The Baker Panel Report - ABSA

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ChairmanBP AmericaRobert MaloneVP Safety &OperationsJohn SiegGroup EngineeringDirectorJohn BaxterHead ofEngineeringStandardsRoss SmithHead of IntegrityManagementPeter ElliottAnalystEngineeringStrategyChris DoranHead of MajorHazards & FireMike ConsidineBP U.S. Refining Organizational Chart(Simplified)CEOJohn BrowneChief of Staff(Corporate)David AllenExecutive Officer,Strategic Resources(Functions)Iain ConnChief ExecutiveRefining & MarketingJohn ManzoniGVP TechnologyTony MeggsSenior GVPSafety & OperationsJohn MogfordGroup VPHSSE & TechnologyRefining & MarketingC.J. WarnerGroup VPRefiningMike HoffmanEngineering TechnicalPractices Project(ETP Project)Jason KestnerEngineering TechnicalPractices Project(ETP Project)John FranzwaConsultant IntegrityManagementGeorge HolmesAnalyst IntegrityManagementMeredith IngramAdvisor RiskKieran GlynnSenior AdvisorRiskSteve HallFireAdvisorKevin WestwoodVP StrategyPlanning &PerformanceSteve FlynnVP Safety &Operations AuditJim O’BrienVP Safety &Industrial HygieneDeb Grubbe(Existing Position Moved Into S&O)VP OrganizationalCapability, Safety& OperationsGill MorrisonVP OperationsExcellenceRudy BlyweertVP HealthRichard HeronDirectorProcess SafetyMike BroadribbTechnology VPProjects andEngineeringChris LondonVP HSSE Refining& MarketingKrish RajuEngineering Authority ManagerTom CerwinskeIntegrity ManagementSPABob McCarthyProcess Safety AdvisorDon Connelly - U.S.Frederic Gil - Int’l.VP HSSE andTechnologyPaul MaslinManufacturing ExcellenceManagerHugh ParsonsHSSE NetworkPerformance LeaderKim BucekCommunity of PracticeProcess SafetyManagementRob ShawProcess Safety CoPCarson - Aaron NagayamaCherry Point - Eric PetersTexas City - Rob DiValerioToledo - Mike FinklerWhiting - Bill LashHRO ManagerColin ReidHSSE ManagerBob DevineHSSE ManagerKaren PayneHSSE ManagerPat KingHSSE ManagerTom GrimmerBUL Cherry PointJeff PitzerHSSE ManagerStan SorrelsBUL Texas CityColin MacleanRefining VPU.S. RegionPat GowerBUL CarsonGeorge NicolaidesBUL ToledoRon UnnerstallBUL WhitingDan SajkowskiLegendPositions Existing Priorto March 23, 2005Positions Created PostMarch 23, 2005REDPersons New to <strong>The</strong>irPosition PostMarch 23, 2005U.S. Refining LineManagementVP OMS/PSMRick PorterProgram DirectorOMSJonathon MillsMgr BusinessArchitectureJoe DurningMgr PSMLee ValentineMgr TechnologyOMSMarty WolfMgr ChangeJeff SeipelMgr PMOPaul SchillerRefinery Single Pointsof Accountability
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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
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BP’S PROCESS SAFETY AUDIT SYSTEM>
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compliance or BP policy (Priority 1
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Interviews with members of the Safe
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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 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 296 and 297: As a result of the failure to isola
Page 298 and 299: IV. The BP Rupture Disk Report’s
Page 301: APPENDIX ETECHNICAL CONSULTANTS’R
Page 304 and 305: Disclaimer NoticeABSG Consulting In
Page 306 and 307: Based on the Scope of Work, the PSM
Page 308 and 309: efineries had an effective and cred
Page 310 and 311: List of TablesNumberPage2.1 PSM Rev
Page 312 and 313: 2. Technical Approach and Project T
Page 314 and 315: 2.3 Review Process2.3.1 Carson, Che
Page 316 and 317: Table 2.1 - PSM Review Team, Techni
Page 318 and 319: Table 3.1 - Summary of System Findi
Page 320 and 321: elief system. All five refineries h
Page 322 and 323: More than 20 process pipe rack stru
Page 324 and 325: PCMS to 8 years, the refinery faile
Page 326 and 327: Notwithstanding BP’s prior implem
Page 328 and 329: Based upon their sampling done at e
Page 330 and 331: System Finding 7 - Action item comp
Page 332 and 333: judgment of the PSM Review Team, se
Page 334 and 335: potential consequences of near miss
Page 336 and 337: 4. Overall ConclusionsEach of these
Page 338 and 339: e. Mechanical integrity and mainten
Page 340 and 341: 3. Understanding and recognition of
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Walter F. FrankMr. Frank has more t
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Appendix C - References1 John Mogfo
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APPENDIX FBP POST-TEXAS CITY MEASUR
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Maintenance operating model and han
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3. Corporate-level measuresBoard of
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BP U.S. RefineriesIndependent Safet
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Have you viewed the survey introduc
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6. WHAT IS YOUR HERITAGE COMPANY?01
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II. MY OPINIONS AND COMMENTSPlease
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Supervisory Involvement and Support
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Worker Professionalism / Empowermen
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III. FINAL COMMENTSPlease provide a
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APPENDIX HGLOSSARY OF SELECTED TERM
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TermProcess Safety Functional Group
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