The Baker Panel Report - ABSA

As the Mogford Report explains, the failure to institute liquid rundown from the raffinate tower, and the failure to take effective emergencyaction, resulted in the loss of containment that preceded the explosion. The report also identifies a failure to follow established policies andprocedures, as well as inadequate supervision. The congregation of many people in or near temporary trailers, which were sited too close to theisomerization unit, contributed to the severity of the accident. Moreover, the report indicates that the likelihood of the accident could have beenreduced if the use of the blowdown stack for light-end hydrocarbon service had been discontinued and if inherently safer options had beeninstalled when they were available. Despite these process failures, the Mogford Report found no evidence that anyone consciously orintentionally took actions or made decisions to put others at risk.In addition to those four critical factors, the Mogford Report identifies the following underlying five cultural issues that were present in therefinery at the time of the accident:(1) Business Context: The working environment had eroded over time to one that was characterized by resistance to change and bylack of trust, motivation, and a sense of purpose. This environment, coupled with unclear expectations about supervisory andmanagement behaviors, led to rules not being followed consistently, a lack of rigor, and individuals feeling disempowered fromsuggesting or initiating improvements.(2) Safety as a Priority: Management did not set or consistently reinforce process safety, operations performance, and systematicrisk-reduction priorities.(3) Organizational Complexity and Capability: Many changes in an already complex organization led to the lack of clearaccountabilities and to poor communication, which together resulted in confusion in the workforce over roles and responsibilities.(4) Inability to See Risk: People accepted levels of risk that were considerably higher than levels accepted at comparable installationsbecause of a poor level of hazard awareness and understanding of process safety. For example, temporary office trailers were placedwithin 150 feet of a blowdown stack that vented heavier-than-air hydrocarbons to the atmosphere without anyone questioningestablished industry practice.(5) Lack of Early Warning: Given the poor vertical communication and performance-management process, there was neither anadequate early warning system of problems, nor any independent means of understanding the deteriorating standards in the plant.The Mogford Report also made numerous proposals for corrective actions. Many of these proposals had been documented previously in existingpolicies and procedures, but either were not followed or were not specific enough.E. The Stanley ReportIn addition to the Mogford investigation, BP commissioned a team composed of BP and external experts to conduct a process and operationalaudit review of the Texas City refinery shortly after the March 2005 accident. BP commissioned this review to provide enhanced assurance ofsafe operations at Texas City. James W. Stanley, former Deputy Assistant Secretary of Labor for Occupational Safety and Health, served as theteam leader.The team audited the Texas City refinery based upon a four-part inquiry:(1) processes and operations;(2) incident management, control of work, risk assessment, and compliance assessment;(3) people and contractor management; and(4) maintenance, reliability, and integrity.Precipitating Events for the Panel’s Assessment and Report C 19