The Baker Panel Report - ABSA

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In performing its audit review, the team conducted interviews, performed inspections, reviewed documents, and made observations at variousunits of the refinery.The team’s final audit report (the Stanley Report), dated June 15, 2005, opined that although the Texas City refinery generally had welldesignedand documented processes and procedures for operations and maintenance, as well as a workforce that was capable of deliveringgood performance, significant changes to the behaviors and performance of the senior and extended leadership teams would be necessary toensure that delivery achieved reality.The Stanley Report identifies issues in five main areas that were preventing the successful execution of key work processes: leadership, riskawareness, control of work, workplace conditions, and contractor management. The Stanley Report also made multiple recommendations ineach of these five major areas of concern.Precipitating Events for the Panel’s Assessment and Report C 20
III. OVERVIEW OF PROCESS SAFETY, PERSONAL SAFETY,AND CORPORATE SAFETY CULTUREUnder its charter, the Panel is charged to examine and to recommend any needed improvements to the corporate safety culture within BP’sU.S. refineries, including the degree to which corporate officials exercise appropriate leadership to promote adherence to safety management systems; process safety is effectively incorporated into management decision-making at all levels; employees at all levels are empowered to promote improved process safety; and process safety programs receive adequate resources and are appropriately positioned within organizational structures.As discussed in Section I, in its assessment the Panel has focused on process safety, rather than personal safety. The Panel believes that itscharter and the CSB’s August 2005 urgent recommendation require this focus. In order to understand the significance of the Panel’s focus onprocess safety, rather than personal safety, the Panel elaborates in this section on some of the key distinctions between the two concepts.A. Comparison of Process Safety and Personal SafetyTypes of risk. In the context of refining operations, “process safety” refers to the prevention and mitigation of unintentional releases ofpotentially dangerous materials or energy from the refining process. 1 Process safety management involves a particular type of riskmanagement—identifying and controlling the hazards arising from refining processes, such as the prevention of leaks, spills, equipmentmalfunctions, over-pressures, excessive temperatures, corrosion, metal fatigue, and other similar conditions. 2 Process safety programs focuson, among other things, the design and engineering of facilities; hazard assessments; management of change; inspection, testing, andmaintenance of equipment; effective alarms; effective process control; procedures; training of personnel; and human factors. 3Process safety management is critical in refining operations because process accidents can have catastrophic effects and result in multiplefatalities and substantial economic, property, and environmental damage. Process hazards at a refinery can give rise to accidents that affectboth workers inside the refinery and members of the public who reside nearby.Typically, process safety risks arise from complex systems with a large number of control measures referred to as hard or soft controls. Hardcontrols are physical elements within the facility, such as barriers, alarms, and improved system design. Soft controls are internal proceduresand best practices, such as standards, operating procedures, training, administrative controls, supervisory oversight, and the experience andknowledge of frontline operators. 4 Generally speaking, process safety relates to the quantity, quality, and variety of controls or protectivefeatures that protect people, the environment, and property from process hazards. 5On the other hand, “personal safety,” which is sometimes referred to as occupational safety, focuses on hazards that are more directly relatedto individual workers. Typically, personal safety programs address risks of various types of physical injuries, including slips, falls, struck-byincidents, physical strains, electrocution, and auto incidents. Such accidents are usually associated with a hazard that is close to workers.Protection against a personal safety hazard is both relatively simple and, for the most part, at least nominally under the control of thepotentially affected worker. Personal safety protections or controls against these types of hazards tend to be fairly simple in nature and limitedin number. For example, personal safety controls place a heavy emphasis on training individual workers to recognize hazards, installingpersonal protective guards on dangerous machinery, and providing personal protective equipment to workers.The literature 6 suggests, and the Panel believes, that the underlying or “root” causes of the large majority of personal and process accidentsare deficiencies in the systems that a facility uses to prevent these two classes of accidents. The literature also suggests, and the Panelbelieves, that the presence of an effective personal safety management system does not ensure the presence of an effective process safetymanagement system. As discussed elsewhere in this report, BP’s personal injury rates were not predictive of process safety performance at BP’sfive U.S. refineries.Overview of Process Safety, Personal Safety, and Corporate Safety Culture C 21
