BP Texas Refinery Incident Causes: A Literature Review
Abstract
The likelihood of incident occurring in oil and gas industries is high due to the inherent risks associated to high temperature, high pressure, hydrocarbon, and etc. One of the prominent incidents that have taken place is the Texas refinery explosion. The purpose of this review was to investigate the causes of the BP Texas refinery incident. There are three sources of references for the reviewed articles: Web of Science, Scopus, and Science Direct. The search results were filtered according to six selection criteria, and after reading the abstracts and full texts, ten articles were included in this review. These studies and reports were reviewed to understand modeling and simulation of the incident process and to identify the root causes of the incident. The review highlights the main factors that led to the incident including: lack of management of change (MOC), maintenance, preliminary hazard analysis, lack of effective safety barriers, and human errors in some sectors. It is recommended that lessons learned from the incident be shared to relevant parties to improve the process safety and further studies on safety barriers and their failure instead of simulation of the incident dynamics.
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2. Abílio ramos m, droguett el, mosleh a, et al. Revisiting past refinery accidents from a human reliability analysis perspective: the bp texas city and the chevron richmond accidents. The canadian journal of chemical engineering. 2017;95(12):2293-2305.
3. Lobato j, rodríguez j, jiménez c, et al. Consequence analysis of an explosion by simple models: texas refinery gasoline explosion case. Afinidad. 2009;66(543).
4. Lundberg j, rollenhagen c, hollnagel e, et al. Strategies for dealing with resistance to recommendations from accident investigations. Accident analysis & prevention. 2012;45:455-467.
5. Sklet s. Comparison of some selected methods for accident investigation. Journal of hazardous materials. 2004;111(1-3):29-37.
6. Vastveit kr, njå o. The roles of incident investigations in learning processes at a scandinavian refinery. Journal of loss prevention in the process industries. 2014;32:335-342.
7. Ccps. Guidelines for implementing process safety management. John wiley & sons; 2016.
8. Kalantarnia m, khan f, hawboldt k. Modelling of bp texas city refinery accident using dynamic risk assessment approach. Process safety and environmental protection. 2010;88(3):191-199.
9. Khan fi, amyotte pr. Modeling of bp texas city refinery incident. Journal of loss prevention in the process industries. 2007;20(4-6):387-395.
10. Isimite j, rubini p. A dynamic hazop case study using the texas city refinery explosion. Journal of loss prevention in the process industries. 2016;40:496-501.
11. Manca d, brambilla s. Dynamic simulation of the bp texas city refinery accident. Journal of loss prevention in the process industries. 2012; 25(6):950-957.
12. Investigation report report refinery explosion and fire. U.s. Chemical safety and hazard investigation board; 2007.
13. Saleh jh, haga ra, favarò fm, et al. Texas city refinery accident: case study in breakdown of defense-in-depth and violation of the safety–diagnosability principle in design. Engineering failure analysis. 2014; 36:121-133.
14. Board). Cuscsahi. Bp texas city refinery explosion and fire e investigation report . Texas city2007.
15. Mogford j. Fatal accident investigation report. Isomerization unit explosion final report, texas city, texas, usa. 2005; 9:2005.
16. Mackenzie c, holmstrom d, kaszniak m, editors. Human factors analysis of the bp texas city refinery explosion. Proceedings of the human factors and ergonomics society annual meeting; 2007: sage publications sage ca: los angeles, ca.
17. Rodríguez jm, payne sc, bergman me, et al. The impact of the bp baker report. Journal of safety research. 2011;42(3):215-222.
18. Kaszniak m, holmstrom d. Trailer siting issues: bp texas city. Journal of hazardous materials. 2008;159(1):105-111.
19. Manca d, brambilla s, villa a. Increasing the understanding of the bp texas city refinery accident. Computer aided chemical engineering. Vol. 29: elsevier; 2011. P. 1266-1270.
20. Palacin-linan j. Fatal accident investigation report, isomerization unit explosion final report, texas city. 2005.
21. Cuscsahi board. Bp texas city refinery explosion and fire e investigation report. Texas city. 2007.
22. Einarsson s, brynjarsson b. Improving human factors, incident and accident reporting and safety management systems in the seveso industry. Journal of loss prevention in the process industries. 2008;21(5):550-554.
