The Baker Panel Report - ABSA

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esponsibilities include building BP’s technology base (essentially research and development efforts), developing BP’s “technology leadershipareas” (such as alternative fuels), overseeing BP’s major projects, and enhancing BP’s engineering capabilities.Meggs told the Panel that prior to the creation of the Safety and Operations function, process safety fell under Group Technology. However,Meggs said that he understands now that both he and Mogford have responsibility for process safety: Meggs, because he heads GroupTechnology, which is responsible for writing the various standards, and Mogford, because he heads Safety and Operations, which is responsiblefor ensuring the implementation of those standards.The Group Technology function was responsible for the promulgation of the integrity management standard, which Browne approved in March2006 and which BP regards as encompassing process safety. All business units, including the U.S. refineries, must be fully compliant with thisstandard by the end of 2008. Any site that is not completely compliant at that time must obtain an exemption from the Executive Officer,Strategic Resources (who reports to Browne) or be shut down.In 2003, BP recognized that while it was making substantial progress on personal safety, it was not experiencing comparable success withlosses of containment, and thus, the company’s engineering capability needed to be built up. BP then created a new position, GroupEngineering Director, and recruited John Baxter from outside BP for this position. Baxter and his 12-member staff are responsible for ensuringconsistency in standards across the company and for reviewing major risks to BP.The Group Technology engineering staff developed hundreds of ETPs, and more than 460 of them apply to BP’s refining operations. The processof developing these ETPs took five years, and Group Technology worked with experts from throughout BP to develop consistent, coherentpractices based on international standards, best practices from BP’s legacy companies, and other sources. While Group Technology continuesto promulgate ETPs, some of which are unique to the refining business, BP has identified 62 of them as being “safety critical.”The ETP requirements are divided between “musts, shalls, and shoulds.” These three terms relate to the sense of urgency for the ETPs andwhich level of BP’s organization is authorized to issue an exception. For example, an ETP that is considered a “must” is a high-priority issue,and only the most senior engineering leadership can grant a refinery an exception for its failure to implement this practice. An ETP classified asa “shall” is slightly less critical, and a refinery can seek an exception to such a practice from the refining engineering authority. The ETPs of thelowest priority are classified as “shoulds.” Although a refinery should implement these practices, it can seek an exception from its refineryengineering authority. Each refinery must comply with the most critical ETPs by 2008 and with all others by 2011.BP’s Head of Major Hazards and Fire reports to the Group Engineering Director and heads BP’s Major Accident Risk assessment project. Thisproject is one of BP’s techniques to identify major risks in any of its businesses that might not otherwise be revealed. The Major Accident Riskassessment project is designed to assess on a consistent basis and bring to the attention of BP senior management those risks that are solarge that they present a risk to BP’s corporate existence.> HSSE and technologyAs a result of the Texas City accident, in July 2005 BP created a new HSSE and Technology organization for the Refining and Marketing segment.The head of that organization has been C. J. Warner, who is Group Vice-President, HSSE and Technology, Refining and Marketing. As a GroupVice-President, Warner is on the same level as the Group Vice-President, Refining (Hoffman), and she reports to the Chief Executive, Refiningand Marketing (Manzoni). She has a degree in chemical engineering, and her career has largely been in refining. Warner is based in London.Overview of BP’s Organizational Structure and Its Five U.S. Refineries C 38
The primary purposes of this new organization are to ensure that the various businesses in the Refining and Marketing segment effectivelyimplement Group standards, to provide a support structure for those businesses’ implementation efforts, to deliver safety coaching andleadership to line management in the segment, and to monitor HSSE (including safety) and technology activity within the segment. InManzoni’s words, Warner is to give him “an independent view of the line.”Warner has seven direct reports. One is the Vice-President of HSSE, whose role is to enhance, embed, and sustain the safety capability in theRefining and Marketing segment. Another direct report, the Head of Projects and Engineering, has three roles: overseeing capital projects in thesegment, managing the implementation of the integrity management standard in the Refining and Marketing segment, and serving as thedesignated engineering authority for the segment.On December 19, 2006, BP announced that Warner will replace Mike Hoffman (who is leaving BP) as the Group Vice-President, Refiningeffective May 1, 2007. BP has not yet named her replacement.> Refining technologyThe Refining Technology organization provides technical and operational support to the global refining business, particularly with respect toprocess safety management. Refining Technology personnel have various responsibilities, such as performing a number of monitoring andreporting functions. They track the refineries’ performance against a set of process safety-related metrics and milestones and report on theseto the Global Refining Leadership team. They review internal and external incidents, particularly those that are process safety related. Inaddition, they prepare a quarterly safety bulletin that discusses the causes of and lessons learned from incidents at BP and elsewhere. Thissafety bulletin is widely disseminated throughout BP. Paul Maslin has been the Technology Vice-President, Refining since 2003. Maslin has achemical engineering degree and a background in refining. He reports to the Group Vice-President, Refining and has a “dotted line” report tothe Group Vice-President, HSSE and Technology, Refining and Marketing. Maslin is based in London, with the Refining Technology staff splitbetween London and Chicago.Following the Amoco merger, BP outsourced much of its refining technology work, and several hundred refining engineers who had beencentrally located within both Amoco and BP left. After several years, BP concluded that it had lost too much in-house technical expertise, and itterminated its outside contract for refining technology work, resolving to rebuild its own capabilities. Refining Technology, which had as few as35 people, now has about 150 people and plans to hire more. Among the current employees are approximately 30 functional experts, referred toas “advisors,” including two process safety advisors. The advisors comment on proposed Group standards from a refining perspective, amongother things.Refining Technology also oversees and supports some of the Refining Networks and Communities of Practice. Networks are intended to be avehicle through which the various refineries will identify and share best practices. Refining has six Networks: HSSE, People, CommercialManagers, Technical Managers, Refinery Operations, and Maintenance. All of these, with the exception of People and Commercial Managers,are run through the Refining Technology organization. Each Network has a performance leader and is composed of the appropriate managersfrom each of BP’s refineries (e.g., the HSSE managers from each of BP’s global refineries are in the HSSE Network). Each Network also developsan annual plan and conducts global and regional meetings several times a year. BP regards these Networks as “the glue which holds Refiningtogether.”Each Network has one or more communities of practice, which are “tagged” to it to help deliver the Network’s plan. Refining presently has34 communities of practice, four of which are designated as “supercharged” (Process Safety, Turnarounds, Inspection, and Hydroprocessing) todenote within BP that they are more active and prominent than others. Each community of practice has a performance leader, and like thenetworks, communities of practice are composed of one or more appropriate persons from each refinery. The relevant functional experts withinOverview of BP’s Organizational Structure and Its Five U.S. Refineries C 39
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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
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 and 44: As the Mogford Report explains, the
Page 45 and 46: III. OVERVIEW OF PROCESS SAFETY, PE
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: The new Safety and Operations funct
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
Page 97 and 98: Refinery plant manager turnoverUnde
Page 99 and 100: EMPLOYEE EMPOWERMENTThe Panel belie
Page 101 and 102: Survey responses substantiate that
Page 103 and 104: As discussed later in this section,
Page 105 and 106: U.S. refinery staff and capabilityB
Page 107 and 108: In 2002, BP commissioned a report b
Page 109 and 110: The process safety culture survey r
Page 111 and 112: 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
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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
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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
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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
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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
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Process Safety TrainingNote: For ea
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PLEASE DO NOT WRITE ON THIS PAGE.14
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TermHSSEIncidentISAIsomerization (I
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ACKNOWLEDGEMENTSMembers of the BP U
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