BP TEXAS

CITY REFINERY
2005
MUHAMMAD BIN ISMAIL
ANAS BIN MOHD RASHID
MOHD FIKRI HAKIM BIN ABDULLAH
ASHLEY WASLI
MUHAMMAD HAFIZZUDIN BIN AZMAN
DIRECT CAUSE

The liquid hydrocarbon is enter the blowdown drum (main)

The liquid has been flow until it release out the drum

The liquid hydrocarbon vaporize to form a cloud

The BP Texas explode when the cloud of hydrocarbon react with the transportation truck.

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INDIRECT CAUSE

UNSAFE ACT : WORKER

Lack of Poor
Continuous adding of
communication acknowledgement Accidental heating of
hydrocarbon as high
between shift toward the changes inlet.
pressure rises.
workers. occur at the splitter.

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 INDIRECT CAUSE
Actual height
164 feet tall,
showed 10 Feet
UNSAFE CONDITION: LEVEL
TRANSMITTER

Providing
faulty
indication of
solution level

Did not operate

properly

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ROOT CAUSE
ORGANISATIONAL
• Failure to invest in plant infrastructure.
• Lack of corporate oversight
• Cost-cutting

TECHNICAL
• Insufficient size and outdated of blowdown drum
• Lack of preventative maintenance
• Inoperative alarms and level sensors

HUMAN FACTORS
• Inadequate training of operators
• Lack of competent supervision
• Poor communication
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• Use of outdated and ineffective work procedures which were often not followed
IMMEDIATE CAUSE
The sensor was designed to
measure heights up to 3m of
the splitter tower, but the
sensor fail to read the actual
amount of liquid.
Liquid leaving the tower was at
This caused liquid in the tower
a very high temperature, and
to boil and expand causing the These valves redirected over
on exiting the heat exchanger
liquid level in the tower to rise 200,000L of flammable liquid to
which not designed to cool
and forced open all 3 safety the blow-down drum of
down very hot liquid, induced a
relief valves near the base of signicantly lower capacity.
temperature rise (over 150 ºC)
the tower.
in liquid being fed to the tower.
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IMMEDIATE CAUSE

Minutes later, there was

The blow-down drum an eruption of very hot
was fitted with a liquid highly flammable liquid,
height sensor and an from the top of the blow-
alarm, but when the down stack, which fell to Ignition of the cloud, by
drum overfilled, the alarm the ground creating a backfire from an idling
failed to alert operators, highly flammable vapour diesel truck
who continued cloud that covered the
redirecting flow to the entire refinery, especially
drum. the trailers housing the
contractors.

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8
WHAT CAN WE
LEARN?

Follow recommend Alert potential Personal safety over

Prevention steps
procedure danger process safety

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THANK
YOU!
FOR YOUR
ATTENTION!