@article{ref1,
title="Human factors analysis of the BP Texas City Refinery explosion",
journal="Proceedings of the Human Factors and Ergonomic Society annual meeting",
year="2007",
author="MacKenzie, Cheryl and Holmstrom, Donald and Kaszniak, Mark",
volume="51",
number="20",
pages="1444-1448",
abstract="On March 23, 2005, the BP Texas City Refinery suffered one of the worst industrial disasters in recent U.S. history. An explosion and fire occurred during the startup of a process unit. Fifteen workers were killed and 180 others were injured when a distillation tower was overfilled and liquid and vapor hydrocarbons were released into the atmosphere. A vapor cloud formed, found an ignition source, and exploded. The U.S. Chemical Safety and Hazard Investigation Board (CSB) deployed a team to Texas City to conduct a root cause investigation. The authors of this paper, working as investigators for the agency, found several pre-existing latent conditions and safety system deficiencies that affected unit operators' decisions and actions on the day of the incident. This submission presents a summary of those deficiencies and the primary human factors issues of the case.<p /><p>Language: en</p>",
language="en",
issn="2169-5067",
doi="10.1177/154193120705102015",
url="http://dx.doi.org/10.1177/154193120705102015"
}