Today, Brent Coon & Associates is releasing a series of documents showing that one fatal decision and an arrogant lapse in engineering judgement were that last and most catastrophic event that killed fifteen people. If BO had followed its own guidelines, 15 people might still be alive after the tragic explosion of March 23, 2005
Summary of Evidence Release
If BP, plc had followed its own guidelines for the placement of trailers, 15 people might still be alive after the tragic explosion on March 23, 2005. Brent Coon & Associates is releasing a series of documents showing that one fatal decision and an arrogant lapse in engineering judgment were the last and most important acts in a catastrophic event that killed fifteen people.
What could be the most important documents uncovered by Brent Coon & Associates are now available as part of the November 9, 2006 plea agreement with Eva Rowe, and can now be viewed on this site. These haunting documents prove that BP gave little importance to internal policies and OSHA regulations.
In 1995, in order to comply with OSHA’s new requirement to address facility siting, Amoco created a workbook for the refineries to use to do their initial hazard analysis. This workbook allowed the trailers to be closer than any other building because the executives believed that the trailers would roll in response to a Vapor Cloud Explosion (VCE). In Texas City, the argument that trailers would roll was completely invalidated because the trailers were intentionally strapped down to prevent rolling in the event of a hurricane.
When the original audit of potential hazards to all buildings at Texas was performed, a college sophomore was put in charge of the project, while other refineries hired experienced engineering firms to do their initial analysis.
Even thought the BP Facility Siting Screening Workbook called for the placement of turnaround trailers to be no closer than 350 feet from a process unit, they placed the occupied the trailers within 150 feet of the process unit - without completing the required process hazard analysis.
The morning of March 23, 2005, BP’s supervisors met to discuss the process and potential risks involved with the scheduled restart of an Isomerization unit. In the main operations room, a supervisor at the end of an 18-hour shift began the procedure with only three out of 18 control panel safety dials working properly. No one thought of warning the contractors stationed at the trailers near the unit.
And on the afternoon of March 23, 2005, fifteen people, unwarned by BP plant operations of the plans to try a difficult and dangerous start-up, were about to become BP’s 24th through 38th victims of “Profits over People”.
What could be the most important documents uncovered by Brent Coon & Associates are now available as part of the November 9, 2006 plea agreement with Eva Rowe, and can now be viewed on this site. These haunting documents prove that BP gave little importance to internal policies and OSHA regulations.
In 1995, in order to comply with OSHA’s new requirement to address facility siting, Amoco created a workbook for the refineries to use to do their initial hazard analysis. This workbook allowed the trailers to be closer than any other building because the executives believed that the trailers would roll in response to a Vapor Cloud Explosion (VCE). In Texas City, the argument that trailers would roll was completely invalidated because the trailers were intentionally strapped down to prevent rolling in the event of a hurricane.
When the original audit of potential hazards to all buildings at Texas was performed, a college sophomore was put in charge of the project, while other refineries hired experienced engineering firms to do their initial analysis.
Even thought the BP Facility Siting Screening Workbook called for the placement of turnaround trailers to be no closer than 350 feet from a process unit, they placed the occupied the trailers within 150 feet of the process unit - without completing the required process hazard analysis.
The morning of March 23, 2005, BP’s supervisors met to discuss the process and potential risks involved with the scheduled restart of an Isomerization unit. In the main operations room, a supervisor at the end of an 18-hour shift began the procedure with only three out of 18 control panel safety dials working properly. No one thought of warning the contractors stationed at the trailers near the unit.
And on the afternoon of March 23, 2005, fifteen people, unwarned by BP plant operations of the plans to try a difficult and dangerous start-up, were about to become BP’s 24th through 38th victims of “Profits over People”.
Federal Criminal Case
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The explosion at BP Texas City has spawned dozens of investigations by various groups, including internal BP personnel, injured victims, and several governmental agencies. The latest investigation, conducted by the Department of Justice, resulted in BP agreeing to plead guilty to various charges. The criminal case against BP centers primarily on two “knowing violations of risk management practices” committed by BP. The first issue is their violation of the Clean Air Act and their failure to adequately maintain a proper pressure relief system on the ISOM unit. Evidence concerning this violation can be found in the TCEQ information release found on this site. The other major violation by BP concerns their placement of temporary trailers next to the ISOM unit and their failure to warn contractors that the unit was starting up that day.
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10/22/2006–Criminal Information
Contains the charges brought by the Federal Government against BP for crimes associated with the March 23, 2005 explosion at BP TX City. DOWNLOAD DOCUMENT 10/22/2006–Plea Agreement BP’s agreement to plead guilty to several criminal charges brought against them by the federal government. VIEW HIGHLIGHT - DOWNLOAD DOCUMENT 10/24/2006–Statement of Facts BP’s stipulation to facts that the government would be able to prove beyond a reasonable doubt, if the criminal case were to go to trial. VIEW HIGHLIGHT - DOWNLOAD DOCUMENT |
BP's General Trailer Siting Policies
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As a result of several high profile explosions at refineries and chemical plants around the world, the federal government and OSHA instituted sweeping changes to the regulations governing Process Safety Management (PSM). The most prominent of these changes was the addition of a new federal regulation: 29 C.F.R. 1910.119—Process Safety Management of Highly Hazardous Chemicals.
