BP Texas City Refinery Explosion: Engineering Ethics Analysis

Introduction

This post-mortem report is directed to the British Petroleum (BP) board of directors concerning the BP Texas City refinery explosion that took place on March 23, 2005. A series of explosions occurred during the restarting of the hydrocarbon isomerization unit at the Texas City refinery. The main technical cause of the initial explosion was the flooding of an over-pressurized distillation column, which resulted in a geyser of combustible vapor being released through the vent stack. A car engine near the tower then ignited the vapor, causing a series of devastating explosions that resulted in 15 deaths and 170 injuries.

This post-mortem report is especially relevant given that the very same Texas City refinery experienced a fire on October 30, 2012, at its Resid Hydrotreating Unit. The fire was extinguished with no major injury or damage, but it was officially rated as a Level 2 emergency for both the refinery and the city. A Level 2 designation suggests "it was not having an effect on the community but it had the potential to" (Pulsinelli, 2012). The Texas City situation reveals deeper ethical issues that need to be addressed by the company.

This report is also timely because, as of November 15, 2012, BP settled with the United States Department of Justice on both civil and criminal charges related to the 2010 Deepwater Horizon explosion incident. In the preceding years, BP accumulated numerous other workplace incidents that point to what can fairly be described as a deplorable safety record. It is argued here that safety hazards like the 2005 Texas City disaster stem from BP's failure to implement a coherent code of ethics. In particular, BP has made disastrous decisions to put profit ahead of social, environmental, and moral responsibility.

By focusing exclusively on financial returns, BP failed to apply even a basic utilitarian ethical framework — one in which the right decision is determined by a single guiding principle: act so as to produce the greatest good for the greatest number. The recommended action for BP, therefore, is to adopt a new process of safety regulation in which workers can report observed hazards without fear of retaliation, reprimand, or ridicule. This procedural reform would represent an important first step toward decision-making grounded in utilitarian ethics.

Description of Engineering Failure

On the morning of March 23, 2005, BP employees and contract workers at the Texas City Refinery "began an especially dangerous procedure: re-starting a unit that had been down for repairs" (Schorn, 2009). As part of the restart procedure, workers began filling an isomerization unit tower with gasoline, but an overflow alarm failed to trigger. Compounding the alarm failure was a shift change: the incoming operator was unaware of the current state of the isomerization unit, because the outgoing operator had failed to maintain a detailed logbook.

A senior supervisor had also arrived late and left early. The new operator continued the feed without any experienced personnel present to provide guidance. By the time the alarm problem was detected, it was too late. The distillation column overflowed with liquid gasoline, which flowed to the vent stack and released itself as a geyser of fumes and liquid visible from a considerable distance. "The plume of gas had formed a massive vapor cloud on the ground, and an idling truck likely had ignited the fumes" (Schorn, 2009, p. 1). The resulting explosion had devastating consequences.

Among the factors worsening the outcome, BP had permitted the construction of worker trailers in close proximity to the isomerization unit. As Schorn (2009) notes, "the blast pulverized several office trailers full of workers parked nearby" (p. 1).

Analysis of Ethical Lapses

The ethical lapses are relatively clear in hindsight, and several specifics stand out. First, BP ignored poor safety standards and conditions at the Texas City refinery for years before the explosion. Reports released after the event reveal the extent to which BP was aware of these deficiencies and chose to do nothing. Equipment was known to be outdated and dangerous: "Unsafe and antiquated equipment designs were left in place, and unacceptable deficiencies in preventative maintenance were tolerated" ("CSB Investigation of BP Texas City Refinery Disaster Continues as Organizational Issues Are Probed," 2006). Investigators "found problems at Texas City just about everywhere they looked: antiquated equipment, corroded pipes about to burst, and safety alarms that didn't work" (Schorn, 2009, p. 2). Indeed, the very vapor release unit that caused the explosion had been known to be faulty for as long as ten years. "In the ten years leading up to the disaster, there had been eight major gasoline vapor releases on that unit — any one of which could have been catastrophic" (Schorn, 2009). The "culture of safety" the company claimed to maintain was focused only on minute procedural details such as OSHA compliance, rather than on the large-scale, systemic issues that ultimately caused the 2005 explosion.

Internal documents on file in the years prior to the explosion also demonstrate "knowledge of significant safety problems at the Texas City refinery and at 34 other BP business units around the world — months or years prior to the March 2005 explosion" ("CSB Investigation of BP Texas City Refinery Disaster Continues as Organizational Issues Are Probed," 2006). Budgets had been cut before the explosion, and the refinery was inadequately staffed, particularly with workers qualified to handle emergencies. Despite these organizational failures, BP "blamed the disaster mostly on operator error and fired six employees," rather than examining the responsibilities of upper-level management (Schorn, 2009, p. 2).

Putting profit first has proven to be a deeply problematic ethical doctrine. Immediately following the 2005 explosion, BP was compelled to implement certain changes, but it did so primarily as a public relations response rather than out of genuine ethical commitment. Had the company been acting on the principle of producing the greatest good for the greatest number, the disaster never would have occurred. The company offered bonuses for cost-cutting rather than for promoting safety and public welfare. Only after — not before — the explosion did BP announce it "will install modern process control systems on major units, transition to a more powerful maintenance management system, improve worker training, remove blow down stacks and implement the other recommendations" (British Petroleum, 2005). All of these measures should have been in place long before the incident.

As Ohreen (2010) observes, "BP's failure…is indicative of a much larger problem with companies that have embraced one of the central ideas in management today: stakeholder theory. The idea that companies can meet the needs of 'stakeholders' leaves them open to moral abuse without normative principles at its core." Stakeholder theory, as practiced by BP, places ethical value on shareholder wealth and profit. What BP requires instead is a framework that places ethical value on people — a utilitarian framework that subordinates profit to human welfare.

Conclusion

The Texas City disaster "killed 15 workers, injured 180 others, and was the worst U.S. industrial accident in more than a decade" ("CSB Investigation of BP Texas City Refinery Disaster Continues as Organizational Issues Are Probed," 2006). The BP board of directors should pursue a new public relations strategy that demonstrates genuine commitment to change — one backed by structural and cultural reform, not press releases. Since the 2010 Gulf oil spill, which returned to public attention with the record-breaking $4.5 billion settlement with the Department of Justice and the charging of two BP personnel with manslaughter, the company's credibility has been severely compromised. BP lied to Congress after the Gulf disaster and handled the 2005 Texas City disaster with equal dishonesty. It is therefore strongly recommended that BP undertake a comprehensive transformation of its organizational culture. A sustained period of institutional introspection is both necessary and overdue for a company in crisis.