The Baker Panel Report - ABSA

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The 2003 audit report for BP South Houston, which at that time included the Texas City refinery, also found deficiencies relating to riskidentification. That report found that “[t]he practice of risk identification and the development of mitigation plans is not evident across thesite.” 12Another BP internal audit report in 2004 reviewed 29 gHSEr audits of business units in BP’s Refining and Marketing segment, including theU.S. refineries, as well as other BP business segments in order to identify systemic issues. This report concluded, among other things, that theapplication of effective risk analysis and mitigation to routine and repetitive operations was variable and that where it was weak, itdesensitized individuals to the potential for injury or material damage.The Mogford Report. The Mogford Report cites several examples of the Texas City refinery’s failure to identify process hazards adequately orto analyze process risks rigorously. For example, the Mogford Report found that a particular process hazard analysis technique 13 that had beenused for an operating unit involved in the incident under investigation was not robust enough to consider all modes of operation or processupset scenarios for the unit. The report states that none of the process hazard reviews would be adequate if real incident and historical datawere not considered. Additionally, the report notes that the ability to identify the major risks at the Texas City site was highly dependent uponthe level of risk awareness of the individuals involved in the process and that the lack of reporting of process incidents hinders all types ofhazard analyses. 14The Mogford Report also found that both management and the workforce were generally unable to see key process risks and appeared toroutinely tolerate a high level of risk. The report indicates that this was largely due to poor hazard/risk identification skills throughout refinerymanagement and the workforce, exacerbated by a poor understanding of process safety. 15BP’s process safety management audits. The most recent process safety management audits conducted at BP’s U.S. refineries under OSHAand EPA regulations also found various deficiencies relating to process hazard identification and analysis. 16 These audits found variousdeficiencies relating to hazard identification or assessment, including various hazards, including the hazard associated with hydrogen sulfide in a sulfur plant, not being identified (Cherry Point, 2005); some equipment failures being categorized as “operability” rather than safety issues, resulting in less management oversight(Cherry Point, 2005); severity of hazard scenarios not being classified accurately (Texas City, 2005); 17 process hazard analysis updates not including incidents that have occurred since the previous hazard analysis (Texas City,2005); 18 and process hazard analysis action items not including risk ranking (Toledo, 2004).OSHA citations at the Toledo refinery. Findings that OSHA made in 2006 relating to BP’s Toledo refinery provide additional examples thatBP’s safety management systems have not adequately identified or rigorously analyzed process hazards. In April 2006, OSHA cited BP foralleged violations of OSHA regulations at the Toledo refinery, seeking more than $2.4 million in penalties. OSHA conducted an inspection thatidentified a number of violations, which OSHA described as being similar to those found during an investigation of the March 2005 accident atTexas City. The OSHA citations included findings that Toledo’s process hazard analyses did not adequately consider facility siting. For additionaldiscussion of the OSHA findings relating to the Toledo refinery, see Section VI.C of this report. The Panel understands that BP is challenging theOSHA citations, findings, and penalties.Process Safety Management Systems C 136
Finding:BP’s safety management system does not ensure adequate identification and rigorous analysis of processhazards at its five U.S. refineries.Process Safety Management Systems C 137
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JANUARY 2007THE REPORT OFTHE BP U.S
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PANEL STATEMENTProcess safety accid
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RETIRED ADMIRAL FRANK L. “SKIP”
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DR. NANCY LEVESON is a Professor of
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DR. DOUGLAS A. WIEGMANN, Ph.D. is t
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• Dennis C. Hendershot, Principal
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The Panel’s FindingsThe Panel foc
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Process safety cultures at BP’s U
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Process safety audits. The Panel fo
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RECOMMENDATION #5 - CLEARLY DEFINED
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TABLE OF CONTENTSI. The Panel’s R
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A. Scope and MethodologyI. THE PANE
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interview, and at least one attorne
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PROCESS SAFETY REVIEWSThe CSB’s u
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BP requested that the Panel use the
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would be positive from a process sa
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more of the Panel’s recommendatio
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management systems. The charter doe
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observed at BP are likely not limit
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II. PRECIPITATING EVENTS FOR THE PA
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As the Mogford Report explains, the
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III. OVERVIEW OF PROCESS SAFETY, PE
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elated to personal safety performan
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ENDNOTES FOR SECTION III1 29 C.F.R.
