The Nimrod Review - Official Documents

The Nimrod Review
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17.39.3 “It enables all relevant factors to be considered and assessed from many different points of view,
including cost. There is no reason why a risk assessment should necessarily be elaborate. All will
depend on the nature of the particular problem being considered. Thus it may be possible to apply
a scientific approach or it may not. As so often, all will depend on the circumstances.”
17.39.4 “It is also essential that the relevant risks and the measures taken to combat them be kept under
review because it is not sufficient to just one snapshot of a problem. Conditions change all the
time.”
BP Texas City oil refinery explosion (2005)
17.40
On 23 March 2005, the BP Texas City oil refinery suffered an explosion which resulted in the deaths of 15
workers and left more than 170 injured. It was the most serious workplace disaster in the U.S. in two decades.
The U.S. Chemical Safety Hazard Investigation Board conducted a detailed investigation into the causes. 47 This
was followed by a review of BP’s corporate safety culture, safety management systems, and corporate safety
oversight at its U.S. refineries, by a panel headed by former US Secretary of State, James A. Baker III. 48
‘Initiative overload’
17.41
The Panel found that BP’s U.S. refineries had been subjected to ‘initiative overload’ in the seven years before
the accident which potentially had had a detrimental effect on process safety. BP’s corporate organisation
had launched “an avalanche of programs and endeavours that compete for funding and attention”, each of
which required the refineries “to develop plans, conduct analyses, commit resources, and report on progress”. 49
The ‘ripple’ effects, of what some workers termed this ‘flavour of the month’ phenomenon, were then felt
throughout the refinery.
De-centralisation and culture
17.42
BP had a decentralised management system and ‘entrepreneurial’ culture which had delegated substantial
discretion to the U.S. refinery plant managers without clearly defining process safety “expectations, responsibilities
or accountabilities” or holding managers accountable for process safety performance. The Panel found “Each
refinery had its own separate and distinct process safety culture”.
Vigilance not complacency
17.43
The Panel emphasised the importance of vigilance to counter complacency:
“Preventing process accidents requires vigilance. The passing of time without a process
accident is not necessarily an indication that all is well and may contribute to a dangerous
and growing sense of complacency. When people lose an appreciation of how their safety
systems were intended to work, safety systems and controls can deteriorate, lessons can
be forgotten, and hazards and deviations from safe operations can be accepted. Workers
and supervisors can increasingly rely on how things were done before, rather than rely on
sound engineering principles and other controls. People can forget to be afraid.” 50
47 US Chemical Safety Hazard Investigation Board Report (March 2005) (Report No. 2005-04-0I-TX).
48 Report of The BP U.S. Refineries Independent Safety Review Panel (January 2007).
49 The BP U.S. Refineries Independent Safety Review Panel Report, page 84.
50 The BP U.S. Refineries Independent Safety Review Panel Report, Panel Statement, page i.