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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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environmental, and operational goal
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THE PROCESS SAFETY CULTURE AT EACH
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Finally, the Panel’s own observat
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Survey responses from Cherry Point
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process safety culture at the refin
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Table 22‘‘I can report hazardou
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- 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
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- Page 143 and 144: Finding:Each of BP’s five U.S. re
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- Page 156 and 157: Finally, because the nature and sco
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- Page 164 and 165: Table 40Percentages of Disagree/Ten
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- Page 168 and 169: Whiting (2006) Not all of the alarm
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- Page 174 and 175: The ANSI Z490.1-2001 standard provi
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- Page 178 and 179: interviews at some of the refinerie
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- Page 184 and 185: Table 48Percentages of Disagree/Ten
- Page 186 and 187: Table 51Percentages of Disagree/Ten
- Page 188 and 189: Computer-based training. Based upon
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- 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
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- Page 204 and 205: on December 4, 2006. In that recomm
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- Page 223 and 224: The Panel also identified some defi
- Page 225 and 226: Similarly, although mixed responses
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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