The Baker Panel Report - ABSA

SHARED PROCESS SAFETY CULTURE ISSUESAlthough the refineries do not share a common process safety culture, they do share similar process safety cultural weaknesses. Based uponthe interviews of the refinery workforce, the process safety culture survey, the technical reviews that the Panel’s consultants performed, and areview of BP documents, the Panel finds that of a lack of operating discipline, toleration of serious deviations from safe operating practices,and apparent complacency toward serious process safety risks existed at each of BP’s U.S. refineries.Texas City. Deviations from safe practices, lack of operating discipline, and apparent complacency toward serious process safety risk at theTexas City refinery have been well chronicled in a variety of BP documents. For example, the Mogford Report observed that at Texas City[t]here was a general inability to see key process risks, and both management and the workforce appear to routinelytolerate a high level of risk. Numerous observations pointed to a high level of risk having become accepted. This waslargely due to poor hazard/risk identification skills throughout management and the workforce, exacerbated by a poorunderstanding of process safety. 58The Mogford Report further concluded that “[s]upervisors and [s]uperintendents did not verify that procedures were available and correct orbeing followed. ...Ingeneral, employees were unaware of the risks of operating without procedures....” 59The Stanley Report similarly includes among its key findings complacency toward serious process safety risks and a lack of awareness of riskreflected in day-to-day operational activity. 60 That report also notes that “[i]nconsistent compliance with rules and procedures across therefinery has reduced the effective management of risks that the procedures are designed to address.” 61 Various other documents reflect thesesame issues at Texas City. 62Interviews of the Texas City workforce, particularly hourly workers, indicated that workers often did not follow policies or procedures.Interviewees cited a number of reasons for this, including a lack of training regarding applicable policies and procedures, a lack of knowledgeregarding where to locate a particular policy, and insufficient time to follow procedures called for by applicable policies. Many hourly workersexplained that prior to March 2005, policies were not enforced strictly and few consequences existed if an employee did not follow a policy.Like the interviews, certain survey responses support the conclusion that the Texas City refinery accepts deviations from safe practices andappears to be complacent toward serious process safety risk. As shown below, for example, toleration of deviations from safe operatingpractices is indicated by the relatively high percentages of the identified employee groups and contractors who expressed a belief that workerssometimes worked around process safety concerns rather than report them.Corporate Safety Culture C 120