The Baker Panel Report - ABSA

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The table below contains the substance of the responses from the refineries to those questions.Table 52Gap Analysis under BP 2006 Integrity Management StandardRelating to Continuous Risk ReductionRefineryNameHow is process of continuousrisk reduction managed?Current Practices/ProcessesGaps to Meet IM StandardExpectationCarson No formalized process No formalized process tomanage continuous riskreduction.Actions Needed to Close Gaps;CommentsDevelop a formalized process formanaging continuous riskreduction.Cherry PointHazard operability studies, managementof change, root cause findinganalysis, and major accident riskanalysis all identity potential risksthat the Cherry Point refinerycontinually manages.Hazard and operability studyrevalidations, risk studies.None.None.[Comment: For the Refining SPU,this will be managed at an SPUlevel. New process required.]Texas City[None identified.]Implement Refining recommendationsin this area.[Comment: For Global Refining,this will be managed at the Refininglevel. New process required.]Toledo* * * *WhitingThe current process is managed byevaluating and prioritizing AvailabilityRisks on a continuous basis.A matrix is used . . . to continuallyrank top items. Asset OperationsManagement reviews the topranked items and appropriates/-schedules funding to promptlyaddress acute hazards. .Quantitative risk analysisusing BP Group Standardsare not in place. TheAvailability Risk Registermay not currently beinclusive of all [IntegrityManagement] Risks bydefinition.Assign accountability for completingmajor accident risk assessmentto Integrity Managementsingle point of accountability.Educate the site on how risks areassessed and managed to closure.Establish performance metrics tobe included in the site annualperformance plan. Consider associatingrisk reduction metrics withsite VPP.[Comment: For the refining SPUthis will be managed at an SPUlevel. New process required.]* BP did not provide to the Panel a response from the Toledo refinery for this item.The responses above indicate an absence of a comprehensive, holistic plan to reduce risk. The variety in the responses also indicates that therefineries do not know what is expected of them in terms of continuous process risk reduction programs. Each refinery had a different response,including one response (Carson) acknowledging no formal process risk reduction process. Two refineries, Cherry Point and Texas City, hadsimilar descriptions of how risks were being managed, but different assessments of actions needed to close deficiencies. Refineries haddifferent proposed plans to close gaps, ranging from a refinery plan to close the gap (Carson) to reliance on corporate management at therefining strategic performance unit level (Texas City, Whiting).Process Safety Management Systems C 170
The Mogford ReportThe Mogford Report found that no plans existed at Texas City to systematically reduce safety risks at the refinery and that no individual or groupseemed to have the accountability for driving process risk reduction across the site. For example, the report found that no plans existedregarding the ultimate replacement/reconfiguration of the blowdown stacks. The report also specifically found that site management did notappear to be focused on understanding and reducing the highest risks. 66> BP’S use of compliance auditsBP appears to have used to some extent infrequent process safety management audits, which are required to be conducted every three years, tomanage toward continuous process risk reduction rather than to have implemented a management system that embodies continuous riskreduction criteria and methodologies. For example, the cover letter transmitting the report for the 2005 Carson process safety managementaudit states that[t]he review reflects the requirements of the Process Safety Community of Practice [Process Safety Integrity Management]compliance protocol that provides the bridge from the high-level gHSEr and [Process Safety Integrity Managment]expectations to actual plant [Process Safety Management] and [Risk Management Program] activities.Priority 2 actions reflect an opportunity and resolution is important to the continuous improvement of the Carson [ProcessSafety Integrity Management] and [Risk Management Program] processes.Letters accompanying the process safety management audits for other refineries during the last few years have been substantially similar tothe 2005 Carson letter.gHSEr audit findings support this apparent misplaced use of compliance audits and reviews, rather than management systems. For example,the summary of findings relating to 2003 gHSEr audits found that “[t]here is a need for greater clarity on HSE monitoring (as part of an HSEmanagement system), specifically ...anentity’s responsibility to monitor and audit its own processes to ensure that they are robust andoperating as intended (rather than rely on external audits).”> Conclusion on continuous risk reductionEven though the MAR engineering technical practice, together with examples, illustrates techniques by which a program of continuous processrisk reduction might be managed, the Panel’s examination found no indication that Refining and Marketing generally, or BP’s U.S. refineriesspecifically, have adopted or implemented any such risk reduction tools. Furthermore, the Panel’s examination indicated that BP has nottranslated its aspirational, high-level corporate goals and expectations as provided in gHSEr and the 2001 process safety/integritymanagement Group standard into specific, operational criteria for managing process risk at the U.S. refineries. While the 2001 standard didexpress the “as low as reasonably practicable” standard for risk reduction, some senior leaders at the U.S. refineries appear generally not tohave been aware of that risk reduction standard—and BP corporate-level management appears to have taken no meaningful steps prior to theTexas City incident to enforce that standard or to translate it into operational reality at its U.S. refineries.Similarly, the Panel’s examination did not detect any indication that BP defined for its U.S. refineries the appropriate role of qualitative orquantitative risk-management criteria. The new Group integrity management standard appears to maintain the status quo regardingcontinuous risk reduction by directing that such risk reduction process be managed at the segment level and continuing the requirement thatglobal business units, such as Refining, identify their top five integrity management risks.Process Safety Management Systems C 171
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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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The Panel found other issues that c
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Table 27“In my opinion, process s
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(2) accountabilities for protection
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All levels of management reported t
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Table 32“The training that I have
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Hourly workers interviewed largely
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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 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 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
Page 219 and 220: BP’s efforts to develop process s
Page 221 and 222: BP’S INVESTIGATION AND ROOT CAUSE
Page 223 and 224: The Panel also identified some defi
Page 225 and 226: Similarly, although mixed responses
Page 227 and 228: Other external reviews of BP’s pr
Page 229 and 230: Table 62Number of Reported Near Mis
Page 231 and 232: Table 64Percentage of Agree/Tend to
Page 233 and 234: BP’S PROCESS SAFETY AUDIT SYSTEM>
Page 235 and 236: compliance or BP policy (Priority 1
Page 237 and 238: Interviews with members of the Safe
Page 239 and 240: Refining line management above the
Page 241 and 242: The audit team found similar proble
Page 243 and 244: 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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