session 12 - texas city syndicate exercise.ppt

8/16/2019 SESSION 12 - TEXAS CITY SYNDICATE EXERCISE.ppt

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Lessons Learned from the Texas CityRenery Explosion


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Texas City Renery

•Texas City Refinery,40 miles fromHouston, Texas, USA

•Staff 1600 plus•contractors

•Processing 460,000 arrels of cru!eoil"!ay# −$ne of t%e largest refineries in t%e USA−Supplies aout &' of gasoline use! in US


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The accident

•An explosion an! fire in t%e

refinery(s isomeri)ation unit

•*xplosion occurre! +arc% &,

00- at 1&.0 /Houston time

•1- people !ie! an! many more

ere in2ure!

•3ote. T%e isomeri)ation unit

oosts t%e octane of gasoline

len!stocs#


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Simplied block diaram of Ra!nate Splitter

Feed

BottomProduct

Condensate

Feed Heat Exchanger

Vent Relief system

Ranate

Splitter

Blowdownstac

Furnace


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Ra!nate Splitter and #lo$do$n %r&m Stack

Ranate Splitter !ower

Blowdown "rum Stac


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(erial )hotoraph of *someri+ation ,nit


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(erial )hotoraph of *someri+ation ,nit

Ranate Splitter

Blowdown "rum

!emporary ca#ins

$ther trailer

Control Room

$utside operator shelter


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/hat happened 0

Prior to 5e 1- Temporary trailers place! 1-0 feet from t%e someri)ation

unit#$n 5e 1 Trailers use! y personnel preparing for a turnaroun! at

anot%er part of t%e refinery

+arc% $n nig%t s%ift, raffinate splitter as eing restarte! aftert%e s%ut!on# Raffinate splitter is part of t%e someri)ation

unit t%at !istills c%emicals for t%e someri)ation process+arc% & Splitter as o7er8fille! an! o7er8%eate!

9%en li:ui! suse:uently fille! t%e o7er%ea! line t%e relief7al7es opene!

T%is cause! excessi7e li:ui! an! 7apour to flo to lo!on!rum an! 7ent at top of its stac

An explosion occurre! %ic% ille! 1- people an! in2ure! manyot%ers


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Texas City Refinery March 23, 2005

15 People Killed

Many more injured

A community devastated

Splitter

Vent stac

"e#ris of ca#ins


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*ncident


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*someri+ation ,nit


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Satellite Control Room


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*nside Satellite Control Room


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Coolin To$er


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Trailer


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Catalyst /areho&se


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Storae Tank


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*someri+ation ,nit


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%o&ble/ide Trailer


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2

%o&ble/ide Trailer


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2

5ey *ss&es

•$perator nattention

•5olloing Proce!ures

•Super7isor Asence

•Communication ; S%ift Han!o7er

•Trailers Too Close to Ha)ar!s

•Some nstrumentation


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2

(nimation

Incident Animation


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2

CRITICAL FACTORS: @ Start-up procedures

and managementoversight

@ Loss of containment

@ esign and engineeringof !"o#do#n unit

@ Contro" of #or$ andtrai"er siting

U%&RL'I%( CULTUR&:

@ Insufficient !usiness conte)t

@ Safet* as a priorit*

@ Organi+ationa" comp"e)it*

@ Ina!i"it* to see ris$

@ Lac$ of ear"* #arningindicators

#) incident in6estiation team reports

!he %nterim Report identi&ed ' critical factors( the Final

Report con&rmed the critical factors and identi&edunderlying cultural issues)


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2

,nderlyin C&lt&ral *ss&es

Business Conte)t• +oti7ation

• +orale

• PAS Score

,rocess. Safet* as a

riorit*• *mp%asis on *n7ironment an!

$ccupational Safety

Organi+ationa" Comp"e)it* /Capa!i"it*• n7estment in People

• =ayers an! Span of Control

• Communication

Ina!i"it* to See Ris$• Ha)ar! !entification Sills

• Un!erstan!ing of Process Safety

• 5acility Siting

• ?e%icles

Lac$ of &ar"* 0arning•


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2

Hazard

Reminder of the 7S$iss Cheese 8odel9

Ha)ar!s are containe! y multipleprotecti7e arriers

>arriers may %a7e eanesses orB%oles(

9%en %oles align %a)ar! energy isrelease!, resulting in t%e potentialfor %arm

>arriers may e p%ysical engineere!

containment or e%a7ioral controls!epen!ent on people

Holes can e latent"incipient, oracti7ely opene! y people

Accident

Protective

‘Barriers’

Weaknesses

Or ‘Holes’


