The Baker Panel Report - ABSA

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Whiting (2006) Not all of the alarms and interlocks that serve a safety function were included in the mechanical integrity maintenance program. Numerous past due inspections and extended inspection due dates existed, and the management system to evaluate and controlvariances to test and inspection intervals was ad hoc or not well defined. Rupture disks positioned below relief valves may have failed in a manner that would have rendered the associated relief valvesineffective.Finding:BP’s safety management system does not ensure timely compliance with internal process safety standardsand programs at BP’s five U.S. refineries.Process Safety Management Systems C 144
IMPLEMENTATION OF EXTERNAL GOOD ENGINEERING PRACTICESExternal codes, standards, industry best practices, recommended practices, and other external guidance (collectively referred to as codes andpractices) play an important role in the management of process safety in refineries operating in the United States. 20 Some of these codes andpractices have the force of law; others do not. Several process safety-related regulations apply to BP’s U.S. refineries, and through theseregulations, various generally accepted codes and practices also apply. OSHA specifically acknowledges various industry codes and practices.For example, the OSHA process safety management standard cites process safety guidance that the API, 21 the CCPS (an industry technologyalliance of the American Institute of Chemical Engineers 22 ), and the American Chemistry Council developed. Even if existing codes andpractices do not have the force of law, they can provide valuable tools for managing and reducing risks associated with process hazards. Thesecodes and practices relate to numerous topics, such as the classification of locations for installing electrical equipment at petroleumfacilities 23 and instrumentation for fired heaters. 24 Following codes and practices relating to refineries helps ensure that refineries operatesafely because the codes and practices represent an accumulation of the knowledge and experience of many industry experts. Systemic failureto consider and adhere to codes and practices can result in operations being conducted at a higher degree of risk than would be the case if theoperations were conducted in conformity with the codes and practices.Under the scope of work used in their review of BP’s U.S. refineries, the technical consultants compared BP’s process safety managementprograms, procedures, and performance not only to applicable regulations, but also to codes and practices. Under the terms of the Panel’sscope of work, the technical consultants evaluated only a sampling of external codes and practices that apply to U.S. refineries as a basis fortheir conclusions. Specifically, the technical consultants reviewed BP’s U.S. refineries’ adherence to applicable codes and practices relating tofour areas: safety shut-down systems, area electrical classification, fired heaters, and facility siting.Based upon their assessment, the technical consultants found a process safety management system deficiency in each of the four sampledareas. In making these findings, the technical consultants identified the particular code and practice to which the finding relates. Basedprimarily on the findings of the technical consultants, the Panel finds that BP’s safety management system does not ensure the timelyimplementation of external good engineering practices that support and could improve process safety performance at BP’s U.S. refineries.> Safety shut-down systemsRefinery process units have important instrumentation systems intended to detect process upsets and then safely shut down equipment priorto reaching unsafe conditions. These systems are usually designed with multiple layers of protection using redundant and highly reliablecomponents. These systems typically remain dormant until an authentic process upset occurs, at which time they act to protect the process byputting it into a safe condition. Because these instrumentation systems are usually dormant, it is difficult to determine at any particular timewhether they are fully functional. As a result, it is important to perform functional testing of these safety systems throughout their operationallives to ensure dependable operation when they are needed.The technical consultants’ report indicates that it is important to consider the entire “life cycle” of a safety system—taking care to properlydesign it, construct it, operate it, and maintain it. In 1996, the Instrumentation, Systems, and Automation Society (ISA) issued an industryconsensus standard to outline the life-cycle care of instrumented safety systems (ISA 84.01-96). OSHA considers ISA 84.01 to be a recognizedand generally accepted good engineering practice under the performance-based requirements of the OSHA process safety managementstandard. ISA published an amended version of this standard in 2004 (ISA 84.01-04).In 2003, BP developed a series of engineering technical practices (ETPs) to provide guidance concerning the application of ISA 84.01. Based onthe technical consultants’ review, none of BP’s U.S. refineries had a comprehensive plan for conforming to ISA 84.01, and only Toledo and CherryProcess Safety Management Systems C 145
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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
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The process safety culture survey r
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Worker fatigue and overtimeThe Pane
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As demonstrated below, process safe
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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 160 and 161: The 2003 audit report for BP South
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 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
Page 211 and 212: Tracking of process safety indicato
Page 213 and 214: Table 57Number of Overdue Inspectio
Page 215 and 216: Although the Panel recognizes that
Page 217 and 218: 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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