23. Boring rl. Defining human failure events for petroleum applications of human reliability analysis. Procedia manufacturing. 2015;3:1335-1342.
24. Dhillon bs. Maintainability, maintenance, and reliability for engineers. Crc press; 2006.
25. Zhou j-l, lei y. Paths between latent and active errors: analysis of 407 railway accidents/incidents’ causes in china. Safety science. 2018;110:47-58.
26. Zhang x, hu w, zhou j, et al. The failure route between active and latent error in bus accident. Ieee access. 2019;7:164941-164951.
27. Daramola ay. An investigation of air accidents in nigeria using the human factors analysis and classification system (hfacs) framework. Journal of air transport management. 2014;35:39-50.
28. Lenné mg, salmon pm, liu cc, et al. A systems approach to accident causation in mining: an application of the hfacs method. Accident analysis & prevention. 2012;48:111-117.
29. Reason j. Human error. Cambridge university press; 1990.
30. Stranks jw. Human factors and behavioural safety. Routledge; 2007.
31. Feyer a-m, williamson am, cairns dr. The involvement of human behaviour in occupational accidents: errors in context. Safety science. 1997;25(1-3):55-65.
32. Yan f, xu k. Methodology and case study of quantitative preliminary hazard analysis based on cloud model. Journal of loss prevention in the process industries. 2019;60:116-124.
33. Herbert il, editor learning the lessons-retrospective hazops. Offshore europe; 2011: society of petroleum engineers.
34. Baybutt p. A critique of the hazard and operability (hazop) study. Journal of loss prevention in the process industries. 2015;33:52-58.
35. (epa) epa. Epa chemical accident investigation report, pennzoil product company refinery, rouseville,pennsylvania.
36. Grossel ss. Guidelines for risk based process safety, aiche center for chemical process safety, wiley-aiche, new york (2007), 768pp., $150.00, isbn: 978-0-470-16569-0. Elsevier; 2008.
37. Keren n, west hh, mannan ms. Benchmarking moc practices in the process industries. Process safety progress. 2002;21(2):103-112.
38. Zwetsloot gi, gort j, steijger n, et al. Management of change: lessons learned from staff reductions in the chemical process industry. Safety science. 2007;45(7):769-789.
39. Wu d, chen z. Quantitative risk assessment of fire accidents of large-scale oil tanks triggered by lightning. Engineering failure analysis. 2016;63:172-181.
40. Wei t, qian x, yuan m. Quantitative risk assessment of direct lightning strike on external floating roof tank. Journal of loss prevention in the process industries. 2018;56:191-203.
41. Jo y-d, ahn bj. A method of quantitative risk assessment for transmission pipeline carrying natural gas. Journal of hazardous materials. 2005;123(1-3):1-12.
42. Chai t, weng j, de-qi x. Development of a quantitative risk assessment model for ship collisions in fairways. Safety science. 2017;91:71-83.
43. Goerlandt f, khakzad n, reniers g. Validity and validation of safety-related quantitative risk analysis: a review. Safety science. 2017;99:127-139.
44. Di domenico j, vaz jr ca, de souza jr mb. Quantitative risk assessment integrated with process simulator for a new technology of methanol production plant using recycled co2. Journal of hazardous materials. 2014;274:164-172.
45. Badri n, nourai f, rashtchian d. The role of quantitative risk assessment in improving hazardous installations siting: a case study. Iranian journal of chemistry and chemical engineering (ijcce). 2011;30(4):113-119.
46. Ahumada cb, quddus n, mannan ms. A method for facility layout optimisation including stochastic risk assessment. Process safety and environmental protection. 2018;117:616-628.
47. Leveson n. A new accident model for engineering safer systems. Safety science. 2004;42(4):237-270.
48. Svedung i, rasmussen j. Graphic representation of accident scenarios: mapping system structure and the causation of accidents. Safety science. 2002.
49. Rasmussen j. Risk management in a dynamic society: a modelling problem. Safety science. 1997;27(2-3):183-213.
50. Möller n, hansson so, holmberg j-e, et al. Handbook of safety principles. Vol. 9. John wiley & sons; 2018.
51. Bakolas e, saleh jh. Augmenting defense-in-depth with the concepts of observability and diagnosability from control theory and discrete event systems. Reliability engineering & system safety. 2011;96(1):184-193.
