The Baker Panel Report - ABSA

ENDNOTES FOR SECTION VI.B1 See Section III and Section VI.A.2 W. Edwards Deming, The New Economics: For Industry, Government, Education (Cambridge: The MIT Press, 2d ed. 1994), p. 50.3 Isadore Rosenthal et al., “Predicting and Confirming the Effectiveness of Systems for Managing Low-Probability Chemical Process Risks,”Process Safety Progress, Vol. 25, No. 2 (June 2006), p. 147.4 29 C.F.R. § 1910.119, Appendix C (2006).5 See American Industrial Hygiene Association, American National Standard for Occupational Health and Safety Management Systems, ANSI/AIHA Z10-2005 (Fairfax, Virginia: American Industrial Hygiene Association, 2005), p. 22.6 See James Reason, Managing the Risks of Organizational Accidents (Burlington, Vermont: Ashgate Publishing Ltd., 1997), p. 8.7 See American Industrial Hygiene Association, American National Standard for Occupational Health and Safety Management Systems, ANSI/AIHA Z10-2005 (Fairfax, Virginia: American Industrial Hygiene Association, 2005), p. iii.8 Ibid, p.v.9 Ibid, p.5.10 This section of the report discusses the system findings related to (2) and (3), as well as part of (1). The system findings related to (4) and apart of (1) are discussed in Section VI.C of the report.11 The stated purpose of the report was “to highlight common and systemic findings from [the 35] audits, especially those where elements ofthe root cause may warrant focus at Segment and/or Group level so that the HSE management system can be improved.”12 BP p.l.c., “getting HSE right Audit Report, BP South Houston, Audit No. 2003-41,” September 22, 2003, p. 6.13 The report referred to a “What If” analysis technique, which is a method in which a multi-disciplinary team with personnel who are familiarwith the particular process brainstorm questions about possible undesired events due to hazards. This technique does not use an inherentstructure, as do other forms of process hazard analysis such as hazard and operability studies. The report stated that the “What If” checklistused did not specifically address certain issues, including previous incidents, facility siting, and consequences of failure of controls. See BPp.l.c., John Mogford, “Fatal Accident Investigation Report, Isomerization Unit Explosion Final Report,” December 9, 2005, p. 64.14 Ibid, p. 67.15 Ibid, p. 141. See also BP p.l.c., James W. Stanley, “Process and Operational Audit Report, BP Texas City,” June 15, 2005, p. 3, (including, as akey finding, “[c]omplacency towards serious process safety risk, driven by a lack of awareness of potential consequences”).16 Not all of the findings related to the identification of hazards; some related to other aspects of conducting process hazard analyses,including timely correction of action items.17 BP p.l.c., James W. Stanley, “Process and Operational Audit Report, BP Texas City,” June 15, 2005, p. 17.18 Ibid, pp. 18-19.19 External codes and practices also govern the conduct of BP’s U.S. refining operations. BP’s implementation of those externally generatedcodes and practices will be discussed later in this section.20 The relatively large number of external standards applicable to the refining industry may be attributable, at least in part, to the fact that therefining industry developed in the U.S. in the early part of the twentieth century, when there was not extensive government regulation. A numberof industry consensus standards developed in the absence of governmental regulations.21 The API has published many recommended practices, standards, publications, and bulletins relating to health and safety matters atrefineries. In October 2005, the CSB issued two urgent safety recommendations to the API and the National Petrochemical & RefinersAssociation (NPRA) relating to safe placement of trailers for workers. The first recommendation called on API to develop new industry guidance“to ensure the safe placement of occupied trailers and similar temporary structures away from hazardous areas of process plants.” U.S.Chemical Safety and Hazard Investigation Board, “Urgent Trailer Siting Recommendations to American Petroleum Institute and NationalPetrochemical & Refiners Association,” October 25, 2005, accessed at http://www.csb.gov/news releases/docs/CSBSitingRecResolution.pdfProcess Safety Management Systems C 179