18 years on: Lessons learned from the Texas City refinery disaster

March 23, 2023 is the 18^th anniversary of the Texas City refinery disaster which claimed 15 lives. As part of the consulting team that helped BP management work through the causes of the disaster, we learned valuable lessons. Some of them were identified in the Baker Report, while others were only identified internally. On this anniversary, I’d like to examine a finding that is relevant to many industries. How do companies ensure that workers are competent to perform tasks for critical roles? It’s a simple concept but difficult to manage.  

Soon after the incident, BP launched a global initiative to make genuine change across its refining operations. This included a series of workshops with a variety of stakeholders. One memorable workshop included the union (OCAW at the time) process safety leader, a man with a large presence and a loud voice. He boomed, “The problem with you guys (BP) is that you teach our brothers and sisters how to work the machines and not how the machine works!” It was a memorable moment for me, and his simple statement spoke volumes. Operators knew they were supposed to follow procedures. However, they had no idea how what they did impacted other parts of the refineries. Local management neglected to teach their workforce how the machine works.

Admiral Rickover, founder of the U.S. Nuclear Navy, knew the danger of operating in a silo. Therefore, he implemented programs to ensure that submariners knew all the processes on their ship. He believed that, “When doing a job — any job — one must feel that he owns it, and act as though he will remain in that job forever.” For Rickover, regular competence testing was part of this process.  

The late Dr. William Corcoran, a nuclear power safety expert, supported both approaches. He would often say, “Operators need to understand the downstream consequences of upstream actions.” 

Today, a few enlightened firms like Dow and Syngenta have embraced this idea by mandating that leaders be able to ‘draw and describe’ a plant or unit’s systems, this is a requirement to become (and remain) a leader. I fully support this process which demands a baseline level of process safety knowledge and understanding.

A practical approach for process safety

Better practices for high-hazard operations include:

1. Teach both the process and the specific job. Operators need to understand how their actions (and inactions) affect an entire process.
2. Identify critical equipment. Operators need to understand what pieces of equipment must always be working as specified. Critical equipment are the pieces of kit that keep an entire component and/or system safe.
3. Define safe operating limits and breach response procedures. Management and operators should have a clear understanding of safe operating limits. These should have defined procedures governing returning the process to steady state and when to initiate a shutdown or bypass. Don’t leave these processes to judgement calls.
4. Barrier thinking. Operators should understand the sources for losing component or system control. The barriers that prevent a loss of control need to be easily understood. Operators should be able to verify they are in place and working.
5. Drill for upset conditions, and learn from them. Do actual, simulated or table-top drills on how to handle an upset condition. Learn from the drills and train on any identified vulnerabilities.
6. Cross-train operators – they should experience jobs that are both upstream and downstream of their regular roles. This will provide them with first-hand knowledge of how their role affects others.
7. Learn from incidents. Routinely share near misses. Celebrate shutdowns and proper applications of process. Build a culture that reinforces courageous actions. Have operators describe how they would react to an incident (not if the incident could happen!).
8. Leaders should always ask four questions: 1) What’s the hazard? 2) What keeps the hazard from happening? 3) Is it working now? 4) How do you know?
9. Leadership inquiry. Leaders should set the tone for culture through the questions they ask. Constant discussion about the job and the systems. Inquiry on operating limits and upset conditions. Questions about the status of critical equipment. Verification of skills and knowledge.  Asking operators about their recollection of an incident or a courageous act.

The incident in Texas City was multifaceted, and while it’s uncertain whether the implementation of these nine practices would have entirely prevented the occurrence 18 years ago, it’s a possibility. Nevertheless, various factors played a role in the event’s unfolding. From this incident, I’ve learned that individuals with good intentions typically strive to do what’s right, but sometimes they lack knowledge of what that entails. Consequently, it falls upon leaders to provide guidance, particularly in matters of safety. Leaders must make safety a priority, even when it means resisting the urge to prioritize operational demands and accept additional risk.

The union leadership at BP was spot on. Employees working around complex and hazardous equipment must understand the entire system, not just their job. Leaders must provide this context. Admiral Hyman Rickover said it best: “Be ever questioning. Ignorance is not bliss. It is oblivion. You don’t go to heaven if you die dumb. Become better informed. Learn from others’ mistakes. You could not live long enough to make them all yourself.”

In memory of Glenn Bolton, Lorenza Cruz, Rafael Herrera, Dan Hogan, Jimmy Hunnings, Morris King, Larry Linsenbardt, Arthur Ramos, Ryan Rodrigues, James Rowe, Linda Rowe, Kimberly Smith, Susan Taylor, Larry Thomas and Eugene White.