The Baker Panel Report - ABSA

More documents

Recommendations

Info

Based on the Scope of Work, the PSM Review Team developed a detailed protocol toguide the review. This protocol included conventional OSHA PSM and EPA riskmanagement program (RMP) technical areas as well as additional process safety areasidentified by the Independent Panel:Conventional PSM/RMP Technical Areas1. Employee participation2. Process safety information3. Process hazard analysis4. Operating procedures5. Training6. Contractors7. Pre-startup safety review8. Mechanical integrity9. Safe work practices10. Management of change11. Incident investigation12. Emergency planning and response13. Compliance audits14. Trade secrets15. Risk management program complianceAdditional Process Safety Areas16. Management leadership, authority, andaccountability17. Process safety measurement18. Risk-based decision making19. Conformance with specific industry codes andstandards20. Management of block valves under reliefdevices21. Facility siting22. Other miscellaneous process safety issuesDuring the reviews, the PSM Review Team developed factual information concerningeach refinery’s performance in the above-listed technical areas and compared it to thefollowing relevant requirements and guidance: OSHA PSM standard (29 CFR 1910.119) EPA RMP rule (40 CFR 68) BP internal standards, policies, and procedures Consensus codes and standards, including appropriate refining industry standards andother recommended and generally accepted good engineering practices Guidelines for process safety issued by the Center for Chemical Process Safety andother external organizationsBased on the Scope of Work provided by the Independent Panel, the PSM Review Teamreviewed representative aspects of the process safety performance and managementsystems at the refineries. The PSM Review Team did not attempt to review (1) all unitsat any particular refinery or (2) all of BP’s process safety management programs,procedures, and actual performance against all external guidance, which includesstandards, recognized and generally accepted good engineering practices, recommendedpractices, best practices, and good engineering practices. For this reason, the PSMReview Team did not catalog every potential process safety issue or concern at therefineries. Rather, the PSM Review Team sampled a sufficient number of items to permitthe development of a view on the effectiveness of BP’s process safety managementsystem.4
Based upon its work, the PSM Review Team developed findings for each BP refinery.The team documented a finding when it found a deficiency that was determined to either(1) broadly exist (i.e., be a systemic problem at an individual refinery) or (2) be of suchsignificance, as a single instance at an individual refinery, that it represented a seriousprocess safety concern. The term serious is used in this report to convey the PSMReview Team’s judgment concerning the gravity or significance of the concern; it is notmeant to correlate to any legal definition or to have any regulatory connotation.The PSM Review Team provided the Independent Panel with a preliminary version of itsfindings for Carson, Cherry Point, Toledo, and Whiting. The Independent Panelsubsequently provided the preliminary findings to BP and directed the PSM ReviewTeam to return to the four refineries to clarify for the sites the factual bases of thefindings, respond to questions from refinery management, and consider any additionalinformation provided by BP.Analyzing these findings, additional documents following the refinery visits, and theresults of the work at the Texas City refinery, the PSM Review Team then identified 12“System Findings.” A System Finding is a finding identified at multiple refineries that,in the judgment of the PSM Review Team, represents a risk-significant situation withcompanywide PSM effectiveness implications. The following is a summary of the 12System Findings relating to BP’s five U.S. refineries.System Finding 1 – Rupture disks under relief valves. BP did not recognize the hazardsof pressurized spaces between rupture disks and relief