Ergonomics society oil and gas conference - part 3

I was a speaker at the Ergonomics Society's conference on 'Human and organisational factors in the oil, gas and chemical industries' on 27-28 November 2007. I am blogging key messages from some of the presentations.

Isadore (Irv) Rosenthal gave a presentation titles 'BP's Texas City accident - are the lessons taught likely to be learned and implemented?' Irv had been a member of the Baker Panel that investigated the management and organisational failures that contributed to this accident. I have blogged findings from the report previously, and Irv covered many of these points. However, his presentation provided further insight, which is summarised below.

It is easy to see BP as a large, highly profitable company that makes you wonder why money was not being spent to improve safety. Whilst this is true, the fact that the refinery arm of the business made a relatively small contribution to the overall profit, well below that of exploration and production. It is estimated that the accident has cost BP over $2.5 billion in fines, settling claims and most significantly lost opportunity. It also had a very negative impact on stock/share prices for up to 18 months.

The findings from the Baker Panel report should not have been a surprise to the company, because many similar issues had been raised by reports of the accidents at BP Grangemouth Refinery in 2000. For example, quoting from reports:

1. Grangemouth - "Insufficient management attention and resources were given to maintaining and improving technical standards for process operations and enforcing adherence to standards, codes of practice, company procedures and HSE guidance"
1. Texas City - "Process safety, operations performance, and systematic risk reduction priorities had not been set and consistently reinforced by management."

2. Grangemouth - There was a need to build awareness and competencies in process safety and integrity management within senior leadership and the organisation in order to develop a meaningful value conversation around cost versus safety. "There was a lack of experience in some areas, and limited refresher training plans."
2. Texas City - The Texas City Refinery suffers from an "inability to see risks and, hence, tolerance of a high level of risk. This is largely due to poor hazard/risk identification skills throughout management and the workforce, exacerbated by a poor understanding of process safety...There was no ongoing training program in process hazards risk awareness and identification for either operators, supervisors or managers."

3. Grangemouth - "With no formal structure or specific focus on process safety, many of the components of process safety management (PSM) were not formalised at Grangemoth. There was no site governance structure to provide overview and assurance that process safety issues were being handled appropriately. Process safety needed to be elevated to the same level as person safety."
3. Texas City - "The investigation team was not able to identify a clear view of the key process safety priorities for the site or a sense of a vision or future for the long term. Focus (was) on environment and personal safety, not process safety. There was little ownership of PSM through the line organisation."

4. Grangemouth - "BP group and Complex Management did not detect and intervene early enough on deteriorating performance....Inadequate performance measurement and audit systems, poor root cause analysis of incidents, and incorrect assumption about performance based on lost time accident frequencies and a lack of key performance indicators.. meant the company did not adequately measure the major accident hazard potential."
4. Texas City - "The safety measures focused primarily on occupational safety measures, such as recordable and lost time injuries. This focus on personal safety had led to the sense that safety was improving at the site. There was not clear focus or visibility on measures around process safety, such as lagging indicators on loss of containment, hydrocarbon fires, and process upsets."

5. Grangemouth - "Over the years, a number of maintenance and reliability reviews, task forces, and studies had been conducted, but many recommendations had not been implemented. There was a maintenance backlog and mechanical integrity testing was not prioritised to ensure that safety critical equipment received timely preventative maintenance."
5. Texas City - Risk awareness "repeated failures to complete recommended actions from audits, peer reviews and past incident investigations." "There is currently a backlog of unclosed action items in the tracking database related to various aspects of process safety management, including those stemming from incident investigation. Some of the the latter extend back over a period of more than twelve months."

In conclusion Irv felt BP will learn from Texas City because:

1. Everyone at the company felt very bad about the accident and it had had a major financial and public relations impact.
2. The board had recognised that good process safety also improves product quality, yields, profits and the public image need to keep its license to operate and win oil leases.
3. Unions, neighbours, regulatory agencies and political concerns will motivate more action
4. BP are implementing process safety that should lead to better process safety practices.

I hope he is right in his conclusions!!

Andy Brazier