The Baker Panel Report - ABSA

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a fatality that results from a mechanic falling from an elevated work surface when the fall was caused by a sudden release of steam;and an OSHA 300 log injury to a responder to an incident that is a release of material or energy from a process.The following are examples of items that do not add to the count total: an OSHA 300 log injury that results from a splash while a lab technician is running a unit sample (not in the process); a small cut to an operator in the unit that does not result in an OSHA 300 log injury; a broken leg that occurred in an operating unit when an operator slipped and fell on ice; an OSHA 300 log injury that results from a wrench falling from an elevated work surface in an operating unit; and a fatality that results from a mechanic falling from an elevated work surface in an operating unit when the fall was caused by a slip.Example CalculationAssumptions: In a calendar year a plant with 400 employees (800,000 hours worked) had 10 fires. One of the fires resulted in a serious injury and a fatality. One of the fires resulted from a release of 2,000 pounds of flammable material. A hot condensate release resulted in two injuries. There were also 8 releases that were reportable under CERCLA. No members of the public were directly impacted by the incidents.10 counts—from the 10 fires3 counts—from the injuries10 counts—from the single fatality1 count—from the release of more than 500 pounds of flammable material8 counts—from the 8 CERCLA reportable releases.32 total process incident index countsProcess Incident Index Calculation:32 counts, divided by 800,000 hours worked, multiplied times 200,000 = 8.0Panel’s Recommendations C 260
In response to the Urgent Recommendation of the U.S. Chemical Safety and Hazard Investigation Board (CSB) (copy attached as Appendix 1),the Group Chief Executive of BP p.l.c., acting under delegated authority of the Board of Directors of that company, hereby commissions anindependent panel, to be named the BP U.S. Refineries Independent Safety Review Panel (Independent Panel). The purpose of the IndependentPanel is to make a thorough, independent and credible assessment of the effectiveness of BP Products North America Inc.’s (BP Products)corporate oversight of safety management systems at its refineries 1 and its corporate safety culture. The commissioning of this review andindependent assessment reflects BP p.l.c.’s ongoing commitment to the safe operation of all its United States refining facilities.I. PurposesAPPENDIX ABP U.S. REFINERIES INDEPENDENT SAFETY REVIEWPANEL CHARTERThe Independent Panel’s written report will examine and recommend any needed improvements to: Corporate safety oversight, including the safe management of refineries obtained through mergers and acquisitions. Corporate safety culture, including the degree to which: Corporate officials exercise appropriate leadership to promote adherence to safety management systems; Process safety is effectively incorporated into management decision-making at all levels; Employees at all levels are empowered to promote improved process safety; and Process safety programs receive adequate resources and are appropriately positioned within organizational structures. Corporate and site safety management systems, specifically: Near miss reporting and investigation programs; Mechanical integrity programs; Hazard analysis programs, management-of-change programs, and up to date operating procedures for processes withcatastrophic potential; and Siting policies for occupied structures near hazardous operating units. The Independent Panel should avoid duplicating the efforts of the CSB to determine the specific root causes of the incident at TexasCity on March 23, 2005. The Independent Panel should not seek to affix blame or apportion responsibility for any past event. Any ambiguities in interpretation of this Charter will be resolved in a manner consistent with the purposes and objectives of the CSBRecommendation.II. Independent Panel Membership The Independent Panel will have at least seven (7) members. Members will be appointed by the Group Chief Executive of BP p.l.c. based on their competence and ability to add substance to thedeliberations of the Independent Panel. Members will be appointed so as to have a diverse makeup, including an external chairperson, labor representatives, and outsidesafety experts, such as experts in process safety, experts in corporate culture, organizational behavior and human factors andexperts from other high risk sectors such as aviation, space exploration, nuclear energy and the undersea navy. Each Member must also be, and remain during the term of his or her service, independent and free from any material relationshipthat, in the opinion of the Group Chief Executive of BP p.l.c., would interfere with the exercise of his or her independent judgment orwould appear to a reasonable observer to do so. Such material conflicts of interest will be avoided in the selection of IndependentPanel Members through the normal vetting process conducted by BP p.l.c. and its counsel. Independent Panel Members will berequired to disclose to BP p.l.c. and to the Independent Panel the nature of any relationship with BP p.l.c. or a BP p.l.c. subsidiary orother relevant entities. Upon its formation, the Independent Panel shall make public a summary of any known material conflicts ofinterest involving its Members and an explanation of how those conflicts have been resolved. Any Independent Panel vacancies will be filled, and any additions to membership will be made, by the Group Chief Executive of BPp.l.c., after consultation with the Chair of the Independent Panel, and will be consistent with the considerations above. The CSB willbe notified of any vacancies and subsequent appointments to the Independent Panel. Only the Independent Panel acting by a majority vote is authorized to remove a sitting member of the Independent Panel for good cause.Panel Charter C A-1
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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
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The Panel also identified some defi
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Similarly, although mixed responses
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Other external reviews of BP’s pr
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Table 62Number of Reported Near Mis
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Table 64Percentage of Agree/Tend to
Page 233 and 234: BP’S PROCESS SAFETY AUDIT SYSTEM>
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Page 237 and 238: Interviews with members of the Safe
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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
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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 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
Page 323 and 324: Once a site specifies the frequenci
Page 325 and 326: System Finding 3 - Equipment inspec
Page 327 and 328: accepted good engineering practice
Page 329 and 330: Not implementing action items or ta
Page 331 and 332: 3.9 Compliance Audit Findings - Rep
Page 333 and 334: 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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