THE UNIVERSITY OF DO DOMA

COLLEGE OF EARTH SCI ENCES

S C H O O L O F M I N E S A N D P ET R O L E UM E NG I NE E R I N G
DEPARTIMENT OF PETRO LEUM AND ENERGYENGIN EERING

DEGREE PROGRAM: BSc. PETROLEUM ENGINEERING

ACADEMIC YEAR: 2018/2019

COURSE NAME: ENVIRONMENT AND SAFETY MANAGEMENT

COURSE CODE: PE 423

COURSE INSTRUCTOR: Dr. G. KOMBE

GROUP ASSIGNMENT

PARTICIPANTS:

NAME REGISTRATION NUMBER

NURU KAMUGISHA T/UDOM/2015/00146
MWILEMELA JUMANNE S T/UDOM/2015/00143
LEMMA ZAHIR Y T/UDOM/2015/00133
MGINA NICHOLAUS E T/UDOM/2015/00135
MULEMWA MISANA S T/UDOM/2015/00139
SALEH OMARY MARYAM T/UDOM/2015/00152
KHEIR FATHIA JOMBI T/UDOM/2015/00130
ULUNGI GLEAM ANDREW T/UDOM/2015/00156
SAWIGA MICHAEL R T/UDOM/2015/00154
 INTRODUCTION

Oxford English Dictionary defines accident as an unfortunate incident that happens

unexpectedly and unintentionally, typically resulting in damage or injury. Causes for an
accident may be classified as immediate causes, underlying causes or root cause,

Oil and gas industry is accompanied with a number of risks and hazards from the exploration
to facility installation throughout its entire life, these risks and hazards give rise to the
incidents/accidents whose extent range from near-miss to a serious accident that cost lives of
people. Flammability of oil and gas products such as crude oil, hydrocarbon gases and refined
products makes the incidents more dangerous due to fire and explosions that may occur once
an ignition is initiated. (Bouti, 2018)

Various literature and statistics have shown that, the rate of incidents/accidents in oil and gas
industry were higher and severe in early times of the industry due to poor safety policies,
awareness and implementations as well as poor technology of preventing and combating those
incidents. However, as time goes on, various advancements in technology and safety policies
have been done to improve the safety of the industry, keeping the incidents at minimum level.
(Bouti, 2018)

This work study three accidents that occurred in oil and gas industry, starting with the short
brief introduction of the accident, its time line of the event, causes and lessons learned from
those incidents.

i
 CONTENTS
INTRODUCTION ...................................................................................................................... i

LIST OF FIGURES ................................................................................................................. iii

LIST OF TABLES ................................................................................................................... iii

1. TIPER TANK OVERFLOW ................................................................................................. 1

1.1 INTRODUCTION ........................................................................................................... 1

1.2 IMMEDIATE ACTIONS TAKEN AFTER INCIDENT ................................................ 2

1.3 CAUSES OF THE ACCIDENT ...................................................................................... 2

1.4 OUTCOME OF THE ACCIDENT .................................................................................. 3

1.5 LESSONS FROM THE ACCIDENT .............................................................................. 3

2. BP TEXAS CITY REFINERY EXPLOSION ....................................................................... 4

2.1 INTRODUCTION ........................................................................................................... 4

2.2 CAUSES OF THE ACCIDENT ...................................................................................... 7

2.3 LESSON LEARNED FROM BP TEXAS CITY REFINERY EXPLOSION................. 9

3. BOHAI 2 OIL RIG ACCIDENT ......................................................................................... 10

3.1 INTRODUCTION ......................................................................................................... 10

3.2 CAUSES OF THE ACCIDENT .................................................................................... 11

3.3 LESSONS LEARNED FROM THE ACCIDENT ........................................................ 11

CONCLUSION ........................................................................................................................ 12

REFERENCES ........................................................................................................................ 13

APPENDIX A .......................................................................................................................... 14

ii
 LIST OF FIGURES

Figure 1: Fire explosion at BP Texas City Refinery .................................................................. 4

Figure 2: Bohai No.2 Oil Rig Accident (Dhillon, 2016) ......................................................... 10
Figure 3: Deformed kick plate on tank S. 34, Courtesy of TIPER Tank S.34 (2018) ............. 14
Figure 4: Deformed roof plate on tank S34, Courtesy of TIPER Tank S.34 (2018) ............... 15
Figure 5: Damaged carbo-angle at tank S34, Courtesy of TIPER Tank S.34 (2018) .............. 15
Figure 6: Raptured weld at carbo-angle/shell seam, Courtesy of TIPER Tank S.34 (2018) ... 16
Figure 7: Raptured weld at roof plate and deformed shell plate at tank S34 of TIPER Tank S.34
(2018) ....................................................................................................................................... 16

