The Baker Panel Report - ABSA

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(f) educate and provide training to enable internal BP process hazard analysis leaders and team members to conduct effective process hazardanalyses using the latest recognized and generally accepted practices; and(g) audit contractors regularly to determine compliance with applicable process safety knowledge and expertise standards.Panel’s Recommendations C 248
RECOMMENDATION #4—PROCESS SAFETY CULTUREBP should involve the relevant stakeholders to develop a positive, trusting, and open process safety culture within each U.S. refinery.Commentary(1) “involve the relevant stakeholders”—In order to achieve outstanding process safety performance, it is important that BP consult and workwith stakeholders at its U.S. refineries in developing and conducting the actions listed in Comment (2) below. BP should ensure thatmechanisms exist that effectively promote and facilitate two-way communication between BP managers and all relevant stakeholders. Therelevant stakeholders include salaried, hourly, and contract employees; employee representatives; contractors; and where appropriate,members of the community in close proximity to BP’s U.S. refineries.(2) “develop a positive, trusting, and open process safety culture”—In order to promote the development of a positive, trusting, and openprocess safety culture, BP should take the actions listed below. The listed actions are not intended to be an exhaustive list, and BP shouldconsider other opportunities to improve the process safety culture at its U.S. refineries. At a minimum, BP should(a) share the results of the process safety culture survey conducted on behalf of the Panel with the U.S. refinery workforce on arefinery-by-refinery basis within six months from the date this report is issued;(b) review the effectiveness of existing refinery-level process safety related policies, practices, and procedures that have a significantpotential to affect BP stakeholders and develop and implement new refinery level process safety goals, policies, practices, and procedures thattake into account stakeholder interests and input;(c) review the effectiveness of existing safety committees in promoting process safety and develop and execute a plan to improve sucheffectiveness. Existing safety committees should be able to assume roles that will have a more significant impact on process safety culture andpromote adherence to good process safety practices. This review should involve all relevant stakeholders and include an assessment of eachcommittee’s composition and purpose and the extent to which its role overlaps with the role(s) of other committees;(d) review practices with contractors for the purpose of eliminating inappropriate inconsistencies, as compared with BP employees, fortraining, discipline, incentives, and communications;(e) implement changes necessary to achieve and maintain compliance with applicable policies, practices, and procedures;(f) distinguish more clearly between acceptable and unacceptable employee acts such that the vast majority of unsafe acts or conditions canbe reported without fear of punishment. A strong process safety culture facilitates the sharing of information that will reduce safety risks. As aresult, BP’s refineries should operate in such a way as to permit the reporting of the vast majority of unsafe acts or conditions by employees andcontractors without fear of punishment. While unsafe acts that are reckless or particularly egregious may warrant some type of sanctions, theculture of each U.S. refinery should promote sharing of information relevant to safety even when that information indicates that workers havemade mistakes;(g) establish a climate in which workers are encouraged to ask challenging questions without fear of reprisal, andPanel’s Recommendations C 249
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JANUARY 2007THE REPORT OFTHE BP U.S
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PANEL STATEMENTProcess safety accid
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RETIRED ADMIRAL FRANK L. “SKIP”
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DR. NANCY LEVESON is a Professor of
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DR. DOUGLAS A. WIEGMANN, Ph.D. is t
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• Dennis C. Hendershot, Principal
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The Panel’s FindingsThe Panel foc
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Process safety cultures at BP’s U
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Process safety audits. The Panel fo
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RECOMMENDATION #5 - CLEARLY DEFINED
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TABLE OF CONTENTSI. The Panel’s R
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A. Scope and MethodologyI. THE PANE
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interview, and at least one attorne
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PROCESS SAFETY REVIEWSThe CSB’s u
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BP requested that the Panel use the
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would be positive from a process sa
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more of the Panel’s recommendatio
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management systems. The charter doe
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observed at BP are likely not limit
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II. PRECIPITATING EVENTS FOR THE PA
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As the Mogford Report explains, the
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III. OVERVIEW OF PROCESS SAFETY, PE
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elated to personal safety performan
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ENDNOTES FOR SECTION III1 29 C.F.R.
