1.2.1 BP Group and Texas City .................................................................................................18
1.2.2 OSHA ...............................................................................................................................20
1.3 Incident Description ...................................................................................................................21
1.4 Conduct of the Investigation.......................................................................................................22
1.5 Key Technical Findings..............................................................................................................22
1.6 Key Organizational Findings......................................................................................................25
1.7 Recommendations ......................................................................................................................26
1.7.1 New Recommendations....................................................................................................26
1.7.2 Previously Issued Recommendations ...............................................................................27
1.8 Organization of the Report .........................................................................................................29
2.0 INCIDENT OVERVIEW ..............................................................................................................31
2.1 BP Corporate and Texas City Refinery Background..................................................................31
2.2 ISOM Unit Process.....................................................................................................................31
2.2.1 Raffinate Splitter Section..................................................................................................32
2.2.2 Raffinate Splitter Tower ...................................................................................................33
2.2.3 Safety Relief Valves .........................................................................................................36
2.2.4 Disposal Header Collection Systems................................................................................37
2.2.5 Blowdown Drum and Stack..............................................................................................37
2.2.6 ISOM Unit Sewer System.................................................................................................40
2.3 Turnaround Activities.................................................................................................................40
2.3.1 Ultracracker Unit and Aromatics Recovery Unit Turnaround..........................................40
2.3.2 Partial ISOM Unit Shutdown............................................................................................41
2.4 The Hazards of Unit Startup.......................................................................................................44
2.5 Incident Description ...................................................................................................................44
2.5.1 Unit Staffing .....................................................................................................................45
2.5.2 Preparations for the ISOM Startup ...................................................................................47
2.5.3 Initial Tower Filling and Shutdown..................................................................................49
2.5.4 Inadequate Shift Turnover ................................................................................................51
2.5.5 Raffinate Tower Startup....................................................................................................52
2.5.6 Tower Overfills.................................................................................................................54
2.5.7 Tower Overflows..............................................................................................................58
2.5.8 Safety Relief Valves Open................................................................................................59
2.5.9 Hydrocarbon Liquid Flows Into Collection Header .........................................................61
2.5.10 Flammable Liquid Flow Into ISOM Sewer System..........................................................61
2.5.11 Flammable Liquid Flow Out of the Blowdown Stack ......................................................62
2.5.12 Flammable Vapor Cloud Formation and Fire...................................................................64
2.5.13 Ignition Source..................................................................................................................66
2.5.14 Blast Pressure....................................................................................................................66
2.5.15 Post-Explosion Fires.........................................................................................................6