LIST OF TABLES

Table 1: Time line of Events Leading to the Tank S34 Overfilling. ......................................... 1
Table 2: Timeline of events leading to BP Texas City explosion.............................................. 4
Table 3: Tank S34 details ........................................................................................................ 14
Table 4: Tank S34 product loss details .................................................................................... 14

iii
 1. TIPER TANK OVERFLOW

1.1 INTRODUCTION

TIPER is bulk petroleum storage terminal that receives, stores imported refined petroleum
product and transfers to other petroleum depots. TIPER is a bounded warehouse for petroleum
product in Tanzania. In 29th July 2017, during normal operation of transferring product from
one tank to another (Internal Tank Transfer, ITT) recipient tank overflowed. Prior to the
incident TIPER had no history of overfilling of the tank. Below is time line of the events.

Table 1: Time line of Events Leading to the Tank S34 Overfilling.

Time Event/ Activity

Around 17:00 hours Operator Shift change occurred.
Around 19:00 hours Gasoil Internal Tank Transfer (ITT) begun
from tank S.5 to S. 34 and S. 35
Around 22:00 hours Tank S. 34 overflow during ITT.
Following the tank overfill, the operation
was immediately suspended by stopping the
pump and closing all the valves.

Parallel to that, lowering of the tank S.34 by

gravity to tank S. 35 started in order to
achieve safe operating level where it was
completed around 22:50 hours.
Around 06:45 hours Shift supervisor reported the incident to
MOP Superintendent.
Safety measures continued and spilled oil
started to be recovered
Around 14:30 hours The condition was contained with total loss
of 253.689 cubic meters.

A study of storage tank accidents by James Chang (2005) reported 206 cases are of fire and
explosion which account 85% of total cases between 1960 to 2003. The overfilling of tank S.
34 didn’t result to fire or explosion but significant product was lost into the ground resulting to
financial loss and environmental pollution. Pertaining the overfill, the tank sustained damage
on its kick plate, roof plate, carbo angle (shell seam), shell plate, hand rails and product loss as
seen in Appendix A.

1
1.2 IMMEDIATE ACTIONS TAKEN AFTER INCIDENT

 Suspending of the operation.

 Transfer of AGO from S34 to S35 by gravity so as to lower the product level in tank
S34.
 Recovery of spilled AGO from dyke of S34 by using a portable pump into shell
manhole of S36 which had been emptied for that purpose.

1.3 CAUSES OF THE ACCIDENT

i. Violation of Operating Practices

From the investigation it was found out the operator where not at their required position as how
the standard operating procedure (SOP) states. The SOP requires two terminal representative
operators to attend the operation one at the transferring tank and another at the receiving tank
continuously monitoring both tank and pump until the operation is completed. Then the two
operators to remain at their work locations ie. Transferring tank and receiving tank and keep
on monitoring the operation while reporting in half hour interval to the MOP Supervisor on the
operation progress (TIPER, 2018)

ii. Blind Operation

Due to absence of the operator at the receiving tank and lack of Automatic gauging system the
operation was carried out blindly (thus without real time information of what’s going on
between the two tanks). The operator relied on a routine half hour check of the tank level only.

iii. Untimely Maintenance

The tank automatic gauging system of the tank where months back reported to malfunction but
measures to rectify their conditions where not taken.

iv. Human Factor

Operators usual behaviours of not following standard tank fill procedures as well as negligence
of proper inspection and maintenance of gauging systems lead to this accident.

2
1.4 OUTCOME OF THE ACCIDENT

i. Product Loss

The incident led to loss of about 274,852 litres of product of which about 50 litres were spilled
at the road via foam generator system to open trench which had to be catered for by TIPER
since the facility stores product for clients; it does not own any product. Any loss that occurred
had to be covered monetarily by the facility.

ii. Financial Loss

A total of Tsh 515,072,648/= was lost due to the lost product. This has been calculated
according to the EWURA CAP diesel price on July 2017.

iii. Environmental Impacts

Given the fact that the containment of S34 was unpaved, severe soil pollution occurred at S34
dyke area due to percolation of diesel into the soil. At the time of incidence, diesel had
percolated to a depth of about 30 cm. Water pollution due to the diesel that spilled into the open
trench which drains into the ocean. Air pollution due to the diesel that volatilized from the
ground causing reduced air quality at the area.

iv. Asset Damage

Severe damage of the tank top shell, roof and hand rails occurred as shown in the appendix A;
the cost of which is yet to be established by the company after insurance coverage.

