The Baker Panel Report - ABSA

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Process Safety TrainingNote: For each statement below, you should select “3” under the response labeled “?” only if you do notknow or you do not have an opinion.DisagreeTend to Disagree?Tend to AgreeAgree45. The training that I have received does not provide me with a clear understanding of theprocess safety risks at my refinery......................................................................................46. I know how to access appropriate process safety resources if I need them ......................1 2 3 4 51 2 3 4 547. The following receive the necessary process safety training to do their job safely:a. New workers...............................................................................................................b. Experienced workers...................................................................................................c. My supervisor...............................................................................................................d. Contractors..................................................................................................................48. The process safety training that I have received allows me to recognize when a processshould be shut down if safety critical interlocks, alarms or other process-safety devicesfail or become unavailable during operation.......................................................................49. The process safety training that workers receive at my refinery is adequate to preventprocess-related incidents, accidents and near misses.........................................................1 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 5Please provide any comments you have about Process Safety Training in the space below.12
III. FINAL COMMENTSPlease provide any other comments you might have regarding process safety at your refinery in thespace below.THIS IS THE END OF THE SURVEY. THANK YOU FOR YOUR PARTICIPATION.13
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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
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Executive SummaryOn March 23, 2005,
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Based upon its work, the PSM Review
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Table of ContentsSectionPageExecuti
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1. IntroductionOn March 23, 2005, t
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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 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 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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