The Baker Panel Report - ABSA

investigated to determine the root cause(s) and identify the actions that will prevent a recurrence.” The process safety/integrity managementstandard also observes that incident investigations should be initiated as soon as possible following an incident.59 BP p.l.c., “getting HSE right: a guide for BP managers,” (December 2002), p. 40 (emphasis in original).60 Ibid, p. 35.61 Ibid, p. 40.62 CCPS defines “root cause” as a “fundamental, underlying, system-related reason why an incident occurred that identifies a correctablefailure(s) in management systems. There is typically more than one root cause for every process safety incident.” Center for Chemical ProcessSafety, Guidelines for Investigating Chemical Process Incidents (New York: American Institute of Chemical Engineers, 2d ed. 2003), p. 179.63 Ibid, p.2.64 James R. Phimister et al., “Near-Miss Incident Management in the Chemical Process Industry,” Risk Analysis, Vol. 23, No. 3 (2003), p. 445.Such a concept is apparent from every day experience (e.g., driving). On average, a driver has more close calls (i.e., a near miss or almost a caraccident) than actual accidents. One typically would not expect to have more accidents than close calls.65 Center for Chemical Process Safety, Guidelines for Investigating Chemical Process Incidents (New York: American Institute of ChemicalEngineers, 2d ed. 2003), pp. 61-62.66 Ibid, p. 62.67 The annual average represents the average of those years where BP has data for both MIAs and near misses.68 According to BP, Carson reports near misses in accordance with the BP near miss reporting definition. BP asserts that the Carson STOMPbehavioral-based safety program also reports several hundred “at risk” behaviors or actions.69 BP p.l.c., John Mogford, “Fatal Accident Investigation Report, Isomerization Unit Explosion Final Report,” December 9, 2005, p. 140.70 Ibid.71 Ibid.72 The Panel interviewed hundreds of hourly workers at BP’s U.S. refineries. Several workers commented that they thought Tr@ction was difficultto use and that they did not consult the program as a part of their daily routine. Many workers noted that they just wrote information down andhanded it to a supervisor, but did not know if the supervisor actually entered the information into the Tr@ction system.73 Fewer than 25 respondents were in this group.74 Fewer than 25 respondents were in this group.75 See American Industrial Hygiene Association, American National Standard for Occupational Health and Safety Management Systems, ANSI/AIHA Z10-2005 (Fairfax, Virginia: American Industrial Hygiene Association, 2005), p. 20. Other well-recognized authorities on safetymanagement systems similarly define system audits. See International Labour Office—Geneva, Guidelines on occupational safety and healthmanagement systems, ILO-OSH 2001 (2001), pp. 15-16.76 29 C.F.R. § 1910.119(o)(1) (2006).77 9 C.F.R. § 1910.119(o)(4) (2006).78 BP p.l.c., “getting HSE right: a guide for BP managers,” (December 2002), p. 22.79 Ibid, p. 24.80 The new BP Group integrity management standard also addresses auditing through self and external assessments. As provided by Element 10,Performance Management and Learning, these assessments occur once per year and evaluate the integrity management program, which includesa comparison of BP’s annual performance to key performance indicators. Element 10 also creates a performance management system, whichincludes self and external assessments, for all projects, turnarounds and major maintenance activities. Part of the performance managementsystem includes an Annual Engineering Plan, prepared by all BP strategic performance units, that describes the top five integrity managementrisks identified during the assessment. Good practices identified during assessments are to be shared among all of BP’s operations.81 BP p.l.c., John Mogford, “Fatal Accident Investigation Report, Isomerization Unit Explosion Final Report,” December 9, 2005, p. 139.Performance Evaluation, Corrective Action, and Corporate Oversight C 238