1.5 LESSONS FROM THE ACCIDENT

 New automatic gauging system should be installed immediately, and routine inspection
and correction action policy should be developed

 Increase in supervision and monitoring of the operations.

3
 2. BP TEXAS CITY REFINERY EXPLOSION

2.1 INTRODUCTION

Texas City refinery was considered the third largest refinery in United States (US) and it was
owned by British Petroleum (BP). It covered a vast amount of area of about 2 mi2 and consisted
of hundreds of workers. Apparently, Texas City was the site of tremendous industrial fire and
explosion on March 23, 2005 when a hydrocarbon vapor cloud was ignited and violently
exploded at Isomerization unit at BP’s Texas City refinery. This explosion was considered the
worst and it killed around 15 people while more than 170 people were injured (Ostrom &
Wilhelmsen, 2012).

Figure 1: Fire explosion at BP Texas City Refinery

Table 2: Timeline of events leading to BP Texas City explosion

Date Event/activity
September BP sites the double-wide trailer between the Naphtha Desulfurization Unit
2004 (NDU) and Isomerization (ISOM) units to house contractor employees for
turnaround work in the nearby Ultra cracker Unit

4
October 2004 The Texas City site leader meets with the R&M Chief Executive and Senior
Executive Team to discuss the 2004 incidents; management discusses how
these incidents are the result of casual compliance and personal risk tolerance
despite two of the three incidents being directly process safety related
2004 The 2004 Process Safety Management (PSM) audit reveals poor PSM
performance of the Texas City refinery, especially in mechanical integrity,
training, process safety information, and management of change (MOC)
November Plant leadership meets with all site supervisors for a “Safety Reality”
2004 presentation that declares that Texas City is not a safe place to work
Late 2004 BP Group refining leadership gives the Texas City refinery business unit leader
a 25% budget cut “challenge” for 2005; the business unit leader asks for more
funds due to the conditions of the refinery, but less than half of the 25% cuts
are restored
Late 2004 The Telos survey is conducted to assess safety culture at the refinery and finds
serious safety issues
2004 The refinery-wide OCAM audit finds that only 25% of ISOM unit operators are
given performance appraisals annually and that no individual operator
development plans are being developed for unit operators; the audit also finds
that the budget allows for no training beyond initial new employee and OSHA-
required refresher information
January– Nine additional trailers are placed in the area between the
February NDU and ISOM units
2005
January 2005 The Telos Report is issued with recommendations to improve the significantly
deficient organizational and cultural conditions of the Texas City refinery
February 2005 The BP Group VP and the North American VP for Refining meet with refinery
managers in Houston, where they are presented with information on the Telos
report findings, the deteriorating conditions of the refinery, budget cuts,
inadequate training, pressures of production overshadowing safety, and the
2004 fatality incidents
2005 The 2005 Texas City HSSE Business Plan warns management that that refinery
will likely “kill someone in the next 12–18 months’’

5
March 2005 The Texas City Process Safety Manager tells management that PSM action item
closure is still a significant concern and this metric is finally added to the site’s
1000-d goals

March 23, Explosion and fire at the Texas City refinery results in 15
2005

April 2005 fatalities and 180+ injuries

Owing to 23 deaths at the Texas City refinery in 30 yr, OSHA puts BP onto its
list of “Enhanced Enforcement Program for
Employers Who are Indifferent to Their Obligations”
July 2005 An incident in the RHU results in a shelter-in-place of the community and $30
million in damage at the refinery

August 2005 A release in the CFHU results in a shelter-in-place and $2 million in damage at
the refinery

September OSHA fines BP $21 million for 301 egregious willful violations
2005

December 13, During unit startup, a distillation tower at the BP Whiting refinery in Indiana is
2005 overfilled, resulting in fire and damage

June 2006 Settlement Agreement’s independent auditor study and recommendations.

Included in the study are recommendations to BPTCR to implement the ISA
S84.00.01 Standard for safety-instrumented systems

June 2006 An employee of a contractor was fatally injured when he was crushed between
a scissor lift and a pipe rack at BPTCR

6
 January 2008 The top head blew off a pressure vessel resulting in the death of a BP employee.
BP was issued four serious citations related to PSM

2.2 CAUSES OF THE ACCIDENT

BP’s own investigation report showed that various causes led to the occurrence of the explosion
as explained below;

i. Inspection and Maintenance

According to ISO, Inspection is an examination of a product, process, service or installation or

their design and determination of its conformity with specific requirement or on the basis of
professional judgement, with general requirements. From dictionary definition, maintenance is
the process of preserving a condition or a situation or the state of being preserved.

