Released today. Review of BP's corporate safety culture, safety management systems,
and corporate safety oversight at its U.S. refineries following the Texas City Fire. Running to 374 pages, it will be a while before I have had the chance to read it all, but the executive summary is very interesting - almost exclusively regarding process safety - see separate post here for an explanation.
The full report is available here
The Report's Recommendations are summarised here.
KEY POINTS FROM EXECUTIVE SUMMARY
The Panel believes that BP has not provided effective process safety leadership and has not adequately established process safety as a core value across all its five U.S. refineries.
BP has not provided effective leadership in making certain its management and U.S. refining workforce understand what is expected of them regarding process safety performance.
BP has emphasized personal safety in recent years and has achieved significant improvement in personal safety performance, but BP did not emphasize process safety.
BP mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance at its U.S. refineries. This created a false sense of confidence.
Process safety leadership appeared to have suffered as a result of high
turnover of refinery plant managers.
At Texas City, Toledo, and Whiting, BP has not established a positive, trusting, and open environment with effective lines of communication between management and the workforce
BP has not always ensured that it identified and provided the resources required
for strong process safety performance at its U.S. refineries.
Despite having numerous staff at different levels of the organization that support
process safety, BP does not have a designated, high-ranking leader for process safety dedicated to its refining business.
The company did not always ensure that adequate resources were effectively allocated to support or sustain a high level of process safety performance.
BP’s corporate management mandated numerous initiatives that applied to the U.S. refineries and that, while well-intentioned, have overloaded personnel at
BP’s U.S. refineries. This “initiative overload” may have undermined process safety performance at the U.S. refineries.
In addition, operations and maintenance personnel in BP’s five U.S. refineries sometimes work high rates of overtime, and this could impact their ability to perform their jobs safely and increases process safety risk.
The Panel also found that BP did not effectively incorporate process safety into management decision-making.
BP tended to have a short-term focus, and its decentralized management system and
entrepreneurial culture have delegated substantial discretion to U.S. refinery plant managers without clearly defining process safety expectations, responsibilities, or accountabilities.
BP has not demonstrated that it has effectively held executive management and refining line managers and supervisors accountable for process safety performance.
Although the five refineries do not share a unified process safety culture, each exhibits some similar weaknesses.
The Panel found instances of a lack of operating discipline, toleration of serious deviations from safe operating practices, and apparent complacency toward serious process safety risks at each refinery.
While all of BP’s U.S. refineries have active programs to analyze process hazards, the system as a whole does not ensure adequate identification and rigorous analysis of those hazards. The
The Panel observed that BP does have internal standards and programs for managing process but found that BP’s corporate safety management system does not ensure timely compliance with internal process safety standards. This included standards applying to rupture disks under relief valves; equipment inspections; critical alarms and
emergency shut-down devices; area electrical classification; and near miss investigations.
BP’s corporate safety management system does not ensure timely implementation of external good engineering practices that support and could improve process safety performance
BP’s system for ensuring an appropriate level of process safety awareness, knowledge, and competence in the organization has not been effective in a number of respects.
BP has not effectively defined the level of process safety knowledge or competency required of executive management, line management above the refinery level, and refinery managers.
BP has not adequately ensured that its U.S. refinery personnel and contractors have sufficient process safety knowledge and competence.
The implementation of and over-reliance on BP’s computerbased training contributes to inadequate process safety training of refinery employees.
BP’s corporate process safety management system does not effectively translate corporate expectations into measurable criteria for management of process risk or define the appropriate role of qualitative and quantitative risk management criteria.
BP has not effectively implemented its corporate-level aspirational guidelines and
expectations relating to process risk. Therefore, the Panel found that BP has not implemented an integrated, comprehensive, and effective process safety management system for its five U.S. refineries.
Significant deficiencies existed in BP’s site and corporate systems for measuring process safety performance, investigating incidents and near misses, auditing system performance, addressing previously identified process safety-related action items, and ensuring sufficient management and board oversight.
Many of the process safety deficiencies are not new but were identifiable to BP based upon lessons from previous process safety incidents, including process incidents that occurred at BP’s facility in Grangemouth, Scotland in 2000.
BP tracked some metrics relevant to process safety at its U.S. refineries. Apparently, however, BP did not understand or accept what this data indicated about the risk of a major accident or the overall performance of its process safety management systems.
BP has not instituted effective root cause analysis procedures to identify
systemic causal factors that may contribute to future accidents. When true root or system causes are not identified, corrective actions may address immediate or superficial causes, but not likely the true root causes.
BP has an incomplete picture of process safety performance at its U.S. refineries because BP’s process safety management system likely results in underreporting of incidents and near misses.
BP has not implemented an effective process safety audit system for its U.S. refineries based
The principal focus of the audits was on compliance and verifying that required management systems were in place to satisfy legal requirements. It does not appear, however, that BP used the audits to ensure that the management systems were
delivering the desired safety performance or to assess a site’s performance against industry best practices.
BP has sometimes failed to address promptly and track to completion process safety deficiencies identified during hazard assessments, audits, inspections, and incident investigations.
The Panel’s review found repeat audit findings at BP’s U.S. refineries, suggesting that true root causes were not being identified and corrected.
BP does not effectively use the results of its operating experiences, process hazard analyses, audits, near misses, or accident investigations to improve process operations and process safety management systems.
The company’s system for assuring process safety performance uses a bottom-up reporting system that originates with each business unit, such as a refinery. As information is reported up, however, data is aggregated. By the time information is formally reported at the Refining and Marketing segment level, for example, refinery-specific performance data is no longer presented separately.
The Panel’s examination indicates that BP’s executive management either did not receive refinery-specific information that suggested process safety deficiencies at some of the U.S. refineries or did not effectively respond to the information that it did receive.
A substantial gulf appears to have existed between the actual performance of BP’s process safety management systems and the company’s perception of that performance.
BP’s Board can and should do more to improve its oversight of process safety at BP’s five U.S. refineries.
The Report's Recommendations are summarised here.
Some comments are made about human factors in the report. They are summarised here