8 replies to this topic

[Art Montemayor]

What probably has to the most tragic and hardest experience for any engineer is to realize and admit that he/she has been the cause of human deaths during his/her watch - moreso when it is admitted that the whole tragedy was easily preventable.

Attached is a local story on the subject disaster. I am posting this as a grim reminder of what dire and tragic circumstances we, as engineers, can bring upon others when we become careless, sloppy, and fail to give importance to the welfare and safety of those people that are under our supervision and care. As I stated in my first posting on this tragedy, almost 3 years ago, it all could have been so easy to avoid; all they had to do was to forbid any outsider within the immediate vicinity of the Isomerization Unit while it was being started up.........and no one would have died.

I hope this serves as a lesson learned for all reading this.
 Victims_decry_BP_plea_deal.doc   32.5KB   188 downloads

[Zauberberg]

Thanks Mr Montemayor, I was really wandering what is the final outcome from this story.

I remember, few years ago when I was reading the official report explaining the sequence of events before the incident finally occured. And I still think, based on this report - that is my opinion - the people who are the most responsible for this tragedy are Operations people. Or shift personnel, whatever you prefer more.

I was working for almost 5 years as Operations and Technical Service engineer, in different positions: plant engineer, plant manager, lead process engineer etc. And I remember very well that behavior of shift personnel - especially night shift people - was far far away from any regular/safety procedure, internal standards etc etc. Simply, there were no people who could look after them, and no one was responsible - at the bottom line. The big news for me is that same things happen all around the globe. I thought I was the only one having privileges to observe such a behavior. The best thing, however, is that I couldn't blame all these people, I don't know why... Maybe because they were (and they still are) the ones that are really responsible for making the profit for a company and ensuring that plant is running - sometimes smoothly, and sometimes not so good. I consider this to be a rather romanthic way of thinking in today's world, but that is my impression.

However, one sentence from the article you posted got my full attention. And that sentence is: "BP cares more about money than safety. To coin a phrase, they will kill again".

From my experience, nothing can be more closer to the truth. And that is the saddest part: who cares about safety, moral, quality engineering work etc., if company is going to loose money by applying safety, basic professional ethic and all other procedures? Or if any kind of politics is involved in business development and operation, there is no justice at all. I've seen that so many times, and it happens over and over again.

One is for sure: there is no rule, internal or external , that could force professional engineer to act in a manner that is opposite to his/her personal and professional ethic. Being - maybe - lucky so far, I didn't reach that point in my career when I should choose between ethic and money. If that ever happens, I am very sure I'll change my profession and become a school teacher somewhere in my homeland's mountains, far far away from today's world madness.

Thank you again for this very enlightening story.
Best regards,

[latexman]

Where I work when a unit starts-up they declare (PA annoncements, two-way radio announcements, flashing lights and signs) a period of heightened risk. Everyone except essential personnel must leave the block until the unit reaches a pre-determined state when the heightened risk can be called off.

It's simple and easily controlled. It's a shame BP didn't follow this practice.

[Art Montemayor]

Latex:

You have confirmed and reinforced what I have maintained and insisted upon most of my professional life. I have worked and been in many processing units - especially in the Texas Gulf Coast - and my experience in them has been just as you describe, and sometimes even stricter. For me, this has been common sense and a result of prior Lessons Learned that all engineers - particularly young ones - should heed. For the benefit of those new members or young engineers who didn't read my first report on this about 3 years ago, allow me to quote what I wrote then about this incident:

"Now we have a situation where 15 innocent contractors have been killed outright. I bring this subject to this forum now because I frankly feel it is so important to study, and the “official” results won’t be issued for over a year – as is the current CSB custom of reporting to the public. I don’t think we should wait to discuss something of this nature that clearly should not have happened. My main, present point is:

Every experienced professional engineer knows that when a Unit is being started up (or shut down) it is common (and almost mandatory by common sense) - and expected - to banish all contractors (& anyone not directly participating in the startup) from the immediate site. This is to be expected as SOP (Standard Operating Procedure) since anyone outside of the immediate operating area has no positive contribution to offer at such a critical time. We all know that, like airplanes, operating plants are more susceptible to mishaps during startups and shutdowns. These are times when no one else should be tolerated in the area. Nevertheless, there were many outside contractors active in the area at the time of this tragedy – something that defies understanding and clearly is a challenge to Sir John Browne & company to explain away as to how this was permitted or tolerated at a site already under severe and critical review from OSHA.

I believe this is the first and foremost lesson to be learned by this tragedy – regardless of the lack of evidence and official reports yet to be issued. The facts are what the facts reveal: outside contractors were tolerated in the immediate area of the Unit undergoing startup. This fact, in my opinion, is a definite NO-NO in any startup, under any circumstances. The only time that outsiders are tolerated should be only during the initial startup where process and instrumentation consultants are kept in the control room environment for immediate consultation due to lack of familiarity with the initial startup. After that, the operations group should kiss-off on all outsiders."

I wrote the above on the day of the incident and I feel very sad about this tragedy because it is truly a LESSON RE-LEARNED - but at a cost of human life.

Thank you.

[afd]

Art thank you for your indepth description and touching the subject matter to the core.

