Texas City refinery accident: Case study in breakdown of defense-in-depth and violation of the safety-diagnosability principle in design

Engineering Failure Analysis

Volumn 36, Issue , 2014, Pages 121-133

  Saleh, Joseph H ^a   Haga, Rachel A ^a   Favarò, Francesca M ^a   Bakolas, Efstathios ^b  

^a Georgia Institute of Technology   (United States)

^b The University of Texas at Austin   (United States)

Author keywords

Accident pathogens; Defense in depth; Refinery explosion; Safety diagnosability principle

Indexed keywords

ACCIDENT INVESTIGATION; CHEMICAL SAFETY BOARDS; CONDITIONAL PROBABILITIES; DEFENSE IN DEPTH; ISOMERIZATION UNITS; QUANTITATIVE RISK ASSESSMENT; SAFETY-DIAGNOSABILITY PRINCIPLE; SITUATION AWARENESS;

ACCIDENTS; LOSSES; REFINING; RISK ASSESSMENT;

EXPLOSIONS;

EID: 84886995011     PISSN: 13506307     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.engfailanal.2013.09.014     Document Type: Article

References (27)

1. AICHE Layers of protection analysis: simplified process risk assessment 2001, American Institute of Chemical Engineers, Center for Chemical Process Safety, New York.
2. Bakolas E., Saleh J.H. Augmenting defense-in-depth with the concepts of observability and diagnosability from control theory and discrete event systems. Reliab Eng Syst Saf 2011, 96(1):184-193.
3. BP, Fatal accident investigation report: isomerization unit explosion (Final report). December 2005. [accessed 10/30/2012]; 2005. http://www.bp.com/liveassets/bp_internet/us/bp_us/final_report.pdf.
4. Choudhry M.R., Fang, Mohamed S. The nature of safety culture: a survey of the state-of-the-art. Saf Sci 2007, 45(10):993-1012.
5. Cowlagi R.V., Saleh J.H. Coordinability and consistency in accident causation and prevention: formal system-theoretic concepts for safety in multilevel systems. Risk Anal 2013, 33(3):420-433.
6. CSB, 2007. US Chemical Safety and Hazard Investigation Board. Investigation report: refinery explosion and fire.
7. Durso F.T., Sethumadhavan A. Situation awareness: understanding dynamic environments. Human Fact: J Human Fact Ergonomics Soc 2008, 50(3):442-448.
8. Endsley M.R. Toward a theory of situation awareness in dynamic systems. Human Fact: J Human Fact Ergonomics Soc 1995, 37(1):32-64.
9. Endsley M.R. Measurement situation awareness in dynamic systems. Human Fact: J Human Fact Ergonomics Soc 1995, 37(1):65-84.
10. Hopkins A. Was the Three Mile Island a normal accident?. J Contingencies Crisis Manage 2001, 9(2):65-72.
11. Kaszniak M., Holmstrom D. Trailer sitting issues: BP Texas City. J Hazard Mater 2008, 159:105-111.
12. Kletz T.A. Hazop and Hazan: identifying and assessing process industry hazards 1999, Taylor & Francis, Philadelphia. 4th ed.
13. Le Bot P. Human reliability data, human error and accident models - illustration through the Three Mile Island accident analysis. Reliab Eng Syst Saf 2004, 83(2):153-167.
14. Lee T., Harrison K. Assessing safety culture in nuclear power stations. Saf Sci 2000, 34(1-3):61-97.
15. Leveson N.G. A new accident model for engineering safer systems. Saf Sci 2004, 42(4):237-270.
16. NRC, US, Causes and significance of design-basis issues at U.S. Nuclear Power Plants, Draft Report. Washington (DC): US Nuclear Regulatory Commission, Office of Nuclear Regulatory Research; 2000.
17. Rasmussen J. Risk management in a dynamic society: a modeling problem. Saf Sci 1997, 27:183-213.
18. Reason J. Managing the risks of organizational accidents 1997, Ashgate, Vermont.
19. Rollenhagen C. Can focus on safety culture become an excuse for not rethinking design of technology?. Saf Sci 2010, 48(2):268-278.
20. Saleh J.H., Saltmarsh E., Favarò F.M., Brevault L. Accident precursors near misses and warning signs: critical review and formal definitions within the framework of Discrete Event Systems. Reliab Eng Syst Saf 2013, 114:148-154.
21. Saleh J.H., Marais K.B., Bakolas E., Cowlagi R.V. Highlights from the literature on accident causation and system safety: review of major ideas, recent contributions, and challenges. Reliab Eng Syst Saf 2010, 95(11):1105-1116.
22. Sorenson J.N. Safety culture: a survey of the state of the art. Reliab Eng Syst Saf 2002, 76(2):189-204.
23. Sorensen JN, Apostolakis GE, Kress TS, Powers DA. On the role of defense in depth in risk-informed regulation, In: Proceedings of PSA '99, international topical meeting on probabilistic safety assessment, Washington (DC), August 22-26, 1999, American Nuclear Society, La Grange Park, Illinois; 1999. p. 408-13.
24. Summers A.E. Introduction to layers of protection analysis. J Hazard Mater 2003, 104(1-3):163-168.
25. Svedung I., Rasmussen J. Graphic representation of accident scenarios: mapping system structure and the causation of accidents. Saf Sci 2002, 40(5):397-417.
26. Turner B.A. Man-made disasters 1978, Wykenham Publications.
27. Venkatasubramanian V., Rengaswamy R., Kavuri S.N., Yin K. A review of process fault detection and diagnosis: Part III: Process history based methods. Comput Chem Eng 2003, 27(3):327-346.