This regulation requires refineries to conduct Process Hazard Analysis of potential dangers to buildings near their process units. By 1995 Amoco developed its own policies and procedures to deal with these facility siting issues. These policies and guidelines were put into the “Facility Siting Screening Workbook” which was forwarded to all of their refineries in the United States. The Facility Siting Screening Workbook allowed for the placement of turnaround trailers no closer than 350 feet from a process unit without a full analysis of the potential hazards, while more sturdy structures had be analyzed even if they were twice as far away from the process unit. This was based on a belief that the trailers would roll in response to a Vapor Cloud Explosion (VCE). Each refinery used the workbook to conduct individual facility siting process hazard analysis. At the Whiting facility they contracted the work to an engineering firm which specialized in facility siting issues. At Texas City the work was assigned to Peter Chang, a summer intern who had just completed his sophomore year at college! However, even Mr. Chang had the common sense to recognize that any validity to trailers rolling in response to VCE’s was not valid in Texas City. Because of the threat of hurricanes, trailers at refineries along the Gulf Coast are typically strapped down so that they won’t roll away during tropical storms. |
OSHA 1910.119
To read more about OSHA 1910.119 and Process Safety Management please visit the OSHA website. EXTERNAL LINK Testimony of Stan Sorrells - former had of Process Safety Management for Amoco, current head of HSSE at the Whiting Facility WATCH VIDEO #1 | DOWNLOAD TRANSCRIPT 4/1/1995–Facility Siting Screening Workbook Amoco’s screening workbook for use in Process Hazard Analysis of facility siting issues. This workbook was still the operative standard being used at BP Texas City in March 2005. VIEW HIGHLIGHT - DOWNLOAD DOCUMENT Testimony of Ross Pillari - former President of BP Products North America WATCH VIDEO - DOWNLOAD TRANSCRIPT Testimony of Stan Sorrells - former head of Process Safety Management for Amoco, current head of HSSE at the Whiting Facility WATCH VIDEO #2 | DOWNLOAD TRANSCRIPT 4/1/1995–Facility Siting Screening Project Guidelines and Results In order to comply with OSHA 1910.119 Amoco had to conduct a facility siting study at all of their facilities in the United States. At the Texas City refinery this work was done by Peter Chang. VIEW HIGHLIGHT #1 - VIEW HIGHLIGHT #2 - DOWNLOAD DOCUMENT 9/1/1999–Letter to Pat Gower Pat Gower received a letter showing the value of blast resistant trailers in a refinery setting. He apparently forwarded this letter to Bill Ralph, head of Process Safety Management at Texas City. VIEW HIGHLIGHT - DOWNLOAD DOCUMENT |
Sitting the Trailers Next to the ISOM
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During the fall of 2004 BP began taking steps to locate the trailers between the ISOM and NDU unit so that they could be used during the Ultracracker turnaround (TAR) in February and March of 2005.
At about that same time the BP Whiting facility was also beginning the process of putting in trailers for their upcoming turnarounds. The Whiting facility recognized the limitations of the Facility Siting Screening Workbook when examining TAR trailers and forwarded this information to Texas City. The Whiting Facility ultimately decided to find a new place for their trailers. Under BP policy, they were supposed to complete a Management of Change (MOC) that would have looked at all of the potential hazards of the trailers’ location. Very few of the trailers in the area even had an MOC done on it. The MOC for JE Merit trailer, that was destroyed during the blast, was never commissioned. Under BP’s own rules none of the trailers in the area of the blast should have been occupied. |
9/27/2004—MOC Form for JE Merit Turnaround Trailer
This is a Management of Change analysis for occupying the JE Merit trailer which was sited between the ISOM and the NDU. VIEW HIGHLIGHT - DOWNLOAD DOCUMENT 9/27/2007—E-mail: Bill Ralph to Jerry Jordan RE: Trailer Siting at Whiting E-mail from Bill Ralph, Head of Process Safety Management at BP Texas City regarding concerns at the Whiting facility over turnaround trailer siting. VIEW HIGHLIGHT - DOWNLOAD DOCUMENT 9/27/2007—E-mail: Hilton Tolbert to Foot Robinson RE: MOC Action Items E-mail from various members of the Process Safety Management team at Texas City pointing out that non-commissioned MOC’s are illegal and in violation of BP policy. VIEW HIGHLIGHT - DOWNLOAD DOCUMENT 8/16//2005—MOC Form for JE Merit Turnaround Trailer (canceled) Because the MOC for the JE Merit trailer was never commissioned it remained in BP’s tracking system for several months after the blast. Eventually BP cancelled the MOC in order to clear it off of their books. VIEW HIGHLIGHT - DOWNLOAD DOCUMENT |
Failure to Warn About the Startup
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Startups and shutdowns are the most dangerous times at a refinery. When a unit is being re-started, all non-essential personnel are evacuated from the area to keep them out of harms way should an upset occur. No one at BP informed the contractors working in the area that the ISOM unit was being started up that day. As a result dozens of people were having their daily meetings in the trailers less than 150 feet away from the blowdown stack when it began to overfill and form a massive vapor cloud.
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Testimony of Joseph Runfola - former I & E Technician responsible for maintenance on the ISOM unit
WATCH VIDEO - DOWNLOAD TRANSCRIPT |