Page 1 and 2: JANUARY 2007THE REPORT OFTHE BP U.S
Page 3 and 4: PANEL STATEMENTProcess safety accid
Page 5 and 6: RETIRED ADMIRAL FRANK L. “SKIP”
Page 7 and 8: DR. NANCY LEVESON is a Professor of
Page 9 and 10: DR. DOUGLAS A. WIEGMANN, Ph.D. is t
Page 11 and 12: • Dennis C. Hendershot, Principal
Page 13 and 14: The Panel’s FindingsThe Panel foc
Page 15 and 16: Process safety cultures at BP’s U
Page 17 and 18: Process safety audits. The Panel fo
Page 19 and 20: RECOMMENDATION #5 - CLEARLY DEFINED
Page 23 and 24: TABLE OF CONTENTSI. The Panel’s R
Page 25 and 26: A. Scope and MethodologyI. THE PANE
Page 27 and 28: interview, and at least one attorne
Page 29 and 30: PROCESS SAFETY REVIEWSThe CSB’s u
Page 31 and 32: BP requested that the Panel use the
Page 33 and 34: would be positive from a process sa
Page 35 and 36: more of the Panel’s recommendatio
Page 37 and 38: management systems. The charter doe
Page 39 and 40: observed at BP are likely not limit
Page 41 and 42: II. PRECIPITATING EVENTS FOR THE PA
Page 43: As the Mogford Report explains, the
Page 47 and 48: elated to personal safety performan
Page 49 and 50: ENDNOTES FOR SECTION III1 29 C.F.R.
Page 51 and 52: IV. OVERVIEW OF BP’S ORGANIZATION
Page 53 and 54: Although lower levels of supervisor
Page 55 and 56: segment includes the manufacturing
Page 57 and 58: Browne, who has a diverse backgroun
Page 59 and 60: BP provides no specific training fo
Page 61 and 62: The new Safety and Operations funct
Page 63 and 64: The primary purposes of this new or
Page 65 and 66: maintain a culture in which reliabi
Page 67 and 68: TEXAS CITYBP acquired the Texas Cit
Page 69: 25 BP evaluates (1) “Level 5 Lead
Page 72 and 73: (7) pre-start-up safety review,(8)
Page 74 and 75: Assessment, assurance, and improvem
Page 76 and 77: BP control of work standardBP issue
Page 78 and 79: BP PROCESS AND PERSONAL SAFETY BOOK
Page 80 and 81: ENDNOTES FOR SECTION V1 BP addresse
Page 83 and 84: A. Corporate Safety CultureVI. FIND
Page 85 and 86: Process safety as a core value in B
Page 87 and 88: contractors and employees in the pr
Page 89 and 90: A fourth and similar survey item ad
Page 91 and 92: The Panel recognizes that Browne is
Page 93 and 94: BP management’s focus on personal
Page 95 and 96:
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
Page 164 and 165:
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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Page 186 and 187:
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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
Page 225 and 226:
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
Page 237 and 238:
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
Page 251 and 252:
Selected excerpts from the EEAC rep
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Group- and refining-level process s
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Knowledge of performance management
Page 257 and 258:
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
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Review of documentsWalkaround inspe
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3. Discussion of FindingsBased upon
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3.1 Rupture Disks Under Relief Valv
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3.2 Equipment Deficiencies - Known
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Once a site specifies the frequenci
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System Finding 3 - Equipment inspec
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accepted good engineering practice
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Not implementing action items or ta
Page 331 and 332:
3.9 Compliance Audit Findings - Rep
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3.11 Near-miss Investigation - Inad
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from water. However, the PHA report
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Appendix A - Scope of Work for BP I
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v. Safety instrumented system desig
Page 341 and 342:
Appendix B - PSM Review Team Leader
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Jack McCavitMr. McCavit is Presiden
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14 Guidance on Practice for Design
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Operations network.performance.Refi
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C. Performance Evaluation, Correcti
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APPENDIX GPROCESS SAFETYCULTURE SUR
Page 356 and 357:
INTRODUCTIONWelcome to the BP U.S.
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I. ABOUT MEIn this section you are
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SURVEY TERM DEFINITIONSPlease read
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Safety Values / Commitment to Proce
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Procedures and EquipmentNote: For e
Page 366 and 367:
Process Safety TrainingNote: For ea
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PLEASE DO NOT WRITE ON THIS PAGE.14
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TermHSSEIncidentISAIsomerization (I
Page 373:
ACKNOWLEDGEMENTSMembers of the BP U
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The Baker Panel Report - ABSA

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