The Baker Panel Report - ABSA

3. Discussion of FindingsBased upon its work, the PSM Review Team developed findings for each BP refinery.The team documented a finding when it found a process safety deficiency that wasdetermined to either (1) broadly exist (i.e., be a systemic problem at an individualrefinery) or (2) be of such significance, as a single instance at an individual refinery, thatit represented a serious process safety concern. The term serious is used in this report toconvey the PSM Review Team’s judgment concerning the gravity or significance of theconcern; it is not meant to correlate to any legal definition or to have any regulatoryconnotation.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 those four refineries to (1) clarify for the sites questions about thefactual bases of the findings, (2) respond to any questions from refinery management, and(3) consider any additional information 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. Table 3.1 summarizes the SystemFindings and cross references them by refinery.15