The Baker Panel Report - ABSA

Table 62Number of Reported Near Misses and Major Incident Announcements (MIAs)Refinery Items Reported 2000 2001 2002 2003 2004 2005 Annual Average 67Carson 68 Near misses N/A 37 17 35 72 20 36.2MIAs 1 1 1 1 0 2 1Cherry Point Near misses N/A 141 213 332 418 371 295MIAs 0 0 0 0 0 1 0.17Texas City Near misses N/A N/A 701 1292 1801 1256 1262.5MIAs 0 1 2 2 5 4 2.33Toledo Near misses 7 16 39 32 89 107 48.33MIAs 0 1 3 0 0 2 1Whiting Near misses 555 430 551 498 472 535 506.83MIAs 6 2 2 3 5 0 3As shown in Table 62, the annual averages of near misses and major incident announcements for a number of the refineries during the six-yearperiod shown above vary widely. The annual averages yield the following ratios of near misses to major incident announcements for therefineries: Carson (36:1); Cherry Point (1770:1); Texas City (541:1); Toledo (48:1); and Whiting (169:1). The wide variation in these ratiossuggests a recurring deficit in the number of near misses that are being detected or reported at some of BP’s five U.S. refineries.Although the Cherry Point refinery’s ratio of annual average near misses to annual average major incident announcements is higher than theratios for the other four refineries, even at Cherry Point a previous assessment in 2003 noted the concern “that the number of near hits reportedappears low for the size of the facility.” The ratios for Carson and Toledo, however, are especially striking. The Panel believes it unlikely thatCherry Point had more than 35 times the near misses than Carson or Toledo. Other information that the Panel considered supports thisskepticism. A BP assessment at the Toledo refinery in 2002, for example, found that “leaders do not actively encourage reporting of all incidentsand employees noted reluctance or even feel discouraged to report some HSE incidents. No leader mentioned encouragement of incident/nearmissreporting as an important focus to improve HSE performance at the site and our team noted operational incidents/issues not reported.”Ratios of high potential incidents to major incidents. In addition to tracking near misses, BP tracks high potential incidents, which BPdefines as an incident or near miss in which “the most serious probable outcome is a Major Incident.” Termed “HiPos,” these high-potentialincidents can be a predictor of the potential for major incidents. The Panel believes that comparing the frequency of high potential incidents tothe frequency of major incident announcements further supports concerns regarding the adequacy of near miss and incident reporting.An examination of the ratio of high potential incidents and major incident announcements reported by BP suggests that high potentialincidents may be going unreported or undetected. As seen in Table 63, the ratios of high potential incidents to major incident announcementsare markedly lower than the ratios for near misses to major incident announcements. At several of the facilities, no high potential incidentswere reported in some years, but one or more major incident announcements occurred in those years. This situation is particularly noticeable atWhiting. From 2000 to 2002, no high potential incidents were reported, but ten major incident announcements occurred: six in 2000, two in2001, and two in 2002. All of the facility ratios of high potential incidents to major incident announcements, viewed as an annual average,yielded ratios of no more than five to one.Performance Evaluation, Corrective Action, and Corporate Oversight C 205