Abstract
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.
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