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From technical investigation

 Blowdown drums are a common feature at refineries, as are towers used to


release evaporating gases. Most tower vents, however, include a flare system --a
sort of pilot light that ignites potentially hazardous vapors as they funnel out. In
1992, the Occupational Safety and Health Administration (OSHA) mandated that the
Texas refinery switch to a flare system. Amoco, which merged with BP in 1998,
appealed and OSHA withdrew the request. The refinery continued to use stacks that
allowed gases to escape.
 Former BP employee Wydell Dixon says she has seen lightning ignite vapors
wafting out of the isom stack. Whether a flare would have ultimately prevented the
explosion is questionable given the quantity of liquid as well as vapor involved, says
Don Holmstrom, an investigator with the U.S. Chemical Safety and Hazard
Investigation Board (CSB), but "a flare does provide an extra layer of safety."
From Organizational and Management

 The most dangerous time for an oil refinery isn't when it is running, but when
it's in transition. During a refinery turnaround, some 30,000 separate
procedures are performed. Dozens are required to move volatile contents
safely out of and into position when the isom unit is coming back on line.
 As workers restarted a component of the unit, abnormal pressure built up in
the production tower, and so three relief valves opened to allow highly volatile
gasoline components to escape to the 10 x 20-ft. "blowdown" drum. But so
much fuel flooded into the drum that its capacity was rapidly exceeded. Liquid
and vapor shot straight up the 113-ft. vent stack, into the open air.
 Tapos yung plant manager that time, hindi nya naipasa sa next na
magduduty yung info about sa transition ng isom unit.

From Safety Management Investigation

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