIDENT Mechanical Failures and Misunderstandings 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 sensors installed in the tower, and […]

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 […]

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… On March 23, 2005, the raffinate splitter process was […]

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Preventative Action with Layers of Process ProtectionProtection for a process plant is built in layers. One layer may fail, but the next one won’t.  Maintaining personal safety, mechanical integrity, and process safety is a critical responsibility of anyone working in a process environment, and that responsibility takes many forms. From preventing small personal injuries to […]

“Safety does not happen by accident. It’s a continuousand collective effort of the industry.” Judith Hackitt CBE, FREng. Chair, UK Health and Safety Executive Anatomy of an Incident Safety continues to be a top concern affecting process operators worldwide.    Learning from process safety incidents and accidents is key to preventing these issues from ever […]

INCIDENT Bayer Crop Science: Running People Past Their Breaking Point One element that figured prominently in the 2008 explosion at the Bayer Crop Science facility in Institute, West Virginia, was a lack of operator training for the new DCS that had just been installed at the methomyl production unit. There were equipment problems to be […]

During the startup, malfunctioning equipment surfaced. But that sort of thing happens on every startup, right? In spite of the fact that the new DCS implementation was still incomplete, restart of the methomyl proceeded anyway, but there were many more equipment problems lurking within the unit. The residue treater vessel had been replaced during the […]

INCIDENT Buncefield: Neglecting the Upper Layers of Protection When the lower layers of protection are effective, upper layers may not get much attention. But then something fails and other weaknesses exposed. The Buncefield oil storage depot fire on December 10, 2005 provides an interesting examination of a fire at a site that most people probably […]

INCIDENT 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. How tightly does a flange have to be bolted to prevent vapor leaks on a condensate line pressurized to […]

INCIDENT Piper Alpha: A process hazard analysis of the human factor 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? On the night of July 6, 1988, five operators […]