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IV. OVERVIEW OF BP’S ORGANIZATION
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Although lower levels of supervisor
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segment includes the manufacturing
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Browne, who has a diverse backgroun
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BP provides no specific training fo
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The new Safety and Operations funct
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The primary purposes of this new or
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maintain a culture in which reliabi
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TEXAS CITYBP acquired the Texas Cit
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25 BP evaluates (1) “Level 5 Lead
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(7) pre-start-up safety review,(8)
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Assessment, assurance, and improvem
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BP control of work standardBP issue
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BP PROCESS AND PERSONAL SAFETY BOOK
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ENDNOTES FOR SECTION V1 BP addresse
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A. Corporate Safety CultureVI. FIND
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Process safety as a core value in B
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contractors and employees in the pr
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A fourth and similar survey item ad
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The Panel recognizes that Browne is
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BP management’s focus on personal
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milestones to guide the efforts of
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Refinery plant manager turnoverUnde
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EMPLOYEE EMPOWERMENTThe Panel belie
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Survey responses substantiate that
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As discussed later in this section,
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U.S. refinery staff and capabilityB
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In 2002, BP commissioned a report b
Page 109 and 110: The process safety culture survey r
Page 111 and 112: Worker fatigue and overtimeThe Pane
Page 113 and 114: As demonstrated below, process safe
Page 115 and 116: decision to reduce spending on insp
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Page 119 and 120: THE PROCESS SAFETY CULTURE AT EACH
Page 121 and 122: Finally, the Panel’s own observat
Page 123 and 124: Survey responses from Cherry Point
Page 125 and 126: process safety culture at the refin
Page 127 and 128: Table 22‘‘I can report hazardou
Page 129 and 130: The Panel found other issues that c
Page 131 and 132: Table 27“In my opinion, process s
Page 133 and 134: (2) accountabilities for protection
Page 135 and 136: All levels of management reported t
Page 137 and 138: Table 32“The training that I have
Page 139 and 140: Hourly workers interviewed largely
Page 141 and 142: Table 34“Refinery management puts
Page 143 and 144: Finding:Each of BP’s five U.S. re
Page 145 and 146: Table 36“Workers sometimes work a
Page 147 and 148: Finally, relatively high percentage
Page 149 and 150: Also indicative of perceived noncom
Page 151 and 152: ENDNOTES FOR SECTION VI.A1 Meredith
Page 153: 51 Ibid, p. ii.52 Ibid, p. 153.53 I
Page 156 and 157: Finally, because the nature and sco
Page 158 and 159: At the Carson, Cherry Point, and To
Page 162 and 163: COMPLIANCE WITH INTERNAL PROCESS SA
Page 164 and 165: Table 40Percentages of Disagree/Ten
Page 166 and 167: Prioritization of inspections and m
Page 168 and 169: Whiting (2006) Not all of the alarm
Page 170 and 171: Point have implemented the standard
Page 172 and 173: the facility siting risk to personn
Page 174 and 175: The ANSI Z490.1-2001 standard provi
Page 176 and 177: key positions, BP should assess and
Page 178 and 179: interviews at some of the refinerie
Page 180 and 181: Information relating to BP’s Texa
Page 188 and 189: Computer-based training. Based upon
Page 190 and 191: TRANSLATING CORPORATE EXPECTATIONS
Page 192 and 193: In early 2005, prior to the Texas C
Page 194 and 195: The table below contains the substa
Page 196 and 197: Interviews with various members of
Page 198 and 199: BP’S PROCESS SAFETY MANAGEMENT SY
Page 200 and 201: usiness units, to prioritize implem
Page 202 and 203: Turnaround deferral procedure (Cars
Page 204 and 205: on December 4, 2006. In that recomm
Page 207 and 208: C. Performance Evaluation, Correcti
Page 209 and 210: valves, and other safety-related eq
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Tracking of process safety indicato
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Table 57Number of Overdue Inspectio
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Although the Panel recognizes that
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Previous concerns about measuring p
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BP’s efforts to develop process s
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BP’S INVESTIGATION AND ROOT CAUSE
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The Panel also identified some defi
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Similarly, although mixed responses
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Other external reviews of BP’s pr
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Table 62Number of Reported Near Mis
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Table 64Percentage of Agree/Tend to
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BP’S PROCESS SAFETY AUDIT SYSTEM>
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compliance or BP policy (Priority 1
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Interviews with members of the Safe
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Refining line management above the
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The audit team found similar proble
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The issues that the Panel’s techn
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USING RESULTS OF INCIDENT INVESTIGA
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Issue Grangemouth Texas CitySafety
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CORPORATE OVERSIGHTAn effective pro
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Selected excerpts from the EEAC rep
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Group- and refining-level process s
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Knowledge of performance management
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Each member of the board needs to a
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ENDNOTES FOR SECTION VI.C.1 America
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43 Health & Safety Executive, Devel
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82 When conducting reviews, BP desi
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138 Health & Safety Executive, Majo
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cultures, process safety management
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(i) implement a policy regarding ar
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(f) educate and provide training to
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workers are educated, encouraged, a
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RECOMMENDATION #6—SUPPORT FOR LIN
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(3) “periodically update”—The
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RECOMMENDATION #9—BOARD MONITORIN
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ANNEX I—PROCESS INCIDENT INDEX EX
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a fatality that results from a mech
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III. Structure and Operations The C
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11. On August 10, 2005, the Texas C
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APPENDIX CBP U.S. REFINING ORGANIZA
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APPENDIX DWHITING RUPTURE DISK: A C
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B. INADEQUATE REVIEW AGAINST TECHNI
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management review or monitoring pro
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214-06GEMS 1544316Review of Process
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Executive SummaryOn March 23, 2005,
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Based upon its work, the PSM Review
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Table of ContentsSectionPageExecuti
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1. IntroductionOn March 23, 2005, t
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Following these general sampling pr
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Review of documentsWalkaround inspe
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3. Discussion of FindingsBased upon
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3.1 Rupture Disks Under Relief Valv
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3.2 Equipment Deficiencies - Known
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Once a site specifies the frequenci
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System Finding 3 - Equipment inspec
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accepted good engineering practice
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Not implementing action items or ta
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3.9 Compliance Audit Findings - Rep
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3.11 Near-miss Investigation - Inad
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from water. However, the PHA report
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Appendix A - Scope of Work for BP I
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v. Safety instrumented system desig
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Appendix B - PSM Review Team Leader
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Jack McCavitMr. McCavit is Presiden
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14 Guidance on Practice for Design
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Operations network.performance.Refi
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C. Performance Evaluation, Correcti
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APPENDIX GPROCESS SAFETYCULTURE SUR
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INTRODUCTIONWelcome to the BP U.S.
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I. ABOUT MEIn this section you are
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SURVEY TERM DEFINITIONSPlease read
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Safety Values / Commitment to Proce
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Procedures and EquipmentNote: For e
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Process Safety TrainingNote: For ea
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PLEASE DO NOT WRITE ON THIS PAGE.14
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TermHSSEIncidentISAIsomerization (I
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ACKNOWLEDGEMENTSMembers of the BP U
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