The Baker Panel Report - ABSA

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countries, many of the underlying deficiencies identified after the incidents appear to be the same, especially as they relate to evaluatingprocess safety performance and then taking corrective actions.MEASURING PROCESS SAFETY PERFORMANCERegular measurement and monitoring of process safety performance allows an organization to evaluate the effectiveness of steps taken tocontrol and reduce process risk. 13 The process of measuring and monitoring should provide “information to determine whether the day-to-dayarrangements for hazard and risk identification, prevention, and control are in place and operating effectively . . . .” 14In order to measure the safety performance of their operations, many companies have incorporated leading and lagging indicators, also knownas metrics or key performance indicators, into their safety management systems. Managers use these metrics to track safety performance,compare or benchmark safety performance against the performance of other companies or facilities, and set goals for continuous improvementof safety performance. The Panel notes that regulatory agencies, industry groups, and labor organizations have undertaken efforts to advancethe state of the art in terms of developing process safety indicators. See Section III for a more complete discussion of indicators. The USW, forexample, developed one such indicator in 1996. The CCPS and the UK HSE also have devoted significant efforts to the issue of process safetyindicators since the mid-1990s. UK HSE, which regulates workplace health and safety in the United Kingdom, recently published DevelopingProcess Safety Indicators, A Step-By-Step Guide for Chemical and Major Hazard Industries. 15 In the United States, the CCPS has renewed itswork with a project on the development of process safety metrics. 16Reactive monitoring: use of lagging indicators. When considering the measurement element of the continuous improvement cycle forprocess safety, it is critical to distinguish between reactive versus active measuring and monitoring. Reactive monitoring of process safetyincludes the identification, reporting, and investigation of process-related injuries, incidents, and property damage. 17 Reactive monitoringallows an organization to identify and correct deficiencies in response to specific incidents or trends. Reactive monitoring uses laggingindicators to measure historical, after-the-fact performance. 18 These indicators show when the desired safety outcome has not been achievedand the safety control system has failed to prevent an incident. Examples of lagging indicators include the number of unexpectedloss-of-containment incidents and failures of safety critical instrumentation/alarms. 19 Because of their nature, lagging indicators of processsafety performance suffer from the disadvantage that they only suggest corrective actions after an accident.The refining industry commonly uses personal safety lagging indicators or injury rates. Largely derived from OSHA reporting, injury rates suchas days away from work and recordable injury frequency have become established and generally accepted measures of personal safetyperformance. Companies collect and report these metrics at regular intervals. Additionally, many companies set goals based upon reducinglagging indicators such as recordable injury frequency. Although companies may set performance targets based upon reducing laggingindicators related to personal injury rates, the Panel believes (as BP aspires) that the ultimate goal for safety performance should be zeroincidents.Although recognized and generally accepted lagging indicators exist in the United States for personal safety, there is no universally agreedupon lagging indicator for process safety. Because process safety accidents occur infrequently and are often unrelated to each other in theircausal factors, past process safety accidents have limited value in predicting future process-related incidents. Consequently, for purposes ofmanaging process risks, organizations should develop leading process safety performance indicators that, if monitored, can be used to avoid orprevent process incidents.Active monitoring: use of leading indicators. Active monitoring evaluates the present state of a facility through the routine and systematicinspection and testing of work systems, premises, plant, and equipment, 20 including rotating equipment, pressure vessels, piping, reliefPerformance Evaluation, Corrective Action, and Corporate Oversight C 184
valves, and other safety-related equipment. Organizations may use active monitoring requirements as leading indicators to provide feedbackon performance before an accident or incident occurs. 21As the term implies, leading indicators attempt to measure variables that are believed to be indicators or precursors of future safetyperformance so that the desired safety outcome (i.e., no incidents) can be achieved. While useful in predicting future process safetyperformance, leading indicators are not absolutely predictive. For example, the percentage of equipment that is past due for inspection can beconsidered a process safety leading indicator because the metric relates to the physical condition of the facility as well as the effectiveness ofoversight systems. However, even if equipment inspections are current, equipment failures can still occur.Using both leading and lagging indicators. Effective measuring and evaluation systems utilize both leading and lagging indicators. The UKHSE recently proposed using a system of “dual assurance” with both leading and lagging indicators. 22 The UK HSE believes that employingboth sets of indicators will provide assurances on the effectiveness of a site’s risk control systems. 23 Trends in these indicators may provideadvance notice of problems.> BP’s measurement of safety performanceBP recognizes the importance of performance indicators for all aspects of its business operations, including operational (Solomon availabilitybenchmarks), financial (gross margin), and safety performance (primarily personal safety metrics such as recordable injury frequency).Expectation 13.1 of gHSEr, which relates to Element 13: Assessment, Assurance and Improvement, creates the expectation that the companywill establish and communicate safety-related performance indicators throughout the organization. 24Reliance on injury rates. Interviews with BP corporate-level managers make clear that BP relied principally on injury rates to monitorprocess safety performance at the U.S. refineries before the Texas City accident. As shown in Table 54, the performance metrics in three keyreports from different levels of the corporation—refining operations, the Refining and Marketing segment, and the BP Group—alsodemonstrate this focus on injury rates.Table 54Tracking Metrics Contained in Key BP Refining and Group-LevelHealth, Safety, Security and Environmental Reports2005Refining HSSEPerformance Report• Fatalities• Days Away From Work CaseFrequency (DAFWCF)• Recordable Injury Frequency• Total Vehicle Accident Rate• Oil Spills One Barrel• Energy Intensity Index• Greenhouse Gas Emissions• Real Sustainable Reductions2005Refining and MarketingSegment HSSE Report• Workforce Fatalities• Third-Party Fatalities• Third-Party Fatalities with MaterialInfluence• DAFWCF• Recordable Injury Frequency• Action-Item Closure• Spills One Barrel• Severe Spills• Total Vehicle Accident Rate• Serious Vehicle Accident Rate• Health Map Completion2005 BP Annual HSSE Report for theEnvironment and Ethics AssuranceCommittee of the Board of Directors• Fatalities• DAFWCF• Recordable Injury Frequency• Uncontrolled Releases• Greenhouse Gas Emissions• HSSE Fines and PenaltiesPerformance Evaluation, Corrective Action, and Corporate Oversight C 185
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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
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Finding:Each of BP’s five U.S. re
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Table 36“Workers sometimes work a
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Finally, relatively high percentage
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Also indicative of perceived noncom
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ENDNOTES FOR SECTION VI.A1 Meredith
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51 Ibid, p. ii.52 Ibid, p. 153.53 I
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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
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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: C. Performance Evaluation, Correcti
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
Page 245 and 246: USING RESULTS OF INCIDENT INVESTIGA
Page 247 and 248: Issue Grangemouth Texas CitySafety
Page 249 and 250: CORPORATE OVERSIGHTAn effective pro
Page 251 and 252: Selected excerpts from the EEAC rep
Page 253 and 254: Group- and refining-level process s
Page 255 and 256: Knowledge of performance management
Page 257 and 258: 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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