valves and did not evaluate andcorrect identified deficiencies in a timely fashion. These conditions potentiallycompromised the effectiveness of the affected pressure vessel relief systems for extendedperiods of time. (Carson, Texas City, Toledo, and Whiting)System Finding 2 – Equipment deficiencies. BP did not correct deficiencies inimportant refinery process equipment in a timely fashion. These deficiencies sometimesexisted for years. (Carson, Texas City, and Whiting)System Finding 3 – Equipment inspections. At all five refineries, BP did not establishappropriate inspection and testing frequencies or meet its internally establishedfrequencies, resulting in extensive backlogs of overdue inspections for important refineryprocess equipment. Some of these backlogs included hundreds of items overdue for longperiods (i.e., years).System Finding 4 – Facility siting. At all five refineries, BP had some outside operatingand maintenance personnel in some refining units occupy permanent buildings that werenot designed to withstand overpressures but are located close to refinery processes.System Finding 5 – Safety shutdown systems. BP has not implemented the industrystandard for the design and care of safety instrumented systems (i.e., ISA 84.01) exceptfor two refineries that implemented it on recent projects. Moreover, none of the five5
Page 1 and 2:
JANUARY 2007THE REPORT OFTHE BP U.S
Page 3 and 4:
PANEL STATEMENTProcess safety accid
Page 5 and 6:
RETIRED ADMIRAL FRANK L. “SKIP”
Page 7 and 8:
DR. NANCY LEVESON is a Professor of
Page 9 and 10:
DR. DOUGLAS A. WIEGMANN, Ph.D. is t
Page 11 and 12:
• Dennis C. Hendershot, Principal
Page 13 and 14:
The Panel’s FindingsThe Panel foc
Page 15 and 16:
Process safety cultures at BP’s U
Page 17 and 18:
Process safety audits. The Panel fo
Page 19 and 20:
RECOMMENDATION #5 - CLEARLY DEFINED
Page 23 and 24:
TABLE OF CONTENTSI. The Panel’s R
Page 25 and 26:
A. Scope and MethodologyI. THE PANE
Page 27 and 28:
interview, and at least one attorne
Page 29 and 30:
PROCESS SAFETY REVIEWSThe CSB’s u
Page 31 and 32:
BP requested that the Panel use the
Page 33 and 34:
would be positive from a process sa
Page 35 and 36:
more of the Panel’s recommendatio
Page 37 and 38:
management systems. The charter doe
Page 39 and 40:
observed at BP are likely not limit
Page 41 and 42:
II. PRECIPITATING EVENTS FOR THE PA
Page 43 and 44:
As the Mogford Report explains, the
Page 45 and 46:
III. OVERVIEW OF PROCESS SAFETY, PE
Page 47 and 48:
elated to personal safety performan
Page 49 and 50:
ENDNOTES FOR SECTION III1 29 C.F.R.
Page 51 and 52:
IV. OVERVIEW OF BP’S ORGANIZATION
Page 53 and 54:
Although lower levels of supervisor
Page 55 and 56:
segment includes the manufacturing
Page 57 and 58:
Browne, who has a diverse backgroun
Page 59 and 60:
BP provides no specific training fo
Page 61 and 62:
The new Safety and Operations funct
Page 63 and 64:
The primary purposes of this new or
Page 65 and 66:
maintain a culture in which reliabi
Page 67 and 68:
TEXAS CITYBP acquired the Texas Cit
Page 69:
25 BP evaluates (1) “Level 5 Lead
Page 72 and 73:
(7) pre-start-up safety review,(8)
Page 74 and 75:
Assessment, assurance, and improvem
Page 76 and 77:
BP control of work standardBP issue
Page 78 and 79:
BP PROCESS AND PERSONAL SAFETY BOOK
Page 80 and 81:
ENDNOTES FOR SECTION V1 BP addresse
Page 83 and 84:
A. Corporate Safety CultureVI. FIND
Page 85 and 86:
Process safety as a core value in B
Page 87 and 88:
contractors and employees in the pr
Page 89 and 90:
A fourth and similar survey item ad
Page 91 and 92:
The Panel recognizes that Browne is
Page 93 and 94:
BP management’s focus on personal
Page 95 and 96:
milestones to guide the efforts of
Page 97 and 98:
Refinery plant manager turnoverUnde
Page 99 and 100:
EMPLOYEE EMPOWERMENTThe Panel belie
Page 101 and 102:
Survey responses substantiate that
Page 103 and 104:
As discussed later in this section,
Page 105 and 106:
U.S. refinery staff and capabilityB
Page 107 and 108:
In 2002, BP commissioned a report b
Page 109 and 110:
The process safety culture survey r
Page 111 and 112:
Worker fatigue and overtimeThe Pane
