The Baker Panel Report - ABSA

20 James Reason, “Achieving a Safe Culture: Theory and Practice,” Work & Stress, Vol. 12, No. 3 (1998), pp. 302-03.21 BP p.l.c., “getting HSE right Audit Report, BP South Houston, Audit No. 2003-41,” September 22, 2003, p. 2.22 BP p.l.c., John Mogford, “Fatal Accident Investigation Report, Isomerization Unit Explosion Final Report,” December 9, 2005, p. 165.23 BP p.l.c. and A.T. Kearney, “Texas City Refinery Retrospective Analysis: Summary of Results,” October 28, 2002, pp. 4, 9.24 Ibid, p.9.25 See ibid, p.4.26 Ibid, p.3.27 Shortly after the release of the Kearney report, BP developed strategies for addressing some of the issues raised by the Kearney report. Forexample, BP developed South Houston Infrastructure for Tomorrow, which had the stated objective of “provid[ing] a safe working environmentwhile restoring the operability, reliability, and profitability of the BPSH infrastructure to a sustainable License to Operate (LTO) state.” Applyingthis plan, Texas City completed 21 projects in 2003 and 2004 at a cost of about $35 million. Additionally, Texas City created the Piping IntegrityProgram. The project’s goals were, in part, to investigate pipe work failures, identify systemic causes contributing to those failures, and reviewand make recommendations for improving pipe work integrity.28 See BP p.l.c. and A.T. Kearney, “Texas City Refinery Retrospective Analysis: Summary of Results,” October 28, 2002, p. 11.29 See generally ibid, p.11.30 Ibid.31 Ibid.32 Ibid.33 The Telos Group, “BP Texas City Report of Findings,” January 21, 2005, p. 31.34 BP p.l.c., John Mogford, “Fatal Accident Investigation Report, Isomerization Unit Explosion Final Report,” December 9, 2005, pp. 60-61.35 Ibid, p. 145.36 BP p.l.c., John Mogford, Senior Group Vice-President, Safety & Operations, “The Texas City Refinery Explosion: Lessons Learned,” Address atthe Center for Chemical Process Safety, 2nd Global Congress on Process Safety, April 24, 2006, p. 1.37 Joel Podolny and John Roberts, British Petroleum (A2): Organizing for Performance at BPX, case study S-IB-16A2 (Graduate School ofBusiness Stanford University, revised April 2, 2002), p. 7.38 Ibid.39 BP p.l.c., John Mogford, “Fatal Accident Investigation Report, Isomerization Unit Explosion Final Report,” December 9, 2005, p. 164; BP p.l.c.,James W. Stanley, “Process and Operational Audit Report, BP Texas City,” June 15, 2005, p. 3.40 The Panel does not believe that the BP Management Framework equates accountability with fault, and the Panel does not imply in anyfashion that any particular person is at fault for the ISOM accident.41 Fewer than 25 respondents were in this group.42 Fewer than 25 respondents were in this group.43 BP p.l.c., Press Release, “BP Issues Final Report on Fatal Explosion, Announces $1 Billion Investment at Texas City,” December 9, 2005.44 BP p.l.c., “Good Practice Sharing Assessment: BP South Houston Final Report,” (August 2002).45 Ibid, p.8.46 BP p.l.c., “getting HSE right Audit Report, BP South Houston, Audit No. 2003-41,” September 22, 2003, p. 2.47 Ibid.48 BP p.l.c., James W. Stanley, “Process and Operational Audit Report, BP Texas City,” June 15, 2005, p. 3.49 Ibid.50 BP p.l.c., John Mogford, “Fatal Accident Investigation Report, Isomerization Unit Explosion Final Report,” December 9, 2005, p. 163.Corporate Safety Culture C 128