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2

Exercise

ou are t%e n7estigation Team

9%at arriers %a7e faile!D

Plant, process, peopleD


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Inherent Design

Plant Layout

Control, Alarm &Shutdown system

•Operate

outside

envelop•No fail-

safeshutdown•No mass

balance orattention to

other data•Lostprocess

control

•Faulty high

level alarm

not reported

Maintenance &

Inspection

Learning from

the Past

•Previousincidents &

upsets not

reported• dmin!

rather than

"#$solutions•%ierarchyof control

not applied

Operations

Procedures

ffecti!e

Super!ision "Leadership

#raining &Competency

"nadeuate%'"$ s(illsLac( of

underpinning

(nowledgeFailure tofollow

procedures

$or% Control

•Failure to

recogni)e ha)ard

to trailers fromstart-up•People notnotified of start-up•*ultiple sources

of ignition inad+acent areas

Support to e't of(in & In)ured

*elief and

+lowdown System

•No up todate relief

study -design basis

unclear •,apacity ofblowdown

drum

eceeded

Audit & Self*egulation

•Pre-start-up review

not performed•Procedural

compliance not

chec(ed•#upervisor offsite•No interventions•"nadeuate .P"/sfor process safety

•No 0 incomplete

*O,/s for trailersiting•1lowdown drummodified without

rigorous *O,

Management ofChange

Acti!e & Passi!e

ire Protection

scape "Access

*escue &

*eco!ery

HAZARD

Normal%ydrocarbon

"nventory in2affinate

#plitter

In!estigation &

Lessons Learned

• ctive &

passive fire

protection

• ccess & escape route

diversity• ccess to scene

•3mergency response

by site and eternalauthorities

•%ospitali)ation

HAZARD

REALIZATION

Loss of

containment

"gnition

3plosion

*ultiple fatalities

and in+uries•"nventory

increased•Proimity of

non-

essential

personnel toha)ard•Flare notused

4eas ,ity 3plosion

5 %a)ard *anagement $iagram

%ierarchy of control 5 1ias towards hardware0inherent safety & reducing the scope for human error 5 multi barrier defence

Communication

•,onfusion over

who was incharge•No verification

on procedures inuse• bsent fromunit at critical

times

•Proceduresnot followed•#teps not

signed off •6se of 7local

practices/

•No effective

handover

between shifts•6nit alarm not

sounded


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2

Exercise

*f yo& $ere Renery 8anaer

/hat actions $o&ldyo& implement0


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2

Strateic concepts

*n order to red&ce the potential for f&t&re ma:or incidents and losses; three layers of protectionare to be considered<

• plant = enineerin hard$are; control systems; and layo&ts to eliminate; control andmitiate potential ha+ards to people; and impro6e prod&cti6ity

• processes = manaement systems to identify; control and mitiate risks; and dri6econtin&o&s operational impro6ement

• people = capability of o&r people in terms of leadership skills; rele6ant kno$lede andexperience; and the orani+ational c&lt&re they create

*n layers of protection; 7hard barriers9 are more reliable than 7soft barriers9; b&t all rely on people

hazard accidentor loss

‘hard’ barriers ‘soft’ barriershazardreduction

physical

controlsprocedures

generic

systems

people’s

behaiors


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3

)rincipal actions

"ant@ 3o trailers or temporary accommo!ation to e place! insi!e areas /ofrefineries containing %y!rocarons, e7en if t%e assessment of ris isnegligile

@ >lo!on stacs use! for lig%t %y!rocaron to e p%ase! out as

:uicly as possile

rocess

@ $perating proce!ures to e clear, appropriate for t%eir purpose, an!alays folloe!

eop"e

@ >uil! capaility for operational lea!ers%ip, super7isors, an! tec%nicians


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3

>ther (ctions

Te)as Cit*

• $rgani)ation, accountailities, communication,

• E1 illion in7estment program, off8site offices, facility siting stu!y, trailersremo7e!, re!uce! 7e%icles, lo!on stacs in lig%t %8c !uty eing remo7e!,engineering stu!ies /relief systems an! SC*,

• Super7isory o7ersig%t, operator training#

B (roup• Safety F $perations organi)ation,

• Assessment of temporary uil!ings, remo7al of lo!on !rums, engineering stu!iesof atmosp%eric 7ents

• Re7ie of operating proce!ures,

•


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3

/hat can $e learn from this incident 0

@ Temporary uil!ing siting is a critical step in managing

flammale " toxic riss

@ Atmosp%eric 7enting nee!s careful !esign an! operation

@ Proce!ures are ineffecti7e if t%ey are not up8to8!ate an!

routinely folloe!@ Competency an! e%a7iors of $perations lea!ers%ip,super7ision an! orforce are fun!amental to safeoperations

$t%er lessons in7ol7e management 7isiility an! accountaility, %a)ar!i!entification, %a)ar!s of startup operations, performance measures forprocess safety, emergency !rills, etc#

nci!ent in7estigation report a7ailale at. #presponse#org

session 12 - texas city syndicate exercise.ppt

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