The Baker Panel Report - ABSA

PANEL STATEMENTProcess safety accidents can be prevented.On March 23, 2005, the BP Texas City refinery experienced a catastrophic process accident.It was one of the most serious U.S. workplace disasters of the past two decades, resultingin 15 deaths and more than 170 injuries.In the aftermath of the accident, BP followed the recommendation of the U. S. ChemicalSafety and Hazard Investigation Board and formed this independent panel to conduct athorough review of the company’s corporate safety culture, safety management systems,and corporate safety oversight at its U.S. refineries. We issue our findings and make specificand extensive recommendations. If implemented and sustained, these recommendationscan significantly improve BP’s process safety performance.Throughout our review, we focused on being thorough and then letting the chips fall wherethey may. As our charter contemplates, we allowed BP to comment on our report to ensureits factual accuracy. However, we are solely responsible for our report’s final content.Although we necessarily direct our report to BP, we intend it for a broader audience. We areunder no illusion that deficiencies in process safety culture, management, or corporateoversight are limited to BP. Other companies and their stakeholders can benefit from ourwork. We urge these companies to regularly and thoroughly evaluate their safety culture,the performance of their process safety management systems, and their corporate safetyoversight for possible improvements. We also urge the same companies to review carefullyour findings and recommendations for application to their situations.Preventing process accidents requires vigilance. The passing of time without a processaccident is not necessarily an indication that all is well and may contribute to a dangerousand growing sense of complacency. When people lose an appreciation of how their safetysystems were intended to work, safety systems and controls can deteriorate, lessons can beforgotten, and hazards and deviations from safe operating procedures can be accepted.Workers and supervisors can increasingly rely on how things were done before, rather thanrely on sound engineering principles and other controls. People can forget to be afraid.When systems and controls deteriorate, everything can come together in the worst possibleway. Equipment malfunctions and controls fail. An explosion and fire occur. People lose theirlives or suffer horrible injuries. Families and communities are devastated.The burden of these catastrophes is uniquely and unfairly borne by the victims, theirfamilies, and their friends. This was the case for the Texas City victims—men and womenwho were providing a livelihood for themselves and their families. These victims were fathersand mothers, husbands and wives, sons and daughters, and friends. We dedicate our reportto the survivors of this tragedy and the memory of those who lost their lives.This report is dedicated to thesurvivors of the Texas City tragedyand the memory of those who losttheir lives.The B.P. U.S. Refineries Independent Safety Review Paneli