Page 113 and 114:
As demonstrated below, process safe
Page 115 and 116:
decision to reduce spending on insp
Page 117 and 118:
environmental, and operational goal
Page 119 and 120:
THE PROCESS SAFETY CULTURE AT EACH
Page 121 and 122:
Finally, the Panel’s own observat
Page 123 and 124:
Survey responses from Cherry Point
Page 125 and 126:
process safety culture at the refin
Page 127 and 128:
Table 22‘‘I can report hazardou
Page 129 and 130:
The Panel found other issues that c
Page 131 and 132:
Table 27“In my opinion, process s
Page 133 and 134:
(2) accountabilities for protection
Page 135 and 136:
All levels of management reported t
Page 137 and 138:
Table 32“The training that I have
Page 139 and 140:
Hourly workers interviewed largely
Page 141 and 142:
Table 34“Refinery management puts
Page 143 and 144:
Finding:Each of BP’s five U.S. re
Page 145 and 146:
Table 36“Workers sometimes work a
Page 147 and 148:
Finally, relatively high percentage
Page 149 and 150:
Also indicative of perceived noncom
Page 151 and 152:
ENDNOTES FOR SECTION VI.A1 Meredith
Page 153:
51 Ibid, p. ii.52 Ibid, p. 153.53 I
Page 156 and 157:
Finally, because the nature and sco
Page 158 and 159:
At the Carson, Cherry Point, and To
Page 160 and 161:
The 2003 audit report for BP South
Page 162 and 163:
COMPLIANCE WITH INTERNAL PROCESS SA
Page 164 and 165:
Table 40Percentages of Disagree/Ten
Page 166 and 167:
Prioritization of inspections and m
Page 168 and 169:
Whiting (2006) Not all of the alarm
Page 170 and 171:
Point have implemented the standard
Page 172 and 173:
the facility siting risk to personn
Page 174 and 175:
The ANSI Z490.1-2001 standard provi
Page 176 and 177:
key positions, BP should assess and
Page 178 and 179:
interviews at some of the refinerie
Page 180 and 181:
Information relating to BP’s Texa
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Computer-based training. Based upon
Page 190 and 191:
TRANSLATING CORPORATE EXPECTATIONS
Page 192 and 193:
In early 2005, prior to the Texas C
Page 194 and 195:
The table below contains the substa
Page 196 and 197:
Interviews with various members of
Page 198 and 199:
BP’S PROCESS SAFETY MANAGEMENT SY
Page 200 and 201:
usiness units, to prioritize implem
Page 202 and 203:
Turnaround deferral procedure (Cars
Page 204 and 205:
on December 4, 2006. In that recomm
Page 207 and 208:
C. Performance Evaluation, Correcti
Page 209 and 210:
valves, and other safety-related eq
Page 211 and 212:
Tracking of process safety indicato
Page 213 and 214:
Table 57Number of Overdue Inspectio
Page 215 and 216:
Although the Panel recognizes that
Page 217 and 218:
Previous concerns about measuring p
Page 219 and 220:
BP’s efforts to develop process s
Page 221 and 222:
BP’S INVESTIGATION AND ROOT CAUSE
Page 223 and 224:
The Panel also identified some defi
Page 225 and 226:
Similarly, although mixed responses
Page 227 and 228:
Other external reviews of BP’s pr
Page 229 and 230:
Table 62Number of Reported Near Mis
Page 231 and 232:
Table 64Percentage of Agree/Tend to
Page 233 and 234:
BP’S PROCESS SAFETY AUDIT SYSTEM>
Page 235 and 236:
compliance or BP policy (Priority 1
Page 237 and 238:
Interviews with members of the Safe
Page 239 and 240:
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
Page 265: 138 Health & Safety Executive, Majo
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 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: Executive SummaryOn March 23, 2005,
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
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
Page 356 and 357:
INTRODUCTIONWelcome to the BP U.S.
Page 358 and 359:
I. ABOUT MEIn this section you are
Page 360 and 361:
SURVEY TERM DEFINITIONSPlease read
Page 362 and 363:
Safety Values / Commitment to Proce
Page 364 and 365:
Procedures and EquipmentNote: For e
Page 366 and 367:
Process Safety TrainingNote: For ea
Page 368 and 369:
PLEASE DO NOT WRITE ON THIS PAGE.14
Page 370 and 371:
TermHSSEIncidentISAIsomerization (I
Page 373:
ACKNOWLEDGEMENTSMembers of the BP U
show all

The Baker Panel Report - ABSA

Create successful ePaper yourself

Delete template?

Save as template?