The workplace at BP Texas City Refinery had disintegrated throughout the years to one
described by protection from change and absence of trust, inspiration, and a feeling of direction.
Combined with indistinct desires around supervisory and executive practices this implied that
principles were not reliably pursued, meticulousness was missing, and people felt
disempowered from recommending and initiating improvements.

ii. Lack of HAZID

HAZID stands for Hazard Identification, It is the qualitative method applicable for
identification of potential hazards and threats affecting people, the environment, assets or
reputation. Apparently, HAZIP deals with description of HSE hazards and threats at their
earliest practicable time

With reference to explosion of BP Texas City refinery, lack of HAZID can be the main cause
for the accidents in oil and gas industry as described below.

At BP Texas City refinery; process safety, operations performance, and systematic risk
reduction priorities had not been set and consistently reinforced by management.

7
 iii. Lack of Knowledge and Training

According to Oxford Dictionary, Knowledge refers to facts, information and skills acquired
through experience or education. On the other hand, according to HSE guide training means
telling people what they should or should not do or simply giving them information.

A poor level of hazard awareness and comprehension of procedure security at BP Texas City
refinery brought about individuals tolerating dimensions of hazard that are extensively higher
than similar establishments. On outcome was that brief office trailers were set inside 150 ft of
a blowdown stack, which vented heavier than air hydrocarbons to the climate without
questioning the set-up industry practice.

iv. Management of Change

The management of change is a best conduct used to ensure the HSE (health, safety and
environmental) issues and risks are controlled to standard level when a company makes
changes in their personnel, operations, facilities and documentation. Many accidents and
incidents can be attributed to changes in process and equipment. Management should have
systems in place to ensure that any proposed changes are evaluated before they are commenced
and implemented.

According to the BP Texas city refinery accidents report, it describes the lack of management
involvement in risk assessment, evaluation and mitigation, for example there was many
changes in a complex organization that led to the lack of clear accountabilities and poor
communication, which in turn resulted in confusion and misunderstanding in the workforce
over roles and responsibilities in safety, health and environmental risks.

v. Poor Design

Sensors for measuring liquid height in the raffinate splitter tower of the Isomerization unit were
designed to measure heights up to 3m only. Thus, during pumping in of the highly flammable
liquid, there was no way to tell the amount of liquid in the tower that went beyond 3m mark,
which in actual fact the tower is believed to have reached 4m. Following a shift change, and
very poor communication, operators recommenced start-up process, adding more liquid to
overfull splitter tower, which latter after becoming hot, erupt over the refinery, leading to fires
and explosions. Safety equipments were not designed to eliminate hazard, rather to alert.

8
 vi. Not Learning from Near Misses

Reports shows that there were several near miss incidents prior the explosion at the refinery,
however no significant measures were taken to combat the situation. For instance, on March 1,
2004 there was an explosion at one of the units (UU4). Also, on September 2, 2004 there was
a steam release in one of the units of the refinery, which altogether indicated occurrence of
disaster.

2.3 LESSON LEARNED FROM BP TEXAS CITY REFINERY EXPLOSION

From this accident, we learn that accidents of this kind can be avoided by the following;
1) Enforcing the refinery’s own standards and ensuring that workers are properly trained
and supervised, the explosion could have been avoided.
2) In addition, if the mobile work trailers had not been moved into the site without first
getting an approved change to the siting plan, the majority of the people who lost their
lives would not have been in harm’s way.
3) Management should accept suggestions or improvements that have been addressed by
the workers which will green light to routine inspection and maintenance.

Furthermore, management should ensure that the following considerations are properly
addressed prior to any change being implemented
i. Impact of the change on the employee health and safety
ii. Modification to operating practices
iii. The technical basis for the proposed change
iv. Necessary time period for the change
v. Authorization requirements for the proposed change
vi. Information on changes of process and equipment to the all employees in proper time
prior to the operation.

9
 3. BOHAI 2 OIL RIG ACCIDENT

3.1 INTRODUCTION

Bohai No.2 oil rig accident is one among the biggest and oldest accident in the life oil and gas
Industry of Asia. It was located in the Gulf of Bohai off the coast of China, and it was managed
and operated by the Ocean Oil Company, China Petroleum Department. The accident occurred
on November 25, 1979 and caused the death of 72 out of 76 persons on board the rig.