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IV. OVERVIEW OF BP’S ORGANIZATION
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Although lower levels of supervisor
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segment includes the manufacturing
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Browne, who has a diverse backgroun
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BP provides no specific training fo
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The new Safety and Operations funct
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The primary purposes of this new or
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maintain a culture in which reliabi
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TEXAS CITYBP acquired the Texas Cit
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25 BP evaluates (1) “Level 5 Lead
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(7) pre-start-up safety review,(8)
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Assessment, assurance, and improvem
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BP control of work standardBP issue
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BP PROCESS AND PERSONAL SAFETY BOOK
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ENDNOTES FOR SECTION V1 BP addresse
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A. Corporate Safety CultureVI. FIND
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Process safety as a core value in B
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contractors and employees in the pr
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A fourth and similar survey item ad
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The Panel recognizes that Browne is
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BP management’s focus on personal
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milestones to guide the efforts of
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Refinery plant manager turnoverUnde
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EMPLOYEE EMPOWERMENTThe Panel belie
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Survey responses substantiate that
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As discussed later in this section,
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U.S. refinery staff and capabilityB
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In 2002, BP commissioned a report b
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The process safety culture survey r
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Worker fatigue and overtimeThe Pane
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As demonstrated below, process safe
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decision to reduce spending on insp
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environmental, and operational goal
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THE PROCESS SAFETY CULTURE AT EACH
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Finally, the Panel’s own observat
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Survey responses from Cherry Point
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process safety culture at the refin
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Table 22‘‘I can report hazardou
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The Panel found other issues that c
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Table 27“In my opinion, process s
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(2) accountabilities for protection
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All levels of management reported t
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Table 32“The training that I have
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Hourly workers interviewed largely
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Table 34“Refinery management puts
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Finding:Each of BP’s five U.S. re
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Table 36“Workers sometimes work a
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Finally, relatively high percentage
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Also indicative of perceived noncom
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ENDNOTES FOR SECTION VI.A1 Meredith
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51 Ibid, p. ii.52 Ibid, p. 153.53 I
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Finally, because the nature and sco
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At the Carson, Cherry Point, and To
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The 2003 audit report for BP South
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COMPLIANCE WITH INTERNAL PROCESS SA
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Table 40Percentages of Disagree/Ten
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Prioritization of inspections and m
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Whiting (2006) Not all of the alarm
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Point have implemented the standard
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the facility siting risk to personn
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The ANSI Z490.1-2001 standard provi
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key positions, BP should assess and
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interviews at some of the refinerie
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Information relating to BP’s Texa
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Computer-based training. Based upon
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TRANSLATING CORPORATE EXPECTATIONS
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In early 2005, prior to the Texas C
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The table below contains the substa
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Interviews with various members of
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BP’S PROCESS SAFETY MANAGEMENT SY
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usiness units, to prioritize implem
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Turnaround deferral procedure (Cars
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on December 4, 2006. In that recomm
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C. Performance Evaluation, Correcti
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valves, and other safety-related eq
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Tracking of process safety indicato
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Table 57Number of Overdue Inspectio
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Although the Panel recognizes that
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Previous concerns about measuring p
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BP’s efforts to develop process s
Page 221 and 222: BP’S INVESTIGATION AND ROOT CAUSE
Page 223 and 224: The Panel also identified some defi
Page 225 and 226: Similarly, although mixed responses
Page 227 and 228: Other external reviews of BP’s pr
Page 229 and 230: Table 62Number of Reported Near Mis
Page 231 and 232: Table 64Percentage of Agree/Tend to
Page 233 and 234: BP’S PROCESS SAFETY AUDIT SYSTEM>
Page 235 and 236: compliance or BP policy (Priority 1
Page 237 and 238: Interviews with members of the Safe
Page 239 and 240: Refining line management above the
Page 241 and 242: The audit team found similar proble
Page 243 and 244: The issues that the Panel’s techn
Page 245 and 246: USING RESULTS OF INCIDENT INVESTIGA
Page 247 and 248: Issue Grangemouth Texas CitySafety
Page 249 and 250: CORPORATE OVERSIGHTAn effective pro
Page 251 and 252: Selected excerpts from the EEAC rep
Page 253 and 254: Group- and refining-level process s
Page 255 and 256: Knowledge of performance management
Page 257 and 258: Each member of the board needs to a
Page 259 and 260: ENDNOTES FOR SECTION VI.C.1 America
Page 261 and 262: 43 Health & Safety Executive, Devel
Page 263 and 264: 82 When conducting reviews, BP desi
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Page 268 and 269: cultures, process safety management
Page 270 and 271: (i) implement a policy regarding ar
Page 274 and 275: workers are educated, encouraged, a
Page 276 and 277: RECOMMENDATION #6—SUPPORT FOR LIN
Page 278 and 279: (3) “periodically update”—The
Page 280 and 281: RECOMMENDATION #9—BOARD MONITORIN
Page 282 and 283: ANNEX I—PROCESS INCIDENT INDEX EX
Page 284 and 285: a fatality that results from a mech
Page 286 and 287: III. Structure and Operations The C
Page 288 and 289: 11. On August 10, 2005, the Texas C
Page 291: APPENDIX CBP U.S. REFINING ORGANIZA
Page 295 and 296: APPENDIX DWHITING RUPTURE DISK: A C
Page 297 and 298: B. INADEQUATE REVIEW AGAINST TECHNI
Page 299: management review or monitoring pro
Page 303 and 304: 214-06GEMS 1544316Review of Process
Page 305 and 306: Executive SummaryOn March 23, 2005,
Page 307 and 308: Based upon its work, the PSM Review
Page 309 and 310: Table of ContentsSectionPageExecuti
Page 311 and 312: 1. IntroductionOn March 23, 2005, t
Page 313 and 314: Following these general sampling pr
Page 315 and 316: Review of documentsWalkaround inspe
Page 317 and 318: 3. Discussion of FindingsBased upon
Page 319 and 320: 3.1 Rupture Disks Under Relief Valv
Page 321 and 322: 3.2 Equipment Deficiencies - Known
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Once a site specifies the frequenci
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System Finding 3 - Equipment inspec
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accepted good engineering practice
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Not implementing action items or ta
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3.9 Compliance Audit Findings - Rep
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3.11 Near-miss Investigation - Inad
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from water. However, the PHA report
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Appendix A - Scope of Work for BP I
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v. Safety instrumented system desig
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Appendix B - PSM Review Team Leader
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Jack McCavitMr. McCavit is Presiden
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14 Guidance on Practice for Design
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Operations network.performance.Refi
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C. Performance Evaluation, Correcti
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APPENDIX GPROCESS SAFETYCULTURE SUR
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INTRODUCTIONWelcome to the BP U.S.
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I. ABOUT MEIn this section you are
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SURVEY TERM DEFINITIONSPlease read
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Safety Values / Commitment to Proce
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Procedures and EquipmentNote: For e
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Process Safety TrainingNote: For ea
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PLEASE DO NOT WRITE ON THIS PAGE.14
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TermHSSEIncidentISAIsomerization (I
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ACKNOWLEDGEMENTSMembers of the BP U
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