Background. The fire and explosion incident at the BP Texas City refinery occurred on March 23, 2005; 15 people were killed and 180 were injured. This catastrophic incident occurred in the isomerization unit during unit startup after a shutdown.Following the recommendations of the US Chemical Safety and Hazardous Investigation Board, the incident was reviewed by an independent panel headed by former US Secretary of State James Baker III. The Baker Panel’s report is now available in the public domain. This report thoroughly reviewed the company’s safety culture, protection systems, employee involvement and commitment by top management. Findings by the panel revealed: the isomerization unit during unit startup after a shutdown. Following the recommendations of the US Chemical Safety and Hazardous Investigation Board, the incident was reviewed by an independent panel headed by former US Secretary of State James
Baker III. The Baker Panel’s report is now available in the public domain. This report thoroughly reviewed the company’s safety culture, protection systems, employee involvement and commitment by top management. Findings by the panel revealed:
1. Production pressures always impaired safety performance.
2. There was no top-level monitoring and oversight of the organizational safety culture or adherence to accident prevention programs. Responsible safety leadership was totally lacking. 3. Low-level personal injury rate was often used as a measure for the reliability of existing safety systems and the prevailing
safety culture. Indeed, there was a wide gap between them. 4. Safety policy and procedural requirements were not complied; instead, paperwork was just collected. Thus, the records and actual practices at the site were lacking.
5. Flaws in the safety reporting systems failed to encourage reporting near-miss incidents.
6. Safety campaigns were heavily oriented on improving personal safety rather than safety management systems.
7. Safety audit findings were compromised and left unaddressed.
8. Cost-cutting on staffing, infrastructure, process equipment and operator training contributed to increased risk.
9. Floor-level information exchanges and lines of communication were ineffective; near-miss incidents were not reported and analyzed.
10. Operators suffered severe fatigue due to work overload and high overtime staffing at this refinery.
11. Operator training was inadequate and did not address the management of plant upsets, startups, shutdowns and other abnormal situations.
12. Certain operations and maintenance procedures, especially startup procedures, were flawed and deviated from safe practices.
Baker III. The Baker Panel’s report is now available in the public domain. This report thoroughly reviewed the company’s safety culture, protection systems, employee involvement and commitment by top management. Findings by the panel revealed:
1. Production pressures always impaired safety performance.
2. There was no top-level monitoring and oversight of the organizational safety culture or adherence to accident prevention programs. Responsible safety leadership was totally lacking. 3. Low-level personal injury rate was often used as a measure for the reliability of existing safety systems and the prevailing
safety culture. Indeed, there was a wide gap between them. 4. Safety policy and procedural requirements were not complied; instead, paperwork was just collected. Thus, the records and actual practices at the site were lacking.
5. Flaws in the safety reporting systems failed to encourage reporting near-miss incidents.
6. Safety campaigns were heavily oriented on improving personal safety rather than safety management systems.
7. Safety audit findings were compromised and left unaddressed.
8. Cost-cutting on staffing, infrastructure, process equipment and operator training contributed to increased risk.
9. Floor-level information exchanges and lines of communication were ineffective; near-miss incidents were not reported and analyzed.
10. Operators suffered severe fatigue due to work overload and high overtime staffing at this refinery.
11. Operator training was inadequate and did not address the management of plant upsets, startups, shutdowns and other abnormal situations.
12. Certain operations and maintenance procedures, especially startup procedures, were flawed and deviated from safe practices.
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