This study discusses some of the engineering flaws that happened during the 2005 explosion at the BP refinery in Texas. The information supplied here will be valuable to the boards of directors of BP and other oil refinery firms. It is worth noting that the explosion at the BP facility in Texas was caused by a number of engineering flaws. First, corporate irresponsibility in the form of failed automated infrastructure and a lack of administrative communication had a significant impact on this avoidable calamity. The majority of these problems were reported to the administration, but no action was taken. Failure of these systems was caused by a lack of protocol. Companies with operations such as BP should ensure practicing of protocols to adequately control system failures. Their employees failed to follow stipulated protocol when carrying out the startup process. For instance, the personnel used to fill the bottom of the tower until the level transmitter reads 99 percent instead of the stipulated 50%. Another failure occurred due to inadequate communication. For instance, the handout notes lack information on the level of the tower. The consequences of all these failures was resulting overflow of fluid from the splitter chamber, which caused the explosion. To prevent such failures from occurring in the future, organizations need to be more proactive in assessing their safety measures. Moreover, individuals need to be held liable for their actions.
Background
On March 23th, 2005, several explosions occurred at aBP refinery for petroleum in Texas City, Texas. The spontaneous combustion of a hydrocarbon vapor cloud led to the preventable deaths of 15 employees along with injuries to several others.. Many of the victims were in or near the work trailers that were located near an atmospheric vent stack. By then, BP refinery in Texas City was the third largest refinery in U.S. and it covered 1,200-acre tracts of land. The plant was mainly used to generate diesel and jet fuels as well as gasoline. The facility had the capacity to process 460,000 barrels of raw crude oil per day. According to the company, the fire started in its isomerization unit. The isomerization unit was used to produce components that were used to boost the level of octane in gasoline (Blumenthal, 2005). It is important to boost the level of octane. The higher the octane level the less the volatility. Low octane fuel is more flammable or hazardous. Boosting the octane levels improves the refining process resulting in more stable gas.
On the fateful day, BP employees and contract workers were re-starting a unit that had been down for repairs. The process of restarting the unit involved filling the distillation chamber with gasoline and hydrocarbons. However, on that day, alarms to indicate the level of gasoline malfunctioned, causing the distillation tower to overflow with gasoline. Back-up units suddenly filled with gasoline, spewing raw gasoline hundreds of feet into the air. A truck which had been left running ignited this highly flammable liquid, causing a large explosion.
Looking at the incident, it is clear that some engineering failures played a role in the accident. First, the malfunctioning of several systems in the splitter tower coupled with individual errors were the main cause of the explosion. The raffinate splinter tower is where isomerization takes place, it involves pumping highly flammable fluid into the tower. The first system that malfunctioned is the splitter level transmitter. The high level alarm for the blow down drum didn't sound on the fateful day making it hard for the personnel to monitor the level of fluid in the tower.
Another system that malfunctioned is the alarm system. According to Chemical Safety and Hazard Investigation Board (CSB) report “the redundancy in the hardwired high-level alarm” (P. 50) failed to send signals on the level of fluid in the raffinate splitter tower. Once the fluid reaches a certain level, there is an alarm system that signals the level. It is worth to note that the splitter had two alarms: the difference between the two is the level at which they go off. One was to send signals when the transmitter reading reaches 72 percent. The second one referred to as redundant hardwired high-level alarm, was to send a signal when the transmitter reading reaches 78 percent. The failure by the redundant hardwired high-level alarm to sound made the personnel to continue filling the tower. This caused the overfilling of the tower. The level sight class were not clear, which made them impossible to use. Together, the failure by these systems contributed to the overflowing in the splitter tower, which later caused an explosion when ignited by a nearby running engine.
Despite noting these engineering failures, the company failed to repair them. There are several reasons why the company never repaired its defective equipment and instruments. Chief among them being the refusal by local engineers to do the safety upgrades in the facility due to hesitance by BP to meet the costs (Mac Sheoin, 2010).
Engineering Failure
Based on the findings of CSB (2007), major engineering failures resulted in the explosion of BP refinery in Texas City. Some of the engineering failures that occurred include: Failure to follow the stipulated safety procedures during start up, failure to repair malfunctioning equipment and instruments, and poor communication between personnel (Okoh & Haugen, 2013).
First, maintenance backlog is to blame; deferred maintenance can often be the source of many engineering failures such as malfunctioning machines and unresponsive warning or safety systems. Equipment and instruments were not repaired. It is worth noting that BP had established key safety procedures that needed to be followed during start-up. One of the procedures was to carryout pre-startup equipment checks which was not followed. This pre-startup check revealed multiple malfunctioning instruments including the splitter level transmitter, level sight glass, and control valve. Despite these findings, maintenance for malfunctioning instruments was deferred. Administrative negligence for the sake of cutting costs can be blamed for lack of repairs. For example, the supervisor deemed it unnecessary to repair the splitter level transmitter due to time constraints. Incomplete action on other repairs is another source of blame. For instance, a functionality check of alarms was carried out, but were not completed in the name of “time constraints.”
