Human Factors Analysis of the BP Texas City Refinery Explosion

On March 23, 2005, the BP Texas City Refinery suffered one of the worst industrial disasters in recent U.S. history. An explosion and fire occurred during the startup of a process unit. Fifteen workers were killed and 180 others were injured when a distillation tower was overfilled and liquid and vapor hydrocarbons were released into the atmosphere. A vapor cloud formed, found an ignition source, and exploded. The U.S. Chemical Safety and Hazard Investigation Board (CSB) deployed a team to Texas City to conduct a root cause investigation. The authors of this paper, working as investigators for the agency, found several pre-existing latent conditions and safety system deficiencies that affected unit operators' decisions and actions on the day of the incident. This submission presents a summary of those deficiencies and the primary human factors issues of the case.