1. What If a Blast* Were to Happen on MY WATCH? by Bob Andrew (© 2005: these are my personal observations alone) ( * Or a Spill, or a Fall, or a Fire …. )

2. Nov. 17, 2005D*R*A*F*T: for Process Engineers 2 The Texas City Refinery our sole purpose: illuminate issues WHAT happened & WHEN? WHO was hurt, or impacted? WHERE was / is impact felt? WHO all, then, got involved? WHAT can WE learn from it? HOW/WHY did this happen? How DO people handle this?

3. Nov. 17, 2005D*R*A*F*T: for Process Engineers 3 WHAT Happened, and WHEN? 1947: fertilizer ship blew up at Texas City docks1947 ~ 600 killed, with damage several miles away Texas City docks leveled: a near total re-build March 23, 2005: a blast during startup of a unit: (subsequent slides to detail key lessons learned) July 28, 2005: Reside Hydrotreater unit on fire: nobody hurt this time, and the fire was contained

4. Nov. 17, 2005D*R*A*F*T: for Process Engineers 4

5. Nov. 17, 2005D*R*A*F*T: for Process Engineers 5 ?

6. Nov. 17, 2005D*R*A*F*T: for Process Engineers 6 WHO was HURT, or IMPACTED? Workers killed, mainly in construction trailer Workers injured & burnt, but NO-ONE offsite Community: fear, then anger, and now mistrust Regulators: took strong action, with real teeth BP: significant re-investment in EVERY refinery Industry: raises the bar for all other turnarounds

7. Nov. 17, 2005D*R*A*F*T: for Process Engineers 7 WHERE was / is IMPACT felt? A new BP Refinery Manager, but from the UK BP Texas City stayed down: weeks after Rita Refineries: Corporate Safety culture, spending OSHA: $25 million fine, with ongoing scrutiny Chemical Safety Board findings and updatefindingsupdate CSB statement to independent BP Safety Panelstatement Industry: impacting plant design & turnarounds

8. Nov. 17, 2005D*R*A*F*T: for Process Engineers 8 WHO All, then, Got Involved? 2005 Houston Chronicle special coverage: www.chron.com/content/chronicle/special/05/blastspecial coverage www.chron.com/content/chronicle/special/05/blast BP Response web: www.bpresponse.orgBP Responsewww.bpresponse.org Federal OSHA inflict official sanctions, andOSHA U.S. appointed Chemical Safety Board e.g.Chemical Safety Board CSB Issues Urgent Recommendations to U.S. Petrochemical Industry, Calls for Safer Placement of Trailers for Workers in Wake of BP Tragedy CSB Issues Urgent Recommendations to U.S. Petrochemical Industry, Calls for Safer Placement of Trailers for Workers in Wake of BP Tragedy

9. Nov. 17, 2005D*R*A*F*T: for Process Engineers 9 © 2005 Houston Chronicle

10. Nov. 17, 2005D*R*A*F*T: for Process Engineers 10 BP Response site

11. Nov. 17, 2005D*R*A*F*T: for Process Engineers 11 WHAT can WE learn from it? Turnaround Planning: Although needed to replace this atmospheric vent with flaring, work was deferred twice, despite being on OSHA list. Unit Level Controls: The failure of liquid high level notification could happen in any system that does not promptly deal with outage of one component, be that the level sensor, DCS communications, or failure of control room to notice in timely manner during a busy startup. Operations: During startup it is vital to have field staff watching local instrumentation in ADDITION to control room guys watching the panel, particularly if ANY part of DCS was worked on during the turnaround. Work Site: Locating a modular building for the turnaround staff in between process units is in violation of the 1972 O.I.A. unit spacing guidelines: which enabled there to be enough space to fit a building! The explosion happened when nearby workers were in this building.

12. Nov. 17, 2005D*R*A*F*T: for Process Engineers 12 How DO People Handle This? Put your self in the shoes of one of these roles: 1) Turnaround planner: with safety list 2) Field operator: on startup of this unit 3) New unit engineer: did not know list 4) Refinery Mgmt: dealing with media 5) Corporate: dealing with US Congress One comment on your role: once around room

13. Nov. 17, 2005D*R*A*F*T: for Process Engineers 13 Public, Published, References CSB Issues Preliminary Findings in BP Texas City Refinery Accident; Investigators Present Data in Public Meeting CSB Issues Preliminary Findings in BP Texas City Refinery Accident; Investigators Present Data in Public Meeting Update on Chemical Safety Board's findings: Alarms failed to sound before blast. 6/28/05. (Houston Chronicle)Chemical Safety Board's findings: Statement of CSB Chairman Merritt to BP Independent Refinery Safety Panel Statement of CSB Chairman Merritt to BP Independent Refinery Safety Panel CSB Issues Urgent Recommendations to U.S. Petrochemical Industry, Calls for Safer Placement of Trailers for Workers in Wake of BP Tragedy CSB Issues Urgent Recommendations to U.S. Petrochemical Industry, Calls for Safer Placement of Trailers for Workers in Wake of BP Tragedy OSHA warning about danger: Ventilation stack cited (2002) OSHA warning about danger: BP Report on 2004 accident: Inadequate training and poor judgment cited. (Houston Chronicle) Report on 2004 accident: BP's findings: Mistakes by staff outlined. 5/17/05 (Houston Chronicle) BP's findings:

14. Nov. 17, 2005D*R*A*F*T: for Process Engineers 14 CSB Current Investigations BP America Refinery ExplosionTexas City, TXRefinery Explosion Acetylene Service Co. Gas Explosion Perth Amboy, NJ Marcus Oil & Chemical Tank ExplosionHouston, TX Combustible Dust Hazard Investigation …………… Sterigenics Ethylene Oxide ExplosionOntario, CA Formosa Plastics ExplosionIlliopolis, IL MFG Chemical Inc. Toxic Gas Release Dalton, GA DPC Enterprises Chlorine Release Glendale, AZ