16b Examining Organizational and Safety Culture Causes of the BP Texas City Refinery Explosion

摘要

On March 23, 2005, a series of explosions and fires occurred at the BP Texas City refinery during the startup of an isomerization (ISOM) process unit. Fifteen workers were killed and about 180 others were injured. However, the catastrophic incident on March 23rd was not the only major incident at the Texas City refinery. As part of its investigation, CSB learned that over the past 32 years, the BP Texas City refinery has had 39 fatalities. This discovery prompted CSB to investigate the organizational and safety culture precursors that produced the multiple safety system deficiencies that lead to the ISOM incident and the history of major accidents and fatalities at this refinery.