The Baker Panel Report - ABSA

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judgment of the PSM Review Team, several prior findings at Carson, Toledo, andWhiting were incorrectly classified as lesser (Priority 2) items instead of as regulatorycompliance or BP policy (Priority 1) issues.System Finding 9 – Compliance audit findings. At all five refineries, BP haddeficiencies in process safety audits, including findings that were repeat findings fromprevious audits or findings that were, in the judgment of the PSM Review Team,improperly classified according to importance.3.10 Fired Heaters – Nonconformance with API StandardsFired heaters are a common energy source for most refining process units. The refiningindustry has experienced heater fires and explosions that have prompted industryorganizations to develop design, operating, and maintenance practices for these units.The American Petroleum Institute (API), for example, has several standards andrecommended practices on fired equipment design, operations, testing, and preventivemaintenance, including API Recommended Practice 556 covering instrumentation andcontrol system requirements for burner management systems. 20,21Legacy BP companies (e.g., Amoco and ARCO) had developed internal standards forfired heaters, but the four legacy refineries (i.e., Carson, Cherry Point, Texas City, andWhiting) have not kept them up to date since being acquired by BP by ensuring thoseinternal standards reflected changes in external standards such as API RecommendedPractice 556. BP has developed an Engineering Technical Practice and internalguidelines for fired heaters, and a handbook for furnace and boiler firing.The PSM Review Team found that the refineries had not implemented the requirementsof these internal BP standards. In addition, fired heaters at Carson, Cherry Point, TexasCity, and Whiting generally did not comply with API RP 556. Also, the various refinerytechnical staffs could not otherwise technically establish that the equipment as currentlydesigned meets standards that are at least as stringent as those established by API.BP is developing its own Process Safety Minimum Expectation (PSME) for fired heatersthat is expected to reflect API recommended practices. Refinery personnel also indicatedthat some recent fired heater installations complied with the anticipated requirements ofthe new PSME.System Finding 10 – Fired heaters. BP does not ensure compliance with API’srecommended practices regarding the design and operation of fired process heaters, andthe refineries could not otherwise technically establish that the equipment as currentlydesigned meets standards that are at least as stringent. (Carson, Cherry Point, Texas City,and Whiting)30
3.11 Near-miss Investigation – Inadequate Reporting,Analysis, or Corrective ActionA near miss is an event in which an accident involving property damage, environmentalimpact or loss of life, or an operational interruption, could have resulted if circumstanceshad been slightly different. In other words, a near miss provides a valuable opportunityto learn from deficiencies or other management system weaknesses that could help avoidpossible future accidents.The OSHA PSM standard and EPA RMP rule require the investigation of incidents thatresult in or could reasonably have resulted in a catastrophic release (so called nearmisses). 22,23 All industry standards and guidance on incident investigation speak to theimportance of recognizing, reporting, evaluating, and learning from near-miss events.All five BP refineries had incident investigation programs and procedures. Typically, arefinery would consider the severity of each reported incident and apply the appropriatelevel of investigation. Such a “tiered investigation” approach based on severity is typicalthroughout industry. BP had two documented management practices that addressed nearmissevents: (1) the common refinery incident investigation procedures that require thereporting and investigation of near-miss events and (2) the High Potential IncidentReporting (HiPo) procedure.The HiPo procedure requires BP personnel to report incidents or near misses where themost serious probable outcome is a Major Incident. A Major Incident is defined as anincident involving any of the following:A fatality associated with BP operationsMultiple serious injuriesSignificant adverse reaction from authorities, media, non-governmentalorganizations, or general public Cost of accidental damage exceeding U.S. $500,000 Oil spill of more than 100 barrels, or less if at a sensitive location (1 barrel = 159liters = 42 U.S. gallons)Release of more than 10 metric tons (22,000 lb) of a classified chemicalThese HiPo events and lessons learned are then communicated across BP’s refineries sothat all facilities can learn and prevent similar future incidents. Under BP’s HSEframework management system, reports of HiPo incident are also distributed to, amongothers, the business group vice president, and the Group vice president of HSE.Despite these management practices, based on its sampling of incident and near-missinvestigations the PSM Review Team found deficiencies in the near-miss investigationsystem at four of the five refineries. At the Carson refinery, the PSM Review Teamidentified 9-out-of-10 sampled closed incident investigation reports that did not specifythe root causes or contributing factors. At the Cherry Point refinery, the PSM ReviewTeam found several instances among the sampled investigation reports where the31
Page 1 and 2:
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
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cultures, process safety management
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(i) implement a policy regarding ar
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(f) educate and provide training to
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workers are educated, encouraged, a
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RECOMMENDATION #6—SUPPORT FOR LIN
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(3) “periodically update”—The
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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 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: 3.9 Compliance Audit Findings - Rep
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
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