The Baker Panel Report - ABSA

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Table 3.1 – Summary of System FindingsDescription of System FindingCarsonCherryPointTexasCityToledoWhiting3.1 Rupture disks under relief valves X X X X3.2 Equipment deficiencies X X X3.3 Equipment inspections X X X X X3.4 Facility siting X X X X X3.5 Safety shutdown systems X X X X X3.6 Critical alarms and emergency shutdown devices X X X X3.7 Action item completion X X X X X3.8 Area electrical classification X X X X X3.9 Compliance audit findings X X X X X3.10 Fired heaters X X X X3.11 Near-miss investigation X X X X X3.12 Process hazard analyses X X X X16
3.1 Rupture Disks Under Relief Valves – Hazard Not Understood orAbatedA rupture disk is a device designed to relieve excessive pressure in a process. When thepressure on one side of the disk exceeds the design limit, which is based on a designateddifference in pressures on opposite sides of the disk, the disk bursts or opens, relievingthe pressure. Once a rupture disk opens, it cannot reclose.A relief valve is a pressure relief device that can reclose after opening. While there aredifferent types of relief valve designs, the basic principle is that when the pressure in theequipment exceeds the relief valve’s set pressure, the relief valve will open and remainopen until the pressure is reduced below the set pressure, after which the relief valverecloses to seal the system.A common design strategy uses rupture disks in combination with relief valves to preventdamage to the relief valve from exposure to process fluid during normal operation. 8,9 Ifthe system pressure on the process side rises above the rupture disk burst point, therupture disk will open, exposing the relief valve to the system overpressure. <strong>The</strong> reliefvalve will then open to relieve the system pressure. For this design strategy to workproperly (i.e., the rupture disk protecting the relief valve until the pressure reaches thedisk’s bursting point), the rupture disk must not leak or fail prior to the system pressureincrease. In a well-designed and maintained system, the space between the rupture diskand the relief valve is normally at atmospheric pressure.A rupture disk can fail in a number of ways: it can experience a pinhole leak or therupture disk can prematurely open or burst. If the rupture disk bursts (i.e., fully opens),the relief valve will still operate as intended as long as the process fluid against which itwas being protected does not degrade the integrity or operation of the relief valve. Onthe other hand, if the rupture disk experiences a pinhole leak, the pressure in the spacebetween the rupture disk and the relief valve can equalize with the system pressure. Inthis situation, the rupture disk will not burst at the system pressure at which it wasdesigned to burst because the rupture disk relies upon the difference in pressures on itsopposite sides. If the pressure on both sides is the same due to a small leak, the rupturedisk will open only at a pressure much higher than the designed system relief pressure.As a result, the system/vessel may be exposed to a much higher pressure than intended,which is potentially a serious process safety hazard. 10For these reasons, it is important to monitor the pressure in the space between the rupturedisk and relief valve to determine whether the rupture disk has failed prematurely. It is arecognized good industry practice to continuously monitor and alarm or frequentlymonitor and log the pressure of the rupture disk/relief valve space. If refinery staffdetects a higher-than-intended pressure in the space between the rupture disk and therelief valve, then the situation can be investigated, evaluated, and remedied. Whilerelatively few (less than 1%) of the relief valves in the BP refineries have rupture disksunder them, the instances in which vessels have the rupture disk/relief valve combinationare nevertheless important because of the potential consequences of a failed pressure17
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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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82 When conducting reviews, BP desi
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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 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 and 314: Following these general sampling pr
Page 315 and 316: Review of documentsWalkaround inspe
Page 317: 3. Discussion of FindingsBased upon
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
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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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The Baker Panel Report - ABSA

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