Life goes on...

disasters will occur or be created by human error, oversight,lack of knowledge and NEGLIGENCE.

negligence cannot be pardoned when it costs human lives or not. All businesses are created to generate profits and that is the core industrial ethic practised everywhere in the world. With globolization, mergers and acquisations everyone wants to be on the top. There is not a fine dividing line between safety and production. The operations staff are compelled to take risks to keep the unit running and is happening every moment around the indutrial world.When nothing happens everything is fine;if something goes wrong then there will fingers to point at, and if's and but's will appear. I encounter this nearly everday and had a bad experience during my sixteen hour duty last evening.

Trevor Kletz in his book" An engineer's view on human error" states " we cannot change people, try to change situations". Technology has led to a greater safety in the process plant but we will find many interlocks bypassed to prevent spurious trips. Fire safety nitrogen purge valves not working. The main reason behind this is fire, explosion and disaster may have a very large severity but the probability is low so everyone(management) makes a trade off between profits and downtime losses.

Even though we have fire drills conducted, in the event of a fire the situation is totally different and everyone will panic. This is more true with the contractors. I was a witness when a unit was preparing for a shutdown and scaffolding work in progress. A gas leak resulted in the contractors jumping down and running helter skelter.Human reaction cannot be predicted.

Unit shutdowns are unpredictable, unless they are planned for maintenance jobs.But whenever a unit is being started up everyone is aware of it,then why should they allow contractors in the vicinity? the tragedy is they did and 15 innocent lives were lost.

The question remains will it happen again? I read an article in Hydrocarbon processing titled " Bhopal: could it happen again" with emphasis on process safety. I strongly feel that engineers and operators are trained on to identify process hazards and their consequences.

I end with a qoute from Jesse C. Ducommun, Director of American Oil Company in 1961, " It shoudle not be necessary for each generation to rediscover principles of process safety which the generation before discovered. We must learn from the expierence of others rather than learn the hard way. We must pass on to the next generation a record of what we have learned ".

Afd

[mishra.anand72@gmail.com]

Lessons are learnt. Procedures will be updated. Where was safety crew?

Thank you for giving story.

[TroyH]

I have just begun a unit in Risk Management as part of my Chem. Eng. degree, and I have found this thread quite interesting.

Having spent all day today reading case studies from Bhopal, Toulouse, Piper Alpha, Seveso and this particular incident at the BP Texas refinery, it is interesting to see this kind of discussion.

The events at BP Texas really surprised me, but reading about Piper Alpha was a real shock.

Has there been much change to procedures (outside of BP) as a result of the incident?

Zauberberg - Perhaps I am oversimplifying your position, but it seems as though you are saying there is nothing that can be done about the bad practices of Operations or shift personnel? Everything I am learning says that whilst you can't eradicate risk, there is always something you can do to reduce it. If personnel are acting in a way that increases risk, then isn't it the responsibility of engineers to either alter the process design to make it inherently safer, engineer the process equipment to make it safer in the event of an incident, to educate personnel about the dangers, or indeed, simply audit them to ensure they are acting in a safe manner?

I apologise if I have taken your comments the wrong way, but the thought of merely shrugging ones shoulders and saying "Oh well, what can I do?" disturbs me.

[Zauberberg]

Good evening Troy,

I cannot say I disagree with you - there is nothing wrong with the concept you are writing about: it is simple and straightforward, fully responsible, and should be completely independent of all other facts. In my opinion, this is the way it should be and how it is written in the books.

However, things are much more complicated in practice - one thing that is certainly out of ANY university book is: human factor. I consider to be something that is definitely outside of all procedures, and can be handled exclusively in two ways: by having strong moral authority of plant manager/engineer or perfect safety system which forces everyone to obey it, without any exceptions. The best thing is when you have both; however, it might come true you don't have either of these two. In such circumstances tragedies can happen, and I think this was the case in Texas City.

During my 6-years long professional life, I had an opportunity to hold different positions within process industry: starting as plant engineer, then becoming plant manager and area manager, after that being Technical Service engineer (coupled with Operations activities) and, finally, I found myself working as process engineer in consultancy. That's why I think I have "a big picture" of what can motivate people, and what can frustrate them in such way there is no procedure or law or punishment that can force them to obey anything. And especially if there is no replacement for these people, or if it cannot be found in a short time. Then you have a problem. But, my idea is that problem is not in the people - it is completely dependent of the whole system and working environment. Having good people around you will make your life happy - you don't need the system actually, it can only spoil them!

This is my personal experience and, perhaps, much different from what one can expect. But simply after changing many positions/companies, this is my general conclusion. Good system and strong moral authority of leader will take the best out of people and make them happy (and you as well) following the procedures. Bad system will simply spoil even the best people you can find on Earth and I'm afraid there is nothing one individual can do about it. Except to leave everything, and start thinking about some other job or even changing the profession.

Best regards,

[gvdlans]

The US Chemical Safety Board (CSB) has now launched a 50+ minutes video on their website ( http://www.csb.gov/i..._...&page=index ) about the Texas City Refinery Explosion. I must say, this film is quite impressive and balanced. Focus is on (lack of) safety culture, lack of supervision (at all levels, including supervision by the authorities) and human factor issues. Replacement of blowdown stacks by flares is mentioned but more as a side-note.

I think it is a good decision of the CSB to make such accident investigation videos available through their website. Incident investigation reports are only read by a few people and are soon forgotten, where videos can make much more (and hopefully longer-lasting) impact on people.