The Baker Panel Report - ABSA

Furthermore, many of the listed systemic factors do not represent systemic issues. Fatigue, for instance, is included as a systemic cause.Although BP identifies some subcategories under fatigue, such as whether fatigue was due to workload, lack of rest, or sensory overload, thePanel does not believe that these types of subcategories represent true systemic causes. For example, a system cause may be that managementrequires too much overtime because they have not hired enough workers or that limits have not been placed on work hours or that required restperiods have not been enforced. Workload, lack of rest, and sensory overload may be the immediate causes of worker error, but not the systemcauses. Although human factors are not split into systemic and immediate causes in the human error analysis, the majority of the factorsoverlap with the CLC and are analyzed in light of their CLC category.Finally, the Panel notes that BP uses the CLC for both personal safety accidents and process safety accidents. As a result, the checklist CLCapproach may tend to bias the analysis toward looking at human error as opposed to engineering and management issues. In the Panel’sopinion, the causal factors involved in occupational or personal safety incidents and process safety incidents typically are very different. Theuse of personal safety incident hypotheticals as the only examples in some of the BP training materials that the Panel reviewed mayinadvertently reinforce this bias. The human error analysis, which focuses investigators’ efforts on personal safety aspects of incidents ratherthan all aspects of an incident, may introduce additional bias in the analysis toward finding behavioral root causes.> The thoroughness of BP’s investigationsSeveral of the technical reviews that the Panel’s consultants conducted and a process safety audit that a third-party consultant conducted atTexas City in 2006 confirm the Panel’s concerns about the effectiveness of BP’s incident and near miss investigations. Based upon theirsampling of incident and near miss investigations, the Panel’s technical consultants found several instances of deficiencies in BP’s near missinvestigation system. At the Carson refinery, the technical consultants identified closed incident investigation reports that did not specify theroot causes or contributing factors. The review at the Cherry Point refinery found several instances among the sampled investigation reports inwhich the potential consequences of near misses had been underestimated, resulting in the events receiving a lower classification and,consequently, a less rigorous investigation. The technical consultants observed that the incident type/scope language in the Toledo refineryincident investigation procedure did not explicitly address the need to investigate near miss type events for process safety managementcompliance purposes.The 2006 third-party audit of process safety management at the Texas City refinery also reveals deficiencies in incident investigation,especially in root cause analysis. For example, approximately 15 percent of the incident reports that the third-party auditor reviewed list poorjudgment as a system cause with no further analysis. Because “many of the causes in the investigation reports involved human errors,” theauditor recommended that BP consider further review “to determine whether the investigators should be drilling down deeper (e.g., by asking“Why?” several more times) in order to reach management systems root causes.” The auditor also found that no procedure or formal trainingwas provided on what constituted an acceptable or “good” recommendation.Performance Evaluation, Corrective Action, and Corporate Oversight C 200