52. Goncalves filho ap, jun gt, waterson p. Four studies, two methods, one accident–an examination of the reliability and validity of accimap and stamp for accident analysis. Safety science. 2019;113:310-317.
2. Abílio ramos m, droguett el, mosleh a, et al. Revisiting past refinery accidents from a human reliability analysis perspective: the bp texas city and the chevron richmond accidents. The canadian journal of chemical engineering. 2017;95(12):2293-2305.
3. Lobato j, rodríguez j, jiménez c, et al. Consequence analysis of an explosion by simple models: texas refinery gasoline explosion case. Afinidad. 2009;66(543).
4. Lundberg j, rollenhagen c, hollnagel e, et al. Strategies for dealing with resistance to recommendations from accident investigations. Accident analysis & prevention. 2012;45:455-467.
5. Sklet s. Comparison of some selected methods for accident investigation. Journal of hazardous materials. 2004;111(1-3):29-37.
6. Vastveit kr, njå o. The roles of incident investigations in learning processes at a scandinavian refinery. Journal of loss prevention in the process industries. 2014;32:335-342.
7. Ccps. Guidelines for implementing process safety management. John wiley & sons; 2016.
8. Kalantarnia m, khan f, hawboldt k. Modelling of bp texas city refinery accident using dynamic risk assessment approach. Process safety and environmental protection. 2010;88(3):191-199.
9. Khan fi, amyotte pr. Modeling of bp texas city refinery incident. Journal of loss prevention in the process industries. 2007;20(4-6):387-395.
10. Isimite j, rubini p. A dynamic hazop case study using the texas city refinery explosion. Journal of loss prevention in the process industries. 2016;40:496-501.
11. Manca d, brambilla s. Dynamic simulation of the bp texas city refinery accident. Journal of loss prevention in the process industries. 2012; 25(6):950-957.
12. Investigation report report refinery explosion and fire. U.s. Chemical safety and hazard investigation board; 2007.
13. Saleh jh, haga ra, favarò fm, et al. Texas city refinery accident: case study in breakdown of defense-in-depth and violation of the safety–diagnosability principle in design. Engineering failure analysis. 2014; 36:121-133.
14. Board). Cuscsahi. Bp texas city refinery explosion and fire e investigation report . Texas city2007.
15. Mogford j. Fatal accident investigation report. Isomerization unit explosion final report, texas city, texas, usa. 2005; 9:2005.
16. Mackenzie c, holmstrom d, kaszniak m, editors. Human factors analysis of the bp texas city refinery explosion. Proceedings of the human factors and ergonomics society annual meeting; 2007: sage publications sage ca: los angeles, ca.
17. Rodríguez jm, payne sc, bergman me, et al. The impact of the bp baker report. Journal of safety research. 2011;42(3):215-222.
18. Kaszniak m, holmstrom d. Trailer siting issues: bp texas city. Journal of hazardous materials. 2008;159(1):105-111.
19. Manca d, brambilla s, villa a. Increasing the understanding of the bp texas city refinery accident. Computer aided chemical engineering. Vol. 29: elsevier; 2011. P. 1266-1270.
20. Palacin-linan j. Fatal accident investigation report, isomerization unit explosion final report, texas city. 2005.
21. Cuscsahi board. Bp texas city refinery explosion and fire e investigation report. Texas city. 2007.
22. Einarsson s, brynjarsson b. Improving human factors, incident and accident reporting and safety management systems in the seveso industry. Journal of loss prevention in the process industries. 2008;21(5):550-554.
23. Boring rl. Defining human failure events for petroleum applications of human reliability analysis. Procedia manufacturing. 2015;3:1335-1342.
24. Dhillon bs. Maintainability, maintenance, and reliability for engineers. Crc press; 2006.
25. Zhou j-l, lei y. Paths between latent and active errors: analysis of 407 railway accidents/incidents’ causes in china. Safety science. 2018;110:47-58.
26. Zhang x, hu w, zhou j, et al. The failure route between active and latent error in bus accident. Ieee access. 2019;7:164941-164951.
27. Daramola ay. An investigation of air accidents in nigeria using the human factors analysis and classification system (hfacs) framework. Journal of air transport management. 2014;35:39-50.
