The Baker Panel Report - ABSA

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INTRODUCTIONWelcome to the BP U.S. Refineries Independent Safety Review Panel2006 Process Safety Culture SurveyThis survey is being administered on behalf of the BP U.S. Refineries Independent Safety Review Panel, anindependent panel formed by BP at the urgent recommendation of the U.S. Chemical Safety and HazardInvestigation Board. The survey contains statements that assess process safety in the refinery where you work.Your responses will provide a means of identifying problem areas in the process safety culture at your refinery,as well as areas that work well. Your input will be important to the work of the Independent Panel, whose finalreport will be available later this year.Completion of the survey is voluntary. However, your cooperation is appreciated, as it will allow theIndependent Panel to complete its task of making a thorough, independent and credible assessment of theeffectiveness of BP Products North America Inc.’s corporate oversight of process safety management systemsand its corporate process safety culture. The Independent Panel believes that its assessment and the report itwill deliver will ultimately lead to a safer work environment for the BP North American refineries. Your opinionsand responses are anonymous, and neither the Panel nor BP will attempt to determine your identity. In orderto maintain anonymity, please do not write your name on any part of the survey.In order to protect your identity, only statistical summaries of groups of 15 or more respondents will bereported. If you work in a group or department with less than 15 respondents, your results will be aggregatedinto the next organizational level (e.g., refinery overall) as well as into BP overall results.As indicated above, the questions in this survey focus on process safety and not on personal safety. Process safetyrefers to the prevention of unintentional releases of chemicals or energy during the course of refinery processesthat can have a serious effect. Process safety involves, for example, the prevention of leaks, spills, equipmentmalfunction, over-pressures,over-temperatures, corrosion, metal fatigue and other similar conditions. Process safety programs focuson design and engineering of facilities, maintenance of equipment, effective alarms, effective control points,procedures and training. By comparison, personal safety focuses on injuries such as slips, trips, falls, struck-byincidents and strains. Personal safety programs place a heavy emphasis on hard hats, glasses, slicker suits, goggles,gloves, steel toe shoes and other personal protective equipment. In general, process safety focuses on workplacesafety, and personal safety focuses on worker safety. This survey is about process safety, not personalsafety.© 2006, ISR (a trademark name of International Survey Research LLC )All Rights Reservedwww.isrinsight.com2
Have you viewed the survey introduction video?12YesNoIt is highly recommended that you watch the video prior to completing this survey.If you responded NO, please take a moment to view the 5-minute video before completing the survey.This survey contains three major sections:I. About MeOVERVIEWThis section asks for information about yourself and your work background. This information is for researchpurposes only and will not be used to identify you.II. My Opinions and CommentsThis section contains statements that ask for your thoughts on what it is like to work at a BP refinery. Thereare no right or wrong answers. We simply ask for your opinion, based on your experience. Please review eachstatement and select the number from 1 to 5 that best expresses your response to the statement. Please notethat selecting number 3 in response to a question means either that you do not know or that you do not have anopinion.Comment sections after each category of questions provide you with an opportunity to express your writtenthoughts regarding the topic. If you do not have enough space to write your comment after each selection, pleasefeel free to continue commenting on the final page of the survey.III. Final CommentsThere is also an open-ended final comment question at the end of the survey in which you will have anopportunity to add any additional feedback that you might have.INSTRUCTIONS FOR COMPLETING THE SURVEYPlease observe the following requirements carefully to ensure that your responses are correctly recorded:• Use a soft lead pencil or a blue or black pen.• Place a heavy “X” in the box which best reflects your answer.• Mark only one opinion for each statement. Multiple marks cannotbe counted.MARKING INSTRUCTIONSCORRECT INCORRECT1 2 3 4• If you want to change an answer, erase completely, or, if you answeredin pen, completely black out the wrong answer and put an “X” in thecorrect box.3
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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
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APPENDIX DWHITING RUPTURE DISK: A C
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B. INADEQUATE REVIEW AGAINST TECHNI
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management review or monitoring pro
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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
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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 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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The Baker Panel Report - ABSA

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