The Baker Panel Report - ABSA

Table 64Percentage of Agree/Tend to Agree Responses to Survey Item:“In general, workers don’t bother to report minor process-related incidents, accidents, and near misses.”Category Carson Cherry Point Texas City Toledo WhitingOperators 35 18 47 44 37Maintenance/Craft Technicians 57 40 56 69 ‡ 32Full-Time HSSE Employees 22 8 36 39 ‡ 33Engineering Professionals 19 7 31 23 27Operations Management 20 3 29 26 17Maintenance Management 50 ‡ 0 ‡ 38 * 9Contractors 60 56 61 61 60* Survey data are not available because of the small number (fewer than 15) of potential respondents.‡ Fewer than 25 respondents were in this group.Information from the hourly interviews also supports this data. Hourly employees interviewed at Texas City, Toledo, and Whiting indicated theirbelief that some incidents, accidents, and near misses were not reported. Some hourly employees interviewed at Carson also expressedskepticism about whether all near misses were reported.Reasons incidents and near misses are going unreported or undetected. Numerous reasons exist to explain why incidents and nearmisses may go unreported or undetected. A lack of process safety awareness may be an important factor. If an operator or supervisor does nothave a sufficient awareness of a particular hazard, such as understanding why an operating limit or other administrative control exists in aprocess unit, then that person may fail to see how close he or she came to a process safety incident when the process exceeds the operatinglimits. In other words, a person does not see a near miss because he or she was not adequately trained to recognize the underlying hazard.As discussed elsewhere in this report, the Panel believes that the general awareness of process hazards at BP’s U.S. refineries is deficient. ThePanel believes that this lack of awareness likely contributes to BP’s insensitivity to near misses and high potential incidents.During BP’s investigation into the Texas City accident, for example, several minor fires occurred at the Texas City refinery. 69 The BP investigatorsobserved that “employees generally appeared unconcerned, as fires were considered commonplace and a ‘fact of life’ in the refinery.” 70Because the employees did not consider the fires to be a major concern, there was a lack of formal reporting and investigation. 71 Any underlyingproblems, therefore, went undetected and uncorrected.A Toledo email shows a similar complacency about the significance of incidents:There apparently was a very small fire at Coker III. The fire was due to vapors coming out of the coke drum overhead linelow point drain (the “flange drain”). I’m not sure if the plug was not installed in this drain before the hot vapor drumpre-heat started, or if the plug was installed but not fully seated, allowing vapors to escape to atmosphere. Either way, Ibelieve that this was a minimal impact, non-event type of fire . . . one that we have seen many times over the years onnumerous flanges and connections on our Cokers. I do not know if a Traction was entered for this event or not.The absence of a trusting environment among employees, managers, and contractors also inhibits incident and near miss reporting. Asdiscussed in Section VI.A, an employee who is concerned about discipline or other retaliation is unlikely to report an incident or near miss out offear that the employee will be blamed.Performance Evaluation, Corrective Action, and Corporate Oversight C 207