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[Music] [Sound of helicopter rotors] Narrator: At 1:20 p.m. on March 23rd, 2005, a massive explosion and fire erupted at the BP Refinery in Texas City, Texas. The explosion killed 15 workers and injured 180 others, many of them seriously. The blast occurred at the isomerization or ISOM Unit, which produces materials to boost the octane rating of gasoline. The explosion shattered windows in homes and businesses up to three-quarters of a mile away from the 1200 acre refinery. As thick, black smoke billowed from the plant, authorities instructed some 43,000 Texas City residents to stay indoors. The accident cost BP billions of dollars in victims compensation, property damage and lost production. Holmstrom: This investigation was the largest and most comprehensive investigation in the history of the Chemical Safety Board. Narrator: CSB Supervisory Investigator Don Holmstrom led a two-year investigation to determine the root causes of the accident. Holmstrom: We interviewed ov