Poor communication was also another administrative failure as the operators of various systems failed to pass information to workers on the subsequent shift. Night shift operators noticed that the system was nearly full of hydrocarbons and stopped the process preventing overflow from occurring. Handout notes, which are relayed to workers on the next shift, were inadequate, failing to notify day-time operators of the situation in the tower. In fact, the report by CSB found that the night personnel left the premises earlier than the stipulated time. This further contributed to miscommunication with the day-time personnel. Due to inadequate handout notes, the day-time personnel re-started the startup process. This then lead to the overflow of the fluid in the tower.
Ethical analysis
The duty framework is an ethical foundation centered on individual duties and obligations. This framework is pertinent to all businesses and industries, as ethical conduct is critical to employers and employees alike. In the engineering realm, ethical conduct is a life or death issue, and should be upheld with a high standard of morality. Thus, the aim of individuals is to perform the correct action, which was insufficient in preventing the loss of life at the BP refinery explosion in Texas.
Failure to follow protocols laid down in the starting up of the tower is also to blame. These protocols are in place to ensure standard safety measures are adhered to. Case in point, the procedure or protocol should involve filling the tower up to half-way mark (50%) but the practice at the British petroleum refinery in Texas City was fill it up to ninety nine percent (90%). Diverting from the laid down protocol put a lot of employees in harm’s way because the risk of overflowing was very high. Divergence from duty is considered unethical. The personnel at the tower filled the tower to dangerous levels as a shortcut and ignored protocol. This is either incompetence or gross negligence on the parts of the operators.
The supervisors were also involved in these ethical lapses. The supervisors either neglected their obligations or performed them unsatisfactory. From the findings by the CSB, the supervisors were informed on several occasions about the malfunctioning of several systems. For instance, they were informed about the malfunctioning of one of the alarm and the splitter level transmitter. However, due to various reasons, they never took the initiatives to repair them. Instead they allowed the startup procedure to proceed. This was despite the fact that they were carrying out dangerous procedures, which required perfection. Was it morally right for the supervisors to allow the process to continue while fully knowing that the key systems were not functional? Absolutely, it was not. As the supervisor, they had the moral authority to stop the process and allow for the repair of the fault systems. If the supervisors had fulfilled their obligations, probably the accident could have been avoided.
The company can also be blamed for the explosion that took place. It is worth noting that it is the moral obligation of the company to assure every employee and other person within their premises of his/ her safety. Did the company assure its employees of their safety? From the look of things, the company did not. In fact, the company had turned down several proposals for safety upgrades. For instance, the CSB investigation found that proposals to remove the blowdown drums were not implemented due to “cost considerations” (p.114). Failure to maintain the facilities at BP refinery had been attributed to an initiative that was initiated by Amoco: the previous owner of the Texas refinery. The initiate was meant to enable the company cut on operation cost. Together with lack of investments, this cost-cutting initiative made the plant vulnerable to disasters. According to CSB, BP targeted to cuts its budgets by 25 percent in 1999 and in 2005. In addition to cutting its budgets, the company had downsized operator training and staffing. All of these actions were meant to enable the company maximize profit. Although it is one of the objectives of companies, was it moral for BP to pursue profits at the expense of safety? Probably, it was not. The company ought to put safety first in its premises. In state of targeting to cut cost, the company should have targeted to improve its safety standards. If the company had performed its obligation of assuring safety to its employees, probably the explosion could not have occurred.
Recommendation
To avoid calamities such as the one that occurred at the BP refinery plant in Texas, it is recommended that everyone performs his or her duties. In the case, the calamity that struck BP refinery was mainly caused by failure by individuals to fulfill their obligations. Organizations also need to focus on safety measures within their premises. From the case, BP had not upgraded its safety systems for long. Moreover, maintenance of systems need to be taken seriously.
The engineering failures that resulted in the tragedy at BP refinery could have been avoided. First, the supervisors should have stopped the startup process once they have been informed about the malfunctioning of several systems. Their decision to allow the process to continue led to the overflow at the splitter tower. One of the main reason, the supervisors allowed the process to continue was due to the tight schedule they were working on. From the case, it appears that the supervisors were required to complete their duties within a specified period. In the future, the supervisors need to be given flexible work schedule, where they can adjust any activities. The organizational management need to increase the powers of supervisors to include the power to adjust schedules. If the work schedule was not tight, probably the supervisors could have postponed the process to a later period. The advantage of this is that it allows room for mistakes to be corrected. However, giving supervisors flexible work schedule would slow down the work in the company.
