Texas City Explosion Hazard

Management Diagram
Hierarchy of control Bias towards hardware/inherent safety & reducing the scope for human error multi barrier defence

Relief and
Blowdown
System

Control, Alarm &

Shutdown system

Inherent Design
Plant Layout

Effective
Supervision /
Leadership

Operations
Procedures

Learning from
the Past
Maintenance
& Inspection

Work Control

Audit & Self

Regulation
Training &
Competency

Communication

Active & Passive

Fire Protection

Rescue &
Recovery

Support to Next
of Kin & Injured

Escape /
Access

Management of
Change

Investigation &
Lessons Learned

HAZARD
REALIZATION

HAZARD
Normal
Hydrocarbon
Inventory in
Raffinate
Splitter

Loss of
containment
Ignition
Explosion

Inventor
y
increased
Proximity
of nonessential
personnel
to hazard
Flare not
used

Multiple fatalities
and injuries

No up to
date relief
study design
basis
unclear
Capacity
of
blowdown
drum
exceeded

Operate
outside
envelop
No failsafe
shutdow
n
No mass
balance
or
attention
to other
data
Lost
process
control

Faulty
high
level
alarm not
reported
Previous
incidents
& upsets
not
reported
Admin.
rather
than ISD
solutions
Hierarch
y of
control
not
applied

Procedure
s not
followed
Steps not
signed off
Use of
local
practices

Failure to
recognize
hazard to
trailers from
start-up
People not
notified of
start-up
Multiple
sources of
ignition in
adjacent areas

Inadequat
e HAZID
skills
Lack of
underpinnin
g
knowledge
Failure to
follow
procedures
Confusion
Pre-start-up
over who
review not
was in
performed
Procedural
charge
No
compliance not
verification
checked
Supervisor
on
procedures
offsite
No
in use
Absent from
interventions
Inadequate
unit at
critical times
KPIs for process
safety

No
effective
handover
between
shifts
Unit alarm
not
sounded
No /
incomplete
MOCs for
trailer siting
Blowdown
drum modified
without
rigorous MOC

Active &
passive fire
protection

Emergency
response by site
and external
authorities
Hospitalization

Access & escape

route diversity
Access to scene