The Baker Panel Report - ABSA

BP’S REPORTING OF INCIDENTS AND NEAR MISSESThe Panel believes that BP has an incomplete picture of process safety performance, and therefore of process risks, at its U.S. refineriesbecause not all incidents and near misses are being detected and reported. This issue is a serious one because the first step in “a successfulincident investigation is to recognize when an incident has occurred so that it can be investigated appropriately.” 63 If BP is not aware of anincident or near miss, it has no opportunity to investigate it and prevent its recurrence or the occurrence of another incident having the sameroot cause.It is generally believed that for every serious incident involving fatalities, serious injuries, or significant damage to the environment or property,a larger number of incidents result in more limited impacts, and an even greater number of incidents result in no loss or damage. 64Near misses in the process safety context can occur in many different forms. Recognized examples include exceeding process operating limits,releases of hydrocarbons or other hazardous substances, and activation of layers of protection such as relief valves, interlocks, or rupture disks,that are built into process equipment. 65In the process safety context, the investigation of these near misses is especially important for several reasons. First, there is a greateropportunity to find and fix problems because near misses occur more frequently than actual incidents having serious consequences. Second,despite the absence of serious consequences, near misses are precursors to more serious incidents in that they may involve systemicdeficiencies that, if not corrected, could give rise to future incidents. Third, organizations typically find it easier to discuss and consider moreopenly the causes of near miss incidents because they are usually free of the recriminations that often surround investigations into seriousactual incidents. As the CCPS observed, “[i]nvestigating near misses is a high value activity. Learning from near misses is much less expensivethan learning from accidents.” 66Ratios of near misses to major incidents. In response to a request from the Panel, BP provided data on the occurrence of major incidents atits U.S. refineries as reflected by major incident announcements and reported near misses. BP considers major incidents to include fatalities,multiple serious injuries, significant economic losses, specific types of large environmental releases, or significant adverse reactions fromregulatory authorities. BP defines a near miss, on the other hand, as “an undesired event, which, under slightly different circumstances, couldhave resulted in harm to people, damage to property, or loss to process.” A table reflecting this data is reproduced below.Performance Evaluation, Corrective Action, and Corporate Oversight C 204