The Baker Panel Report - ABSA

Refining line management above the refinery level was aware of the company’s poor record on closing out action items. For three years in a row,the company’s annual gHSEr assessments identified BP’s failure to timely close out action items as a repeat finding. In addition, the status ofopen Priority 1 action items was reported to the Global Refining leadership. Prior to the Texas City incident, personnel at the BP Refining levelbegan tracking the status and closure of action items.BP’s own process safety audits and gHSEr assessments highlighted what the Panel considers to be a continuing and significant deficiencywithin the company. There is no shortage of assessments, reviews, and audits within BP, and company internal auditors have examined theperformance and management systems of many of BP’s business units and segments. The follow through after the review, however, has fallenshort repeatedly. This failure to follow through compromises the effectiveness of even the best audit program or incident investigation:The ultimate objective of incident investigation is preventing recurrence of a specific incident scenario or related similarincidents. Considerable effort and resources are expended in determining an incident’s root causes and identifyingsuggested preventive measures. Despite this effort, the potential for a repeat occurrence remains unchanged untilrecommendations are implemented. The value of the investigation is entirely dependent on the effectiveness offollow-up activities. 92For these reasons, the Panel observes that BP seemingly has been unable to close out its own repeat finding that the company does noteffectively correct the deficiencies that it identifies.> Repeat findings in BP’s process safety auditsAs OSHA requires, BP audits its process safety compliance at each of the U.S. refineries at least once every three years. 93 The Panel recognizesthat BP appears to have promptly corrected many of the deficiencies or uncontrolled hazards identified by these reviews.BP has sometimes failed, however, to address corrective and preventive actions recommended during hazard assessments, audits, inspections,and incident investigations. The Panel’s review of the reports summarizing BP’s prior process safety audits, described in more detail below,confirms this view. As Browne now acknowledges, some of the prior process safety audits identified the same issues again and again: “Therewas a stubbornness around getting things done.”Carson audit reports. The Panel reviewed process safety audit reports for the Carson refinery dated July 2002 and December 2005.The 2002 audit report indicates that the audit team could not verify whether previous recommendations were closed because the site did notuse an action item tracking system for process safety audit corrective actions. The audit team also found that the site did not resolve overdueaction items identified during hazard assessments. At the time of the review, for example, the site had more than 60 open action items thatwere more than three years old. In addition, 62 pressure vessels and 650 pressure relief valves were past inspection due dates. Previousrecommendations resulting from incident investigations were also overdue. The auditors noted that up-to-date information on the status ofthese recommendations was difficult to obtain.The 2005 audit reveals similar issues. With respect to process hazard assessments, the report notes that “[t]here are around 200 RevalidationHAZOP action items open and [three] overdue. However, some open items are more than eight years old.” The audit team issued a repeat findingfrom the 2002 audit because one unit at the facility used a different categorization of operating procedures. The audit team also issued repeatPriority 1 findings because numerous pressure relief valves (134) and pressure vessels (166) were past due for inspection. The Priority 1findings on these issues made in 2005 are virtually identical to the Priority 1 findings on these same issues made in 2002.Performance Evaluation, Corrective Action, and Corporate Oversight C 215