I held the hard hat in my hands.  The inside stained with sweat; the owner’s name written in permanent ink.

“Maybe the family will want it back?” The safety inspector asked as he stared at my hands.

“There’s a hole in the side.  I just. I just don’t think I can. Who would want it?” I put my forefinger through the gap and felt around the browned edge. The hat was meant to protect, but it didn’t.

Twenty-four hours after the explosion, I surveyed the site….cars, trucks, and vans were burnt to a crisp and riddled with holes from flying shrapnel.   Steel and pipes were twisted, left barely recognizable. I rode with a first response management inspection team. Forced to remain in the car because the risk of benzene filled air and smoldering rubble, we viewed the remnants of the explosion. We drove over debris and around distorted metal; it was numbing and surreal.

On a sunny day in 2005, like hundreds of others, I went to work.  I attended meetings, had telephone conversations.  I made plans. It should have been a day like any other.  Unfortunately, a series of bad decisions led to an event that changed many lives including mine.

1:19pm: “Upset at CAT 3.” The plant, built in 1934, was in a constant state of upgrading and revamping.  It was not uncommon to get plant wide e-mails warning workers of a possible emergency situations.  This particular “upset” email came through, maybe the second of the day, probably the fifth for the week, as I was preparing for a meeting.  It was “business as usual” I thought, except it wasn’t.

1:21pm: The ground rumbled.  Tiles fell from the ceiling of my construction trailer.  Computers turned off. Multiple concussions from explosions thundered.  I looked towards the Alkylation unit.  If it were up in smoke, we were to shelter-in-place.  It wasn’t.

At that moment, I couldn’t see the explosion, but it had to be from the west plant. I called for an office evacuation to a preset location 3 miles from the plant.  As I left the construction trailer and saw the fire and smoke, I called my boss. “Sir, I think we have a very bad situation…we have people working in that area.”

On that March day at 1:21pm a child lost his daddy.  A little girl lost both her mother and father. A church lost its pastor. Someone who shouldn’t have been there was in the wrong place at the wrong time.  And the sad stories go on and on….

On that March day, the plant restarted one of its units which had been shut down for maintenance. At 1:19 pressure built up in a ventilation stack, prompting an alert and an emergency email from a downstream unit.  At 1:20 the pressure reached critical levels emitting large amounts of vaporized hydrocarbon from the blowdown stack.  The vaporized hydrocarbon was heavy and started blanketing the area around the unit, including under a construction trailer in the vicinity.   At this point it was inevitable that something would ignite it.  At 1:21, 180 workers were injured, fifteen killed, four severely wounded.  At 1:22 my team evacuated the site but another team, the one whose construction trailer sat only 150 yards from the restarted unit didn’t have that chance.

There is a lot of blame to spread around and the EPA, FBI, OSHA, and Department of Justice spent thousands of hours sifting through the rubble to find it.  A truck engine cranked igniting the initial spark. But that’s not what really caused the explosion. The system restart sent fumes into a blowdown stack with a faulty pressure-relief valve.  Responding to the problem, the controllers notified the people nearby but a defective alarm designed to warn all employees of potential problems failed to work properly.  At 1:21, people working on an unrelated project in a construction trailer 150 yards from the site were still unaware of the emergency.  The truck sparked, the explosion boomed, and nineteen people were left dead or severely injured.

As we drove towards the construction trailer twenty-four hours later, the wreckage crunched under our tires.  Cars and trucks sat exposed; the seat coils visible, tires melted away. Oddly, the only things left of the construction trailer complex were filing cabinets which stood like steely sentinels overlooking the burnt out office.

What would have happened if the alarm worked properly? All the people who died were in that doomed construction trailer. But, not everyone in the trailer died, only the people who sat with their backs towards the plant. The initial alarm went off at 1:19. The blast happened at 1:21. If the alarm worked properly, all the employees would have evacuated far enough from the site that deaths could have—should have—been prevented.

In 1995, a similar accident involving a construction trailer, a refinery, and multiple deaths lead the oil and gas industry to conclude that trailers should not be placed near refinery plants. But this new standard was ignored for some reason.  Someone else’s mistake should have created a teachable moment. This would not have prevented the explosion, but it could have averted some of the tragic outcome.

However, those aren’t the only would haves, could haves, and should haves. The plant had a history of poor management choices. In 1992, OSHA fined the refinery for unsafe pressure-relief systems; OSHA later dropped the citation in favor of less strict compliance. The unit had faulty pressure-relief instrumentation and they had been flagged for repair. A work order had been signed but the project wasn’t complete. In 1991 and 1993, proposals to eliminate the blowdown stack systems in favor of a safer enclosed flare system were delayed because of budget constraints. What if they found the capital to perform this upgrade?  Ironically, the plant was forced to install the safer flare system on all the units after the accident at an enormous expedited capital cost.

Suggestions were made and ignored, operating costs were controlled and repairs remained slow. Complacency begot complacency. The would haves, could haves, and should haves were left to dangle in the air until a truck’s key was  turned which ignited a spark which blew up a trailer and injured hundreds, severely wounding others, and killing fifteen.

Forty-eight hours after the explosion, I met with the local police at the employee parking lot where my coworkers in that fateful trailer would have parked.  As the police unlocked unclaimed vehicles, I scanned the interiors: A minivan with a baby seat and toys; a sedan with a gym bag; a pick-up truck, packed with a duffel bag ready for a day at the beach; and a station wagon with a Bible lying on the front seat.  It is then the hard reality set in for me…These employees had arrived at work not planning to die.  They arrived at work trusting that the decisions made before them were the proper ones.  The safe ones.   These images haunt me still today.

The week following the explosion, I attended nine funerals. I interviewed many of these people prior to them coming to work at the plant.  I watched mothers cry and children sob. The damage extended beyond the physical; it wrecked lives and paralyzed others with fear. It left me wondering about other people’s woulda’s—coulda’s— and shoulda’s.

My world changed seven years ago. Driving through the smoldering refinery, viewing abandoned cars of the deceased, and attending funerals have strengthened my commitment to a culture of safety prevention.  While this is a story that is difficult for me to tell, it’s not a story about destruction; it’s a story about doing the right things for the right reasons regardless of the cost.   It’s about doing it today…..