The Baker Panel Report - ABSA

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Disclaimer NoticeABSG Consulting Inc. (ABS Consulting) and its employees, subcontractors, consultants, andother assigns and JL McCavit Consulting, LLC cannot, individually or collectively, predict whatwill happen in the future. Both companies have made a reasonable effort, based on theinformation provided by BP Products North America Inc. (or the BP U.S. Refineries IndependentSafety Review Panel), to assess the effectiveness of BP Products North America Inc.'s corporateoversight of safety management systems at its five refineries and its corporate safety culture asprovided in the charter of the BP U.S. Refineries Independent Safety Review Panel. However,even if all the assessment findings and observations were addressed, accidents may still occur.Moreover, the actions associated with addressing the findings and observations resulting fromthis work may subject the refineries’ employees or the communities in which the refineries resideto unforeseen or unacceptable hazards. Therefore, all of the assessment team’s findings andobservations should be reviewed before addressing them to determine if they are in the bestinterests of BP Products North America Inc., its employees, and contractors and of thecommunities in which BP Products North America Inc.’s refineries are located. Also, applicableOSHA, EPA, and state regulations are subject to interpretation, and no one can guarantee howthey will be interpreted in the future. As a result, neither ABS Consulting nor JL McCavitConsulting, LLC can guarantee that future agency audits will not result in any regulatorycitation. Therefore, ABS Consulting and JL McCavit Consulting, LLC accept no liability for anyaccident or regulatory impact that may occur at any facility assessed by them.2
Executive SummaryOn March 23, 2005, the BP Texas City refinery experienced an accident that resulted in15 fatalities and injured over 170 BP employees and contractors. The accident involved avapor cloud explosion resulting from a release of flammable material from a raffinatesplitter tower and the associated blowdown system.The U.S. Chemical Safety and Hazard Investigation Board (CSB) and other federal, state,and local agencies immediately began an investigation. The CSB subsequently issued tothe BP Global Executive Board of Directors an urgent recommendation to commission anindependent panel to evaluate the effectiveness of BP Products North America’scorporate oversight of safety management systems at its U.S. refineries. BP accepted thisrecommendation and formed the BP U.S. Refineries Independent Safety Review Panel(Independent Panel) on October 24, 2005.In January 2006, the Independent Panel retained ABSG Consulting Inc. (ABSConsulting) and JL McCavit Consulting, LLC (collectively, the PSM Review Team) toconduct process safety management (PSM) reviews at all five BP refineries in the UnitedStates. This is the final report that the PSM Review Team submitted to the IndependentPanel.This report summarizes the results of the PSM Review Team’s assessment of BP’srefineries located in Carson, California; Cherry Point, Washington; Texas City, Texas;Toledo, Ohio; and Whiting, Indiana. Four of the refinery reviews were conducted using2-week visits by five- or six-person teams. The Texas City refinery review differed fromthe other four refinery reviews. At the Independent Panel’s direction, the PSM ReviewTeam relied in part on a 3 rd -party audit of PSM systems at Texas City conducted under aSettlement Agreement between BP Products North America, Inc. and the OccupationalSafety and Health Administration (OSHA). In all of these reviews, BP personnel gavethe PSM Review Team full cooperation in providing access to facilities, records, andpeople.The Independent Panel prepared a comprehensive Scope of Work for the process safetyreviews, a copy of which is provided as Appendix A. The Scope of Work contemplated areview of the process safety management programs, procedures, actual performance, andprocess safety culture at the five refineries. In directing the PSM Review Team, theIndependent Panel emphasized that the reviews should focus not only on the processsafety management systems at each refinery, but also on the actual performance anddocumentation of performance.ABS Consulting’s project manager, Mr. Steve Arendt, led the Carson and Whitingreviews and participated in the other three refinery reviews. Mr. Walt Frank of ABSConsulting led the Cherry Point and Toledo refinery reviews and participated in theTexas City refinery review. Mr. Jack McCavit, the Independent Panel’s technical projectmanager, led the Texas City refinery review, participated in all of the refinery reviews,and coordinated all reviews with other Independent Panel activities.3
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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
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The audit team found similar proble
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The issues that the Panel’s techn
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USING RESULTS OF INCIDENT INVESTIGA
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Issue Grangemouth Texas CitySafety
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CORPORATE OVERSIGHTAn effective pro
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Selected excerpts from the EEAC rep
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Page 259 and 260: ENDNOTES FOR SECTION VI.C.1 America
Page 261 and 262: 43 Health & Safety Executive, Devel
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Page 268 and 269: cultures, process safety management
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Page 272 and 273: (f) educate and provide training to
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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: 214-06GEMS 1544316Review of Process
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
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Page 331 and 332: 3.9 Compliance Audit Findings - Rep
Page 333 and 334: 3.11 Near-miss Investigation - Inad
Page 335 and 336: from water. However, the PHA report
Page 337 and 338: Appendix A - Scope of Work for BP I
Page 339 and 340: v. Safety instrumented system desig
Page 341 and 342: Appendix B - PSM Review Team Leader
Page 343 and 344: Jack McCavitMr. McCavit is Presiden
Page 345: 14 Guidance on Practice for Design
Page 348 and 349: Operations network.performance.Refi
Page 350 and 351: C. Performance Evaluation, Correcti
Page 353: 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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