Reanalyzing the BP Texas City Refinery Accident with FRAM (Functional Resonance Analysis Method) - 20 years of complexity and learning

Abstract: This study reanalyzes the BP Texas City refinery accident of March 2005 using the FRAM (Functional Resonance Analysis Method) methodology, based on technical-scientific materials such as reports, articles, and documents from the institutions involved, regulatory agencies and interviews with former employees. The goal is to uncover the human factors and its complex interactions overlooked by traditional risk assessment techniques, which are suited for linear systems, but limited for complex high-risk workplaces, such as an oil refinery. The FRAM methodology was chosen for its ability to address the interactions in a complex sociotechnical system, enhancing a human factors approach. This reanalysis revealed the significant influence of organizational elements, as a fragmented culture and the workforce reduction, influencing the decision-making through hierarchical structures. Even two decades later, the study could highlight that there is still much to learn from this event, especially as FRAM enables a deeper understanding of the complexities inherent in high-risk work environments that compose most of the workplaces of the O&G industry, from the new plants to their decommissioning. The findings underscore the limitations of linear methodologies in analyzing complex sociotechnical systems, as well as provided a broader understanding of the event, emphasizing the importance of advanced approaches to address the variability and interconnectedness of tight coupled high-risk process plants.

Keywords: FRAM, Human Factors, Process Safety, Accident Analysis

DOI: 10.54941/ahfe1006279

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