The Baker Panel Report - ABSA

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Appendix C – References1 John Mogford, Fatal Accident Investigation Report, Isomerization Unit Explosion FinalReport, December 9, 20052 CSB Urgent recommendation to BP Global Executive Board of Directors, August 17,2005, http://www.csb.gov/news_releases/docs/CMerritt%20Statement%208.17.05.pdf3 Charter for BP U.S. Refineries Independent Safety Review Panel, October 24, 2005,http://www.safetyreviewpanel.com/cmtfiles/panel_charter.php?file_id=83&link_id=394 Process Safety Management of Highly Hazardous Chemicals (29 CFR 1910.119), U.S.Occupational Safety and Health Administration, February 24, 1992, www.osha.gov5 Accidental Release Prevention Requirements: Risk Management Programs UnderClean Air Act Section 112(r)(7), 40 CFR 68, U.S. Environmental Protection Agency,June 20, 1996 Fed. Reg. Vol. 61[31667-31730]6 Center for Chemical Process Safety, American Institute of Chemical Engineers, NewYork, NY, www.aiche.org/ccps/7 AcuTech Consulting Group, Process Safety Management (PSM) Systems ComplianceAudit Report for the Texas City Refinery, June 23, 20068 Sizing, Selection, and Installation of Pressure-Relieving Devices in Refineries. Part I -Sizing and Selection. 5th Edition, RP 520, American Petroleum Institute, Washington,D.C. (July 1990)9 ASME Boiler & Pressure Vessel Code. Section VIII, Division I, American Society ofMechanical Engineers, New York, 199510 D. C. Hendershot and A. M. Dowell, III, “No Good Deed Goes Unpunished: CaseStudies of Incidents and Potential Incidents Caused by Protective Systems,” Proceedingsof the AIChE 31st Annual Loss Prevention Symposium, Houston, TX, Paper 44c, March13, 199711 Getting HSE Right – A Guide for BP Managers, High Potential Incident Reportingrequirements, pg. 42, BP 000349, December 200212 Management of Hazards Associated with Location of Process Plant Buildings, RP 752,Second Edition, American Petroleum Institute, Washington DC, November 200313 Guidelines for Evaluating Process Plant Buildings for External Explosion and Fires,G-26, ISBN No: 0-8169-0646-7, CCPS, New York, 199642
14 Guidance on Practice for Design and Location for Design and Location of OccupiedPortable Buildings Within Refineries and Chemical Plants, BP Group EngineeringTechnical Practice, RM-GP 04-30, December 1, 200515 ANSI/ISA 84.01-1996, Application of Safety Instrumented Systems for the ProcessIndustries, ISBN: 1556175906, The Instrumentation, Systems, and Automation Society,April 199616 ANSI/ISA 84.00.01-2004 Parts 1-3, Functional Safety: Safety Instrumented Systemsfor the Process Industry Sector, ISBN: 1556179197, 1556179200, and 1556179219, TheInstrumentation, Systems, and Automation Society, September 200417 Guidance on Practice for Safety Instrumented System (SIS), BP Group EngineeringTechnical Practices, GP 30-75, 76, 80, 81, and 801, 200318Classification of Locations for Electrical Installations at Petroleum FacilitiesClassified as Class I, Division 1 and Division 2, RP 500, Second Edition, AmericanPetroleum Institute, November 199719 NFPA 496: Standard for Purged and Pressurized Enclosures for Electrical Equipment,2003 Edition, National Fire Protection Association, Quincy, MA,http://www.nfpa.org/aboutthecodes/AboutTheCodes.asp?DocNum=49620 Fired Heaters for General Refinery Services, Std. 560, 3rd Edition, AmericanPetroleum Institute, Washington DC, May 200121 Fired Heaters & Steam Generators, RP 556, First Edition, American PetroleumInstitute, May 199722 OSHA Process Safety Management Standard – Incident Investigation Requirements,29 CFR 1910.119(m)(1)23 EPA Risk Management Program Rule Prevention Program - Incident InvestigationRequirements, 40 CFR 68.8124OSHA Process Safety Management Standard – Process Hazard AnalysisRequirements, 29 CFR 1910.119(e)(3)(i)25 Guidelines for Hazard Evaluation Procedures, 2nd Edition, CCPS, ISBN: 0-8169-0491-X, New York, April 199226OSHA Process Safety Management Standard – Process Hazard AnalysisRequirements, 29 CFR 1910.119(e)(3)(iii)-(iv)43
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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
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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
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ANNEX I—PROCESS INCIDENT INDEX EX
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a fatality that results from a mech
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III. Structure and Operations The C
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11. On August 10, 2005, the Texas C
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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 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: Jack McCavitMr. McCavit is Presiden
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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