Last January, a panel led by James A. Baker III, issued its report on one of the most serious U.S. workplace disasters in the past two decades: the 2005 Texas City BP refinery explosion that killed 15 workers and injured 170. The 374 page report includes some very important lessons for occupational health and safety professionals.

The Baker Report

The Baker Panel investigated the "safety culture" at BP's five North American refineries. The final report includes a scathing indictment against the giant oil company for putting production targets, operational goals and budgets ahead of workplace safety.

The report also includes 10 recommendations that, although addressed to BP, apply to just about any other workplace. If you want to read the full report, click here. If you want a summary of the recommendations, keep reading.

1. PROCESS SAFETY LEADERSHIP

The Board of Directors of BP p.l.c, BP's executive management (including its Group Chief Executive), and other members of BP's corporate management must provide effective leadership on and establish appropriate goals for process safety. Those individuals must demonstrate their commitment to process safety by articulating a clear message on the importance of process safety and matching that message both with the policies they adopt and the actions they take.

2. INTEGRATED & COMPREHENSIVE PROCESS SAFETY MANAGEMENT SYSTEM

BP should establish and implement an integrated and comprehensive process safety management system that systematically and continuously identifies, reduces and manages process safety risks at its U.S. refineries.

3. PROCESS SAFETY KNOWLEDGE & EXPERTISE

BP should develop and implement a system to ensure that its executive management, its refining line management above the refinery level and all U.S. refining personnel, including managers, supervisors, workers and contractors, possess an appropriate level of process safety knowledge and expertise.

4. PROCESS SAFETY CULTURE

BP should involve the relevant stakeholders to develop a positive, trusting and open process safety culture within each U.S. refinery.

5. CLEARLY DEFINED EXPECTATIONS & ACCOUNTABILITY FOR PROCESS SAFETY

BP should clearly define expectations and strengthen accountability for process safety performance at all levels in executive management and in the refining managerial and supervisory reporting line.

Conclusion

Next week, I'll describe the other five recommendations of the Baker Panel and draw some lessons of general application to all safety management systems and programs.

HISTORIC MOMENTS IN WORKPLACE SAFETY

The Texas City refinery after the explosion

The BP Texas City Refinery Explosion

By Glenn Demby

For those of you unfamiliar with the incident, Wayne is referring to the massive explosion that occurred at BP's Texas City Refinery in 2005. The facility, the third largest oil refinery in the U.S., is spread over 1,200 acres and had 1,600 permanent workers.

On March 23, 2005, a cloud of hydrocarbon vapors ignited a fire in the Isomerization Unit (ISOM) that triggered an explosion killing 15 people and injuring 170 more. BP accepted responsibility for the explosion and admitted that it made mistakes that contributed to the tragedy:

• The explosion and fire occurred because established procedures weren't followed during the restart of the raffinate splitter tower that allowed the fluid level in the tower to be 20 times higher than it should have been just before the explosion occurred.
• There was a failure to evacuate workers from temporary office trailers near the F-20 blow down stack before the startup of the raffinate tower and a failure to warn them of danger, both of which increased the number of killed and injured.
• The use of a pressure relief system routed to a flare or closed relief system would have reduced the severity of the incident.

The OSHA Response

After the blast, OSHA inspected the Texas City facility and cited BP for more than 300 violations, including:

• 167 citations for non-intrinsically safe electrical equipment;
• 76 instances of failure to correct deficiencies in equipment that are outside acceptable limits for the pressure relief header subysystem, liquid knockout subsystem and other subsystems and equipment;
• Failure to compile written process safety system for each of the four systems in the ISOM unit;
• 18 instances of failure to properly evaluate the safety and health impact of a catastrophic blast for temporary trailers near the ISOM unit; and
• 31 instances of failure to evaluate the reliability of alarms and the integrity of process systems to determine criticality or Safe Integrity Level

The Legal Fallout

Eva Rowe: Both parents killed in BP explosion

On September 22, 2005, OSHA announced that British Petroleum Products North America had agreed to pay more than $21 million to settle the violations - the largest fine OSHA has ever assessed, practically doubling the old record of $11 million against a Louisiana fertilizer company.

BP also paid $1.2 billion to settle the lawsuit filed by a woman named Eva Rowe whose parents were killed in the explosion. "This is not about the money," Rowe is quoted as saying after the suit was settled. "I want the world to know what BP did."

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