Figure 2: Bohai No.2 Oil Rig Accident (Dhillon, 2016)

Time Line of The Event

While the rig was being towed, it was hit by the violent storm. The high wind broke the
ventilator pump, and created a large hole in the deck which quickly became filled with water,
and the weight of the rig was imbalanced. The flooding, along with the existing adverse weather
conditions eventually caused the rig to keel over. Bad enough, the crew members had little to
no proper training on emergency evacuation procedures in the use of life saving equipment.
Fortunately, the accompanying tow boat was able to rescue 4 persons out of 76 workforces on
board. In 1981, the sunken rig was salvaged by The Yuntai Salvage Company, and the
investigation showed that, the deck equipment had not been properly stowed before towing.
(Dhillon, 2016)

10
3.2 CAUSES OF THE ACCIDENT

On accordance to our findings and understanding, the accident was mainly caused by the
following factors:

i. Incorrect deck stowing and Poor permit to work Systems.

Failure to properly stow the deck before towing was the main factor which resulted from
improper following the standard tow related procedures in regard to the weather. According to
the investigation if the deck could be properly stowed and if the standard procedures for towing
were accurately followed then, it was likely that the accident wold not occur as approved by
Yuntai Salvage Company in 1981. And in accordance to the figure, sinking of the deck was the
main cause resulted from poor stow.

ii. External causes

It’s clearly that, even if the deck had not been properly stowed but the weather condition was
stable and safe (no strong winds) then the deck cold be safe. The forces of the high wind were
the cause of the failure to a great extent, since it caused the damage of the ventilator pump and
in return caused a large hole on the deck and this was the beginning of the problem.

iii. Poor Knowledge and Insufficient Training

In Oil and Gas industries, safety is a major regarded subject on both workforce’s welfare and
property safety. Safety is highly attained if proper induction on proper conducts, hazards,
emergence evacuation procedures and lifesaving equipment during disasters is done. However,
for Bohai No.2 Oil rig accident, proper training was not prioritized because the crew members
had not received proper training on emergency evacuation procedures as well as the use of life
saving equipment. If only the workers were trained properly then more than 50% of the crew
members could be rescued alive.

3.3 LESSONS LEARNED FROM THE ACCIDENT

From this oil rig disaster, we learn the following:

i. Proper and standard installation procedures and methods for the particular oil and gas
facility must be followed in accordance to the surrounding environments.
ii. Working crew must be full trained against any emergence that is likely to occur in the
respective site, including proper use of life saving equipments as well as evacuation
procedures before they are allowed to work on the facility.
iii. Offshore platforms must always have sufficient rescue mechanism(s) in case of
emergence. (Santos, n.d)

11
 CONCLUSION

Despite various measures that are taken to prevent accident from happening in oil and gas
industry, complete prevention is still ideal as risks and hazard continue to exist as long as
industry exist. Thus, happening of one incident/accident must be a way for far better prevention
of occurrence of another similar incident in the same department as well as other departments.

Safety must always be given a first priority prior any operation within the industry together
with the establishment of safety attitude and culture within the industry in such a way that
chance of occurrence of accident is kept as low as possible.

12
 REFERENCES

Bouti, M. Y. (2018). Analysis of 801 Work-Related Incidents in the Oil and Gas Industry that
Occured Between 2014 and 2016 in 6 Regions. 8.
doi:doi.org/10.5539/eer/v8n1p32anadian Center of Science and Education

Dhillon, B. S. (2016). Safety and Reliability in the Oil and Gas Industry. A Ptractical
Approach.

Ostrom, L. T., & Wilhelmsen, C. A. (2012). Risk Assesment. New jersey: John wiley & Sons
Inc.

Santos, R. S. (n.d). Safety Challenges Associated with Deepwater Concepts Utilized.

Standard-2350, A. (2013). Overfill Protection for Storage Tanks in Petroleum Facilities.

13
 APPENDIX A

Table 3: Tank S34 details

Tank ID S34
Tank type Fixed roof tank
Product stored AGO
Containment type Unpaved dyke
Maximum capacity 3,906,641 liters
Safe fill capacity 3,821,205 liters

Table 4: Tank S34 product loss details

Safe fill capacity 3,821,205 liters

Amount spilled 294,172 liters
Amount recovered 19,320 liters
Amount lost 274,852 liters

Figure 3: Deformed kick plate on tank S. 34, Courtesy of TIPER Tank S.34 (2018)

14
Figure 4: Deformed roof plate on tank S34, Courtesy of TIPER Tank S.34 (2018)

Figure 5: Damaged carbo-angle at tank S34, Courtesy of TIPER Tank S.34 (2018)

15
Figure 6: Raptured weld at carbo-angle/shell seam, Courtesy of TIPER Tank S.34 (2018)

Figure 7: Raptured weld at roof plate and deformed shell plate at tank S34 of TIPER Tank
S.34 (2018)

16