Washington, DC, March 26, 2007 - The Chemical Safety Board (CSB) today released online the Investigation Report on the BP Texas City refinery explosion and fire that killed 15 and injured 180 others on March 23, 2005. CSB board members voted to approve the report in draft form at a public meeting in Texas City on March 20, 2007. At over 300 pages, the report, which may be viewed and downloaded at www.csb.gov, contains hyperlinks to internal BP documents that support many of the key findings in the report. These documents may be found on the CSB's BP Investigation Page. The public release of these documents was approved by BP.
|Burnt vehicles and debris left by hydrocarbon vapor explosions that killed 15 workers at the BP Texas City refinery March 23.
"This report is the most comprehensive chemical accident report the CSB has produced," said CSB Chairman Carolyn Merritt. "It describes in detail how the accident occurred, the human factors such as operator fatigue that contributed to it, safety deficiencies at the facility, equipment design issues, unsafe placement of work trailers, the lack of process safety analysis, cuts in operations and maintenance costs and lack of investment in safer equipment, and a thorough analysis of BP's safety culture."
Ms. Merritt continued, " It is our hope that this report and its recommendations will not only help guide BP in the future, but will be useful throughout the chemical industry as an object lesson on what happens when a corporation's safety culture fails."
Don Holmstrom, lead investigator said, "Throughout the process of investigation, analysis, and writing, we have worked to present as clear a picture as possible of what led to the tragedy on March 23rd, 2005. We are certain the findings and conclusions will be of benefit to all in the chemical industry."
In the 335-page final report, federal investigators from the U.S. Chemical Safety Board (CSB) conclude that 'organizational and safety deficiencies at all levels of the BP Corporation' caused the March 23, 2005, explosion at the BP Texas City refinery, the worst industrial accident in the United States since 1990. The report calls on the U.S. Occupational Safety and Health Administration (OSHA) to increase inspection and enforcement at U.S. oil refineries and chemical plants, and to require these corporations to evaluate the safety impact of mergers, reorganizations, downsizing, and budget cuts.
Highlights of the report include:
· Safety Harmed by Cost-Cutting, Production Pressures, and Failure to Invest
· Blast Modeling Shows Vulnerability of Temporary Trailers
· Human Factors Analysis: Fatigue, Other Conditions Made Errors More Likely
· Refinery Had Longstanding Process Safety Deficiencies
· Near Misses Ignored
· Required Inspections Not Conducted
· Preventative Maintenance Program Ignored
· Dysfunctional Safety Culture Existed at All Levels of BP
· Recommends that OSHA amend its Process Safety Management standard and increase inspections