28. Lenné mg, salmon pm, liu cc, et al. A systems approach to accident causation in mining: an application of the hfacs method. Accident analysis & prevention. 2012;48:111-117.
29. Reason j. Human error. Cambridge university press; 1990.
30. Stranks jw. Human factors and behavioural safety. Routledge; 2007.
31. Feyer a-m, williamson am, cairns dr. The involvement of human behaviour in occupational accidents: errors in context. Safety science. 1997;25(1-3):55-65.
32. Yan f, xu k. Methodology and case study of quantitative preliminary hazard analysis based on cloud model. Journal of loss prevention in the process industries. 2019;60:116-124.
33. Herbert il, editor learning the lessons-retrospective hazops. Offshore europe; 2011: society of petroleum engineers.
34. Baybutt p. A critique of the hazard and operability (hazop) study. Journal of loss prevention in the process industries. 2015;33:52-58.
35. (epa) epa. Epa chemical accident investigation report, pennzoil product company refinery, rouseville,pennsylvania.
36. Grossel ss. Guidelines for risk based process safety, aiche center for chemical process safety, wiley-aiche, new york (2007), 768pp., $150.00, isbn: 978-0-470-16569-0. Elsevier; 2008.
37. Keren n, west hh, mannan ms. Benchmarking moc practices in the process industries. Process safety progress. 2002;21(2):103-112.
38. Zwetsloot gi, gort j, steijger n, et al. Management of change: lessons learned from staff reductions in the chemical process industry. Safety science. 2007;45(7):769-789.
39. Wu d, chen z. Quantitative risk assessment of fire accidents of large-scale oil tanks triggered by lightning. Engineering failure analysis. 2016;63:172-181.
40. Wei t, qian x, yuan m. Quantitative risk assessment of direct lightning strike on external floating roof tank. Journal of loss prevention in the process industries. 2018;56:191-203.
41. Jo y-d, ahn bj. A method of quantitative risk assessment for transmission pipeline carrying natural gas. Journal of hazardous materials. 2005;123(1-3):1-12.
42. Chai t, weng j, de-qi x. Development of a quantitative risk assessment model for ship collisions in fairways. Safety science. 2017;91:71-83.
43. Goerlandt f, khakzad n, reniers g. Validity and validation of safety-related quantitative risk analysis: a review. Safety science. 2017;99:127-139.
44. Di domenico j, vaz jr ca, de souza jr mb. Quantitative risk assessment integrated with process simulator for a new technology of methanol production plant using recycled co2. Journal of hazardous materials. 2014;274:164-172.
45. Badri n, nourai f, rashtchian d. The role of quantitative risk assessment in improving hazardous installations siting: a case study. Iranian journal of chemistry and chemical engineering (ijcce). 2011;30(4):113-119.
46. Ahumada cb, quddus n, mannan ms. A method for facility layout optimisation including stochastic risk assessment. Process safety and environmental protection. 2018;117:616-628.
47. Leveson n. A new accident model for engineering safer systems. Safety science. 2004;42(4):237-270.
48. Svedung i, rasmussen j. Graphic representation of accident scenarios: mapping system structure and the causation of accidents. Safety science. 2002.
49. Rasmussen j. Risk management in a dynamic society: a modelling problem. Safety science. 1997;27(2-3):183-213.
50. Möller n, hansson so, holmberg j-e, et al. Handbook of safety principles. Vol. 9. John wiley & sons; 2018.
51. Bakolas e, saleh jh. Augmenting defense-in-depth with the concepts of observability and diagnosability from control theory and discrete event systems. Reliability engineering & system safety. 2011;96(1):184-193.
52. Goncalves filho ap, jun gt, waterson p. Four studies, two methods, one accident–an examination of the reliability and validity of accimap and stamp for accident analysis. Safety science. 2019;113:310-317.
| Files | ||
| Issue | Vol 12 No 3 (2020) | |
| Section | Review Article(s) | |
| Published | 2020-09-30 | |
| Keywords | ||
| Texas Refinery Explosion Incident Process Safety Hazard Analysis | ||
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How to Cite
1.
Abbasi S, Khourdustan P, Sayyadi R, Jalilpour S, Alizadeh SS. BP Texas Refinery Incident Causes: A Literature Review. Int J Occup Hyg. 2020;12(3):256-270.
