The Baker Panel Report - ABSA

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workers are educated, encouraged, and expected to examine critically all process safety tasks and methods prior to taking them;(h) involve all relevant stakeholders in investigating and preventing accidents, incidents, and near misses, reviewing the results of process safety management audits, developing recommendations for corrective actions when audit deficiencies are identified, and tracking recommendations to completion in a timely manner; and(i) measure the effectiveness of this effort to improve process safety culture by conducting periodically an anonymous process safety culturesurvey among the U.S. refineries. The first survey should be conducted approximately one year from the date of this report.Panel’s Recommendations C 250
RECOMMENDATION #5—CLEARLY DEFINED EXPECTATIONS AND ACCOUNTABILITY FOR PROCESSSAFETYBP should clearly define expectations and strengthen accountability for process safety performance at all levels in executivemanagement and in the refining managerial and supervisory reporting line.Commentary(1) “clearly define expectations and strengthen accountability”—Ultimate accountability and responsibility cannot be delegated and rests atthe top of the organization. BP must strengthen accountability and responsibility for process safety performance in executive management andin the U.S. refining managerial and supervisory reporting line. Delegations of authority and related accountabilities must be made withoperational clarity and specificity about process safety expectations and performance criteria. Accountability should include ensuring that process safety performance goals, objectives, and expectations are included in performance contracts, employeesgoals and objectives, and discretionary compensation arrangements for line managers, supervisors, and workers in BP’sU.S. refineries, making a significant portion of total compensation of refining line managers and supervisors contingent on satisfactorily meetingprocess safety performance indicators and goals in the U.S. refineries, making a significant portion of the variable pay plan for non-managerial workers in BP’s U.S. refineries contingent on satisfactorilymeeting process safety performance objectives, and making process safety performance and leadership significant considerations in career advancement and succession planning.(2) “for process safety performance”—Because major process safety incidents occur relatively infrequently, process safety performancecannot be measured effectively by the occurrence of such incidents alone. Accordingly, BP should establish performance expectations that(a) eliminate on a prescribed schedule gaps in process safety practices at the U.S. refineries as compared with applicable internal and externalstandards and practices, including best practices and other recommended external practices and standards, and (b) include identified processsafety performance indicators as described in Recommendation #7 (and the related commentary).(3) “at all levels in executive management and in the refining managerial and supervisory reporting line”—All levels of management andsupervision play an important role in process safety performance, from the Group Chief Executive to refinery level supervisors and first levelleaders. At each of these levels, process safety accountabilities should be defined in operational terms that are understood—and thenenforced. Managers and supervisors must know that a failure to perform according to operationally defined process safety expectations willhave consequences.BP should also ensure that each U.S. refinery plant manager is primarily responsible for the safe operation of the refinery. The first priority forthe top line manager at each U.S. refinery must be to operate the refinery safely. Commercial responsibilities should not take priority over safetyfor this key line manager.Panel’s Recommendations C 251
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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
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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 272 and 273: (f) educate and provide training to
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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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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