Texas City Disaster: A 20-Year Reflection on Systemic Safety Failures

March 23rd is the 20th anniversary of the BP Texas City refinery disaster. This incident tragically claimed 15 lives and serves as a stark and enduring reminder of the catastrophic consequences of prioritizing commercial success over operational safety. This reflection is particularly pertinent today for operations executives and safety professionals as we navigate similar pressures and strive to prevent future tragedies.

While the immediate causes of the explosion were technical, the underlying factors involved a complex interplay of systemic, people and cultural issues. Cost-cutting measures and subsequent under-resourcing were contributing factors. Like the recent issues with Boeing, BP prioritized commercial success over operational safety.

BP in general, and Texas City in particular, had many brilliant, talented and well-intentioned individuals. In the face of cost constraints, overwhelming workloads and limited capital, these individuals did the best they could.

Those limitations, however, became contributing factors to the tragedy. As part of the team investigating the cultural elements of the incident, we found that refinery engineering teams were significantly overworked. A simple estimation found that the engineering team was over 300% utilized.? That means each engineer was trying to perform a job meant for three people!?

Members of the team were constantly making decisions on what needed to get done and how best to complete the tasks with limited resources.? That meant making choices, selecting to delay or stop some work, or to take shortcuts. Choices were made that seemed right for the moment. In hindsight, many choices would eventually suboptimize safety.

This pressure created what I call a 'so loop.’ ‘So loops are patterns of behavior that degrade performance over time. These loops are hard to break and require rebuilding of trust and engagement.? At Texas City, the lack of time led to decisions to skip steps and take shortcuts, which led to taking on more risk. That additional risk was fed into additional project work and the cycle would continue in a downward, spiraling loop.? As safety consultant Eduardo Lan says, “When you’re working in a faulty system, people will do what they need to do. Taking shortcuts is the only way to get by!’ ?Furthermore, the ability for supervisors to provide thorough oversight diminishes when everyone is overburdened, creating a situation where errors go unnoticed and projects can go unchecked.

At the front line, employees felt the impact of these decisions. Maintenance processes were deferred to the detriment of safety critical equipment.? Those maintenance deferrals would eventually destroy employee trust and confidence. The line employees knew the consequences of those deferrals.? Another so loop was created.? Operators knew what needed to get done. They completed work orders. The work orders were deferred or denied, so they stopped creating work orders.

Even well intended employees will eventually stop participating in safety efforts when they know the answer is delay, defer, diminish or ignore. That shift created a deep hole that eventually would end in disaster. It would only be fixed after the explosion, a change in refining leadership, the development of OMS (BP’s Safety Management System), millions of dollars in upgrades, and the appointment of an independent monitor to oversee risk and safety.

Consider these mandates for leadership to prevent future incidents:

1.????? Actively monitor and address employee workloads to prevent overburdening, which inevitably compromises safety oversight and decision-making.

2.????? Find out where your so loops exist and rebuild trust to eliminate them.

3.????? Mandate safety design reviews with mandatory safety sign-off for all capital expenditures.

4.????? Systematically incorporate the question: 'With an additional 10% in funding, how can we enhance the safety of this project for our personnel?' into the capital approval process.

5.????? Upon asset acquisition, ensure the immediate definition and dedicated budgeting of safety 'Get Well' plans with a minimum three-year horizon.

6.????? As leaders, cultivate a culture where consistently compromising safety is unacceptable, and empower individuals to prioritize safety without fear of reprisal. Recognize the inherent difficulty of seeing systemic risks from within

7.????? Be prepared to make difficult choices and potentially lose your job rather than perpetuate unsafe practices.

Ultimately, the Texas City disaster serves as a stark reminder that even with a workforce comprised of well-meaning individuals, systemic failures can have catastrophic consequences. The confluence of under-resourcing, pressure to cut costs, and a lack of robust safety management systems created an environment where the earnest efforts of employees inadvertently contributed to a tragedy.

In remembrance of the 15 people who lost their lives: Bolton - Cruz - Herrera - Hogan - Hunnings - King-Linsenbardt - Ramos - Rodrigues -Rowe, J - Rowe, L - Smith - Taylor - Thomas – White

Other Articles by the Author:

(6) Faster Than the Disaster: BP Texas City 19 Years Later | LinkedIn

(6) Reflections on The 14th Anniversary of the BP Texas City Disaster: Seven Guidelines for Safety Management Systems Implementation | LinkedIn

(6) Was HR complicit in the 15 deaths on March 23, 2005? | LinkedIn

Eduardo Lan, MSOD, CRSP

SafetyAnd Consulting Associates, Inc.

National Safety Council

SafeStart, A division of Electrolab

#ProcessSafety

#SafetyCulture

#Safety

#TexasCity