The Baker Panel Report - ABSA

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2. Technical Approach and Project Team2.1 Technical AreasThe Independent Panel prepared a comprehensive Scope of Work for the process safetyreviews to be conducted by the PSM Review Team – a copy of which is provided asAppendix A. The Scope of Work contemplated a review of the process safetymanagement programs, procedures, actual performance, and process safety culture at thefive refineries. In directing the PSM Review Team, the Independent Panel emphasizedthat the reviews should focus not only on the process safety management systems at eachrefinery, but also on actual performance and documentation of performance.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 issuesThe Scope of Work provided by the Independent Panel did not contemplate “wall-towall”audits or inspections of BP’s five U.S. refineries. The Independent Panel did notview such extensive activities to be necessary to fulfill the Panel’s mandate of focusingon the effectiveness of process safety management systems. Instead, the Scope of Workprovided by the Independent Panel directed the PSM Review Team to reviewrepresentative aspects of the process safety performance and management systems at therefineries. The Panel believed that such a representative review would provide anappropriate foundation for conclusions about the effectiveness of BP’s process safetymanagement system.10
Following these general sampling principles, the depth and breadth of the technicalreviews sometimes varied. The PSM Review Team did not attempt to review all units atany particular refinery. In addition, the PSM Review Team reviewed BP’s process safetymanagement programs, procedures, and actual performance against selected externalguidance, including standards, recognized and generally accepted good engineeringpractices, recommended practices, best practices, and good engineering practices.Specifically, the PSM Review Team reviewed the adherence by BP’s five U.S. refinerieswith applicable codes and practices relating to (1) safety shutdown systems, (2) areaelectrical classification, (3) fired heaters, and (4) facility siting.After the PSM Review Team identified what in its professional judgment represented anarea of deficiency based on the sampling of items or a review of existing practice relatingto observance of applicable guidance in a particular area, the team members moved on toanother aspect of the review. For this reason, the PSM Review Team did not catalogevery potential process safety issue or concern at the refineries. Rather, the PSM ReviewTeam sampled a sufficient number of items to develop a view on the effectiveness ofBP’s process safety management system.2.2 Relevant Requirements and GuidanceDuring 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 requirement and guidance: OSHA PSM standard (29 CFR 1910.119) 4 EPA RMP rule (40 CFR 68) 5 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 6 andother external organizationsExternal codes, standards, industry best practices, recommended practices, and otherexternal guidance (collectively, “codes and practices”) play an important role in themanagement of process safety in the United States. Some of these codes and practiceshave the force of law. OSHA specifically acknowledges the relevance of variousindustry codes and practices. The OSHA process safety management standard, forexample, cites process safety guidance developed by the Center for Chemical ProcessSafety of the American Institute of Chemical Engineers, the American ChemistryCouncil, and the American Petroleum Institute. Even where existing codes and practicesdo not have the force of law, they can provide valuable tools for managing and reducingprocess risks. Systemic failure to adhere to codes and practices can result in operationsbeing conducted at a higher than necessary risk.11
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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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Group- and refining-level process s
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Knowledge of performance management
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Each member of the board needs to a
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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 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 and 306: Executive SummaryOn March 23, 2005,
Page 307 and 308: Based upon its work, the PSM Review
Page 309 and 310: Table of ContentsSectionPageExecuti
Page 311: 1. IntroductionOn March 23, 2005, t
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
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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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