Although actions or errors by operations personnel at the BP Texas City site, as described in the
preceding section, were immediate causes of the March 23 accident, numerous latent conditions and
safety system deficiencies at the refinery influenced their actions and contributed to the accident.
Addressed here are the human factors53 that explain why feed was added to the tower for three hours
without liquid being removed. While recognizing that human errors were made in the raffinate startup,
this investigation goes beyond individual failures to gain a deeper understanding of why the incident
occurred, which is more useful in major accident prevention.54 Renowned process safety expert Trevor
Kletz puts it plainly: “To say accidents are due to human failing is like saying falls are due to gravity. It is
true but it does not help us prevent them.” The broader aspects of this investigation revealed serious
management safety system deficiencies that allowed the operators and supervisors to fail. The following
underlying latent conditions contributed to the unsafe start up