The Baker Panel Report - ABSA

B. INADEQUATE REVIEW AGAINST TECHNICAL STANDARDSVarious company standards and the codes referred to in the standards explicitly address the hazard of pressure between rupture disks andrelief valves. 2 Over the long history of the rupture disk situation, there were at least two opportunities to consider the rupture disk/relief valveproblems during required process hazard analysis revalidations. However, refining personnel overlooked this issue in both cases.C. INADEQUATE OPERATIONAL DISCIPLINE AND ATTENTION TO DETAILWhiting operating staff recorded the quarterly readings of pressure between rupture disks and relief valves. However, they ignored the explicitrequirement on the log sheet that a work order be submitted if they recorded non-zero pressures. While BP noted in the BP Rupture Disk Reportthis breakdown in the work order system, in the opinion of the Panel’s consultants, the breakdown was only a symptom, not a root cause. Basedon interviews that the Panel’s consultants conducted, Whiting operators appeared to believe that it was pointless to write work orders becausethe repair might only last for a brief time and, as a result, they stopped writing the work orders. Apparently for the same reason, supervisorypersonnel stopped enforcing the requirement.D. INADEQUATE MANAGEMENT OF CHANGE REVIEWSAt least two changes occurred during the long period in which the rupture disk situation developed that, if reviewed under a more effectivemanagement of change system, should have resulted in appropriate corrective action. First, an effective review of personnel changes that led tothe project being “lost” after the 1998 turnaround could reasonably have been expected to result in corrective action. Second, the BP RuptureDisk Report notes that at some point the refinery blocked or plugged vents required between the rupture disks and relief valves, allowingpressure to remain trapped above the rupture disks. Appropriate review of this change also could reasonably have been expected to lead tocorrective action.E. LACK OF AN EFFECTIVE MANAGEMENT REVIEW SYSTEMThe Panel’s consultants found no organized system by which a manager or supervisor could identify breakdowns in safety managementsystems. A periodic review of the relief valve log sheets might have prompted someone to realize there was an ongoing reliability problem (andinquire about the 1998 turnaround project status) and that the work order/repair system had broken down. A management review of themanagement of change system might have questioned the plugging of the vents or the suspension of the project in 2005 to remove the rupturedisks. A management review of the special projects system might have questioned why the refinery did not institute any interim controls untilthe project to upgrade the rupture disks could be completed (scheduled for the second quarter of 2006), even though the refinery gave theproject to upgrade the rupture disks the highest risk ranking in the refinery of all 2006 special projects.Because BP failed to identify most of the broader systems failures as root causes, BP’s proposed corrective actions focused only on rupture diskspecificissues. As a result, in the opinion of the Panel’s consultants, the proposed response will do little to prevent future refinery-widemanagement system breakdowns.Whiting Rupture Disk Case Study C D-3