Maintenance of systems, instruments and equipment need to be carried out more frequently. Most of the systems that malfunctioned during startup process was mainly due to lack of maintenance. Organizations need to have a department; whose specific role is to check on the functionality of equipment. In case of a malfunctioning system, this department would carry out maintenance and repair work. For the department to be functional, it must be provided with enough resources including personnel and budgets. The advantage of having a department that is only concerned with maintenance is that it would reduce the number of malfunctioning systems and equipment. The disadvantage, is however, increased operational costs as additional budget will be required to run the department.
Safety upgrade procedures need to be mandatory for organizations. Authorities need to enact laws that makes it mandatory for organizations to carry out safety upgrades. For instance, laws can be enacted that forces companies to carry out safety upgrades annual. Companies that fail to abide by such laws need to be punished severely including withdrawal of their operational license. In the case, BP refused to carry out safety upgrade due to cost consideration. Making safety upgrades a mandatory would force companies to carry out the procedures no matter the costs. The advantage of this would be increased safety level in all organizations. However, enforcing such a law may be detrimental to investors as it increases the cost of operating a business.
Conclusion
There are many lessons that can be drawn from the case. First, individual errors, though small, are costly. The engineering failure at BP refinery in Texas was mainly caused by individual errors and negligence. Glaring mistakes were made throughout the startup process. Failure to address these mistakes resulted into the calamity that claimed the lives of 15 individuals while injuring a dozen others. From the case, one thing is clear: even the smallest mistake may turn to be costly. This then calls for individuals to be extra vigilant when dealing with such errors.
Another thing that is clear from the case is the importance of effective communication. Most of the problems in the case can be attributed to lack of effective communication. For instance, the night supervisor left the premises before properly describing the condition of the tower to the day-time supervisors. This lack of communication caused the day-time supervisors to restart the startup, although it had been stopped by the night-time supervisor due to overfilling.
Another lesson that can be obtained from the case study is the importance of companies fulfilling their corporate responsibilities. BP failed to fulfill one of its social responsibilities of providing safety to its employees. The employees working in their premises were constantly exposed to dangers. Yet, the company never took any initiative to address them. After the incident, the company swung into action. It has since implemented a lot of safety measures that are meant to protect individuals within the organization.
Works Cited
Blumenthal, Ralph. "14 Die in Blast at BP Oil Refinery in Texas." The New York Times - Breaking News, World News & Multimedia, 24 Mar. 2005, www.nytimes.com/2005/03/24/us/14-die-in-blast-at-bp-oil-refinery-in-texas.html.
Brown University. "A Framework for Making Ethical Decisions | Science and Technology Studies." Brown University, www.brown.edu/academics/science-and-technology-studies/framework-making-ethical-decisions.
Chemical Safety and Hazard Investigation Board (CBS). "Investigation Report: Refinery Explosion and Fire." 2007,
Gillikin, Jason. "Duty-Based Ethics in the Workplace: A Critique." Gillikin Consulting Group LLC, 20 May 2012, www.gillikinconsulting.com/2012/05/duty-based-ethics-in-the-workplace-a-critique/. Accessed 11 Nov. 2017.
Mac Sheoin, Tomás. "Chemical Catastrophe: From Bhopal to BP Texas City." Monthly Review, vol. 62, no. 4, 2010, p. 21, doi:10.14452/mr-062-04-2010-08_4.
Manca, Davide, and Sara Brambilla. "Dynamic simulation of the BP Texas City refinery accident." Journal of Loss Prevention in the Process Industries, vol. 25, no. 6, 2012, pp. 950-957.
Mouawad, Jad. "BP Has a History of Blasts and Oil Spills." The New York Times - Breaking News, World News & Multimedia, 8 2010, www.nytimes.com/2010/05/09/business/09bp.html.
Occupational Safety & Health. "Fire and explosion hazards." Occupational Safety & Health Guide Series, 2001, pp. 71-78.
Okoh, Peter, and Stein Haugen. "The Influence of Maintenance on Some Selected Major Accidents." The Italian Association of Chemical Engineering, vol. 31, 2013, pp. 493-498, DOI:10.3303/CET1331083.
Schorn, Daniel. "The Explosion At Texas City." CBS News - Breaking News, Live News Stream 24x7, 30 Oct. 2006, www.cbsnews.com/news/the-explosion-at-texas-city/.
Wolf, Daniel D., and Mohamed Mejri. "Crisis communication failures: The BP Case Study." management journal, 2013, www.managementjournal.info/.
