Wednesday, August 19, 2009

“A Failure To Learn” - Texas City Refinery Disaster 2005

BP suffered from an all-too-common “learning disability” which was the fundamental and underlying cause of the Texas City Refinery disaster on 23 March, 2005 which killed 15 and seriously injured two hundred, according to Professor of Sociology, Andrew Hopkins, of Australian National University.

Direct costs incurred by BP well exceeded $3 billion as $2 billion and $1 billion respectively went on compensation for the victims families and the subsequent recovery and overhaul of the Texas City site and Refinery. Reputational and share price costs are probably immeasurable.

It is easy to ask why the operators simply didn’t allow the liquid distillate to be released from the distillation column with the 9ft high level exceeded many times before the liquid eventually purged into the atmosphere some 158ft later. All it took was an idling work vehicle to set off the massive explosion and resultant fire.

The reasoning for an apparent strange set of actions was actually sound. There were no warning alarms to indicate the exceeding of safe liquid distillate levels; there was no process HAZOP identifying the criticality of the hazard; and finally, there was no corrective action taken as a result of the chronic overfills of the column that had become an operational norm. The focus on process safety took a very distant seat to that of occupational safety.

According to Professor Hopkins the lessons from Esso Longford (1998), the NASA Challenger (1986) and Columbia (2003) disasters and the Texas City disaster are so similar it’s striking--they failed to learn from previous mistakes. BP was so attentive to the ‘high frequency-low consequence’ events of lost time injuries they were found to be inept and “systematically inattentive” to the risks associated with the ‘low frequency-high consequence’ events relating to process safety incidents.

There are many lessons out of this disaster, all tabled in detail in Professor Hopkins’ book, Failure to Learn: the BP Texas Refinery Disaster.[1] But the key lesson for all organisations is to actually commit to taking action from the learnings from related incidents.

It is no good to know intimately about what’s happened within other companies--the lessons must be personalised.

A parting thought: ‘Lost time injuries tell us nothing about how safe we are in high hazard environments.’




[1] Andrew Hopkins, Failure to Learn: the BP Texas Refinery Disaster (North Ryde, Sydney: CCH Australia Limited, 2009).

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