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69. BP’s internal investigation into the Texas City disaster, published in December 2005,<br />

found a number of underlying causes. Over the years, the working environment had eroded<br />

to one characterized by resistance to change and lacking in trust, motivation and a sense of<br />

purpose. Coupled with unclear expectations around supervisory and management<br />

behaviours, this meant that rules were not consistently followed, rigour was lacking and<br />

individuals felt disempowered from suggesting or initiating improvements. Process safety<br />

operations and systemic risk reduction priorities had not been set and consistently<br />

reinforced by management. Many changes in a complex organization had led to a lack of<br />

clear accountabilities and poor communication, which together resulted in confusion in the<br />

workforce over roles and responsibilities. A poor level of hazard awareness and<br />

understanding of process safety resulted in people accepting levels of risk that were<br />

consistently higher than in comparable installations. Given the poor vertical<br />

communication and performance management process, there was neither an adequate early<br />

warning system of problems, nor any independent means of understanding the<br />

deteriorating standards in the plant. 22<br />

70. Some criticisms of BP centred on the management’s philosophy of focusing intensively on<br />

containing costs and pursuing profits while giving occupational safety and health a lower<br />

profile within the company operations. 23 There were three external reviews of the<br />

accident. The Independent Safety Review Panel headed by James Baker published its<br />

findings in 2007 24 and made recommendations in a number of key areas, which included<br />

process safety leadership; the process safety management system; safety knowledge and<br />

expertise; and safety culture. Some of the recommendations in these categories are<br />

reproduced in box 3.1.<br />

22 www.bp.com/genericarticle.do?categoryId=9005029&contentId=7015905.<br />

23 S. Reed: “BP feels the heat”, in Business Week, 22 Jan. 2007, pp. 52–53.<br />

24<br />

Report of the BP US Refineries Independent Safety Review Panel, Jan. 2007, www.bp.com/<br />

bakerpanelreport.<br />

40 TMOGE-R-[2008-12-0110-1]-En.doc/v3

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