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Warning: Prepare to have your conscience shocked.
On March 23, British Petroleum's Texas City, Texas refinery exploded, killing and injuring the plant's workers. Confined Space tells more of the story.
The U.S. Chemical Safety and Hazard Investigation Board is investigating the explosion that killed 15 workers and injured at least 80 more. The Boardhas taken the unusual step of releasing findings before completing their investigation, in the hope of averting such disasters at workplaces across the country.
Who is to blame?
The CSHIB tells management to stop putting the blame on workers and to look in the mirror.
The CSHIB report states that the actions that led to the fatal explosion grew out of decisions made by the facility's managers and corporate managers. Its findings are not bland. They point out mismanagement and lack of concern for worker safety that shocks the conscience
Here is the Statement for the BP Independent Safety Review Panel by Carolyn W. Merritt, Chairman & CEO U.S. Chemical Safety and Hazard Investigation Board, Houston, Texas November 10, 2005.
The Chemical Safety Board issued the recommendation to form this panel after our investigators uncovered evidence of serious management problems at the Texas City refinery. We began to realize there might be systemic issues of management culture and oversight that are not localized to one site. These management problems set the stage for catastrophic and tragic incident. Our investigation has revealed that this incident was completely preventable. We felt the situation was urgent and did not want to wait until our investigation was complete - which could take another year - to get this panel's work started. And so we issued the first recommendation that was designated as "urgent" in the Board's eight-year history.
The March 23 incident in Texas City was the one of the worst U.S. workplace disasters in fifteen years. This incident was followed by other serious incidents at the same facility in July and August that had the potential for harm.
. . .
My experience shows that if the highest level of management and the corporate board do not actively support operational safety and management of risk, then safety programs don't have much of a chance. Safety cannot be achieved from the shop floor alone.
One thing I have often observed is that there is a great gap between what executives believe to be the safety culture of an organization and what it actually is on the ground. Almost every executive believes he or she is conveying a message that safety is number one. But it is not always so in reality.
. . .
One of my aspirations is that all industrial managers treat safety and major accident prevention with the same degree of seriousness and rigor that is brought to financial transactions. Few people would operate a major corporation today without a strict system of financial controls and auditing, where everyone within the corporation recognizes the severe consequences for noncompliance.
That same standard of diligence is not always applied to risk management and safety. If you get away with a flawed safety decision one day or repeatedly, far from facing penalty you may actually end up rewarded, perhaps for boosting production. You may come to believe that what was thought to be unsafe is actually safe, based on your experience. It is a phenomenon that is sometimes called "normalization of abnormalities."
. . .
The findings also raised serious concerns about the effectiveness of mechanical integrity programs, hazard analyses, management of change programs, and incident investigation programs.
Here are some examples from the report:
- One is management of fatigue. Our information indicates that on the day of the incident, some BP operators had worked 30 days straight, 12 hours per day, some with two-hour commute times.
- Another is the downsizing of both supervision and training. For example, BP Texas City went from 38 trainers in 1998 to just nine in 2005. And on the day of the incident there was no supervisor with appropriate experience overseeing key phases of the startup operation.
- Another concern is workload management. On March 23, a single board operator was responsible for simultaneously running the controls of three different complex process units, including the isom unit that was starting up.
- Finally, there is the issue of how obsolete equipment is managed. The blowdown drum and stack in Texas City was half-century old technology. Yet in the 1990s it was completely rebuilt according to its original design, which was by then recognized as antiquated and unsafe. How does BP's management assure they are using current safety equipment that is appropriate for the risks involved?
And here is the charge for future work.
In conducting your work, it will be useful to establish some terms of comparison. For example, it will be important to understand how BP's North American refineries, which were mostly acquired through recent mergers, have been assimilated into the corporation. Do these facilities have similar cultures, and what measures has BP taken to establish a favorable culture at these sites? How do these facilities compare with other BP sites in the UK or elsewhere? We would ask the panel to consider establishing some measurable benchmarks for the safety management systems and culture of other high-risk sectors, such as the aviation and nuclear industries. The panel may also benefit from seeking the cooperation of at least one other oil or chemical corporation that is willing to share information about its management systems and cultural performance.
Here and here are links to the CSHIB and related reports and testimony.