The Baker Panel Report - ABSA

CORRECTION OF IDENTIFIED DEFICIENCIES> Importance of corrective and preventive actionsThe Panel believes that an effective process safety management system necessarily requires the prompt correction of identified deficienciesand inadequately controlled hazards. As noted in the voluntary ANSI Z10 standard: 84An organization needs to address all identified system deficiencies and inadequately controlled hazards through thecorrective and preventive action process, regardless of how those deficiencies and hazards were identified. This ensuresthat corrective and preventive actions are undertaken in a systematic fashion, whereby the most serious hazards areaddressed in an expedited fashion and all actions are followed through to completion. 85In the United States, OSHA’s process safety management standard requires the correction of specified deficiencies. The provisions related toprocess hazard analysis, for instance, require an employer subject to the standard to “establish a system to promptly address the team’sfindings and recommendations; assure that the recommendations are resolved in a timely manner . . . [and] complete actions as soon aspossible . . . .” 86 Similar requirements exist for deficiencies identified during incident investigations and compliance audits. 87As noted above, an organization identifies the need to take corrective and preventive action in different ways, including hazard assessments,audits, routine inspections, and investigations into incidents and near misses. After a company identifies a deficiency, it should develop a planto correct it, establish a deadline for doing so, implement the plan, and then track the plan to closure. Actions not implemented by theirdeadlines should be considered overdue.> BP’s processes for closing out action itemsBP’s internal standards recognize the importance of correcting deficiencies as well as learning and sharing lessons from previous incidents.The company’s entire process safety management system is based upon a Plan-Perform-Measure-and-Improve cycle. 88 The gHSEr elementregarding Assessment, Assurance and Improvement, for example, provides for the closure of actions items: “Findings from learning processes(e.g., audits, incident investigations, near misses, HAZOPs, etc.) are prioritized, tracked and used to systematically improve the HSEmanagement system.” 89 gHSEr Element 12: Incidents Analysis and Prevention requires incidents to be “reported, investigated and analysed toprevent recurrence and improve our performance. . . . Corrective actions and preventive measures will be utilized to reduce future injuries andlosses.” 90 The BP standard also provides that preventive actions from incident investigations will be “documented and closed-out.” 91The BP Group process safety/integrity management standard provides additional support for the importance of corrective and preventiveactions. Element 1.0, Hazard Evaluation, provides that “[t]he output of the risk assessment and process hazard analyses should includeidentification of specific hazards and the accepted recommendations from these studies shall be implemented in a timely manner to minimisethe risk or eliminate the hazard.” The process safety/integrity management standard also provides that “[t]horough incident investigations,with complete follow-up and closure of action items, are critical to achieving an injury and incident free workplace.”Although BP expends significant effort to identify deficiencies and to correct many identified deficiencies, which BP often does promptly, thePanel’s review found an apparent inability to address repeat audit findings at BP’s U.S. refineries by correcting true root causes. This problem isespecially apparent in overdue mechanical integrity inspection and testing. BP would often identify overdue items and then make a concertedeffort to close them out. Because the fundamental cause of the problem remained unaddressed, however, the list of overdue items would beginto grow again and be observed in the next round of audits.Performance Evaluation, Corrective Action, and Corporate Oversight C 214