2000 5 29 Flare 6 7 A904 9 18 300 6 22 250,000 6 10 FCC 750,000 2000 5 29 2,000 5 11kV ; 700M 1 5 33kV 5 25 33kV ( ) 5 29 18:07 ( 3000A 1sec) 1,5,10 2

BP 2005 3 23 (BP) Texas City 1990 15 180 2007 3 (U.S. Chemical Safety and Hazard Investigation Board, CSB) BP 2000 5 29 6 10 BP Grangemouth (Health and Safety Executive, HSE) 2003 8 18 CSB (1) (2) BP 2000 5 6 BP Grangemouth Grangemouth (Edinburgh) 20 BP 700 Grangemouth A904 1924 2,000 11,000 1/13

2000 5 29 Flare 6 7 A904 9 18 300 6 22 250,000 6 10 FCC 750,000 2000 5 29 2,000 5 11kV ; 700M 1 5 33kV 5 25 33kV ( ) 5 29 18:07 ( 3000A 1sec) 1,5,10 2000 6 7 5 30 12 A904 U 18 6 2 5 6 7 23:18 (Condensation induced water hammer) (Tee) 2000 6 10 FCC FCC 5 29 6 9 1:00 (E5) 6 10 03:19 (E5) 3 6 10:30 2/13

1. 2. ( 1951 ) 3. 4.1998 revamp ( 11 19 7 ) 5.1999 3 6.E5 7. 2005 3 23 BP Texas City BP Texas City BP (BP 5 ) 30 490 (1,200 ) 29 1,800 800 2005 3 23 13:20 15 180 1. 2:00 6.5ft 10ft 10ft (Redundant) 2. 3 30 10ft 3/13

13ft 3. 9 50 4. 10 00 20 138ft 10ft 5. 12 40 2 6. 13:00 150 7. 13:05 8. 13:10 150 ft 9. 13:14 1 10. 13:20 25ft Grangemouth 1. 1 1994-12 50,000 4/13

2 1998 Flare 250,000 500,000 3 1999-07-27 Flare 4 1999-11-20 FCC 5 1999-12-28 6 2000-01-20 2.HSE BP HSE grangemouth 1 HSE HSE ( ) BP Grangemouth 2 HSE (KPIs) BP KPIs 3 HSE 1987 5/13

BP ( ) KPIs Grangemouth 4 HSE (Safety Assurance) A. B. C. D. --- --- BP A. B. C. D. E. F. 5 HSE BP HSE BP A. BP 6/13

B. C. BP D. E. 6 HSE BP BP BP Texas City 1. 1 2 3 Flare 4 5 6 7 8 2.CSB Texas City 1 BP 7/13

2 BP BP 3 4 Run to Failure 5 6 BP 7 8 9 3. 2004 Telos Group 1 2 3 4 5 6 7 8 8/13

9 4. 1 ( ) 2 (KPIs) 3 4 Texas City Grangemouth 4 5 BP HSE Texas City (Telos Report 2005 ) BP HSE Grangemouth Texas City ( ) 9/13

Grangemouth BP Texas City Texas City Grangemouth ( ) HSE Texas City BP BP Getting HSE Right (GHSER) --- BP HSE 65 Grangemouth BP CSB 142 Texas City (An Organizational Acccident, BP ) BP 1. 2. 3. 10/13

(AIChE) CCPS(Center for Chemical Process Safety) (A discipiline that focuses on the prevention of fires, explosions and accidental chemical releases at chemical process facilities) (Apply management principles and analytical tools to prevent major accidents rather than focusing on personal safety issues such as slips, trips, and falls) OSHA 29 CFR Ch. XVII (7-1-98 Edition) 1910.119, Process Safety Management of Highly Hazardous Chemicals (PSM) (a) (i) (b) (j) (MI) (c) (k) (d) (l) (e) (m) (f) (n) (g) (o) (h) (p) CCPS 1. Guidelines for Risk Based Process Safety, New York, AIChE, 2007. 2. Building Process Safety Culture: Tools to Enhance Process Safety Performance, New York, AIChE, 2005. 3. Interface Management: Effective Communication to Improve Process Safety, New York, AIChE, 2004. 11/13

HSE Developing Process Safety Indicators: A Step-By-Step Guide for Chemical And Major Hazard Industries, U.K.:HSE Books, 2006a CSB API (United Steelworkers International Union(USW) (ANSI) HSE HSE Grangemouth (Industry must not become complacent about the risks posed by major accident hazards) (good fortune) 12/13

CSB BP CSB 18 Columbia Accident Investigation Board(CAIB) NASA (Immediate cause) BP KPIs KPIs (1) HSE, Major Incident Investigation Report, BP Grangemouth, Scotland, 18 th August 2003. (2) CSB, Investigation Report, Refinery Explosion and Fire, Report No. 2005-04-I-TX, March 2007. 13/13