The Baker Panel Report - ABSA

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2.3 Review Process2.3.1 Carson, Cherry Point, Toledo, and Whiting RefineriesThe reviews at the Carson, Cherry Point, Toledo, and Whiting refineries occurred duringFebruary through June 2006. Each onsite review lasted approximately 2 weeks. Duringeach review, a five- or six-person team evaluated representative process safety systemsand practices, consistent with the Scope of Work provided by the Independent Panel,through the following activities:Pre-visit conference calls with BP to coordinate visit logisticsReview of preliminary documentation provided by BPKickoff meeting with refinery leadership, staff, hourly, and employee unionrepresentatives (except at Cherry Point where a bargaining unit does not representemployees)Presentation by BP of a refinery and PSM program overviewOrientation tourReview of documentsWalkaround inspections of refinery process areasObservations of ongoing work in process areas by BP employees and contractorsInterviews with BP management, supervision, hourly employees, and contractorsDaily coordination meetings with refinery personnel to confirm factual informationand to review next-day plansCloseout meeting with refinery personnel to summarize factual information forfindings and other assessment resultsFollow-up visits and conference calls to clarify information2.3.2 Texas City RefineryThe Texas City refinery review differed from the other reviews. At the IndependentPanel’s direction, the PSM Review Team relied in part on an audit of PSM systems atTexas City conducted by a 3 rd -party consulting firm under a Settlement Agreementbetween BP Products North America, Inc. and OSHA (the Settlement Agreement Audit). 7The PSM Review Team reviewed the work plan for the Settlement Agreement Audit andcompared it to the Independent Panel’s Scope of Work. Where the Independent Panel’sScope of Work was broader than the work plan for the Settlement Agreement Audit, thePSM Review Team conducted additional field work at the site in June 2006 to addressthose additional items. Specifically, the PSM Review Team undertook the followingactivities with respect to Texas City:Pre-visit conference calls with BP to coordinate visit logisticsReview of preliminary documentation provided by BPKickoff meeting with the refinery’s Senior Process Safety ConsultantPresentation by BP of a refinery and PSM program overviewOrientation tour12
Review of documentsWalkaround inspections of refinery process areasObservations of ongoing work in process areas by BP employees and contractorsInterviews with BP management, supervision, hourly employees, and contractorsCoordination meetings with refinery personnel to confirm factual information and toreview next-day plansCloseout meeting with refinery personnel to summarize factual information and otherassessment resultsFollow-up conference calls to clarify informationBP also permitted the PSM Review Team to meet with the Settlement Agreement Auditteam, observe its work, and review the resulting report. The PSM Review Teamconcludes that the Settlement Agreement Audit of the Texas City refinery was thoroughand its findings are credible.2.4 Review Team MembersABS 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 project manager, led the Texas Cityrefinery review, participated in all of the refinery reviews, and coordinated all reviewswith other Independent Panel activities. Table 2.1 lists the PSM Review Team members,their process safety technical areas, and the sites where they participated.13
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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
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43 Health & Safety Executive, Devel
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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 and 312: 1. IntroductionOn March 23, 2005, t
Page 313: Following these general sampling pr
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
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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
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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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