Dr. Paul  V. Tebo is President - The Tebo Group, an organization focused on helping companies integrate sustainability as a framework for business growth through research, teaching and consulting. He retired in April 2004 as Vice President - Safety, Health and Environment for DuPont. Dr. Tebo served on the BP U.S. Refineries Independent Safety Review Panel (commonly called the Baker Panel).  He recently discussed the Panel findings and process safety management with DuPont. 

There have been many improvements in process safety management since the 1970s when DuPont and other companies first began formulating the principles of process safety management.  Unfortunately, many of these improvements were in response to serious process safety incidents, such as the Union Carbide Bhopol disaster in India and the Phillips explosion and fire in Pasadena, Texas. 

On March 23, 2005, there was another serious explosion at the BP refinery in Texas City, Texas.  It was a human tragedy, with 15 lives lost and 170 injured. 

At the urgent recommendation of the U.S. Chemical Safety and Hazard Investigation Board (CSB), BP sponsored a study led by Mr. James A. Baker III, former U.S. Secretary of State, to conduct a thorough review of the company’s safety culture, safety management systems and safety oversight at its U.S. refineries. 

From my perspective, many of the Panel findings can be grouped into four major categories: leadership behavior and expectations, accountabilities and consequences, operating discipline, and leading and lagging indicators.

Leadership Behavior and Expectations

BP had a goal of “no accidents, no harm to people” but its leaders did not communicate process safety performance expectations to its management and site employees.  Additionally, BP was operating in a culture of low frequency, high consequence events.  While lost work day and total recordable injury rates were improving, the BP global system continued to suffer significant fatalities among employees and contractors – 23 in 2000, 21 in 2003 and 27 in 2005.  A common metric at BP refineries is number of Great Days – those days with no accidents, injuries or unexpected releases to the environment.  The target number of Great Days in 2006 was 85%, meaning that 15% could still involve accidents and injuries.

The BP site leaders, referred to as business unit leaders, were responsible for broader business aspects beyond site leadership.  At large, complex sites like Texas City (3,000 employees and contractors), the business unit leaders were limited in their time spent in the field – a critically important activity to safety performance.  In addition, the high turnover rate among site leaders, particularly at Texas City, left the organization with little technical knowledge of process safety. 

Accountabilities and Consequences

The Panel found that establishing clear line accountability for process safety within BP was difficult.  The Panel recommended that BP “define expectations and accountability for process safety performance at all levels in executive management and in the refining managerial and supervisory reporting line.”

One short story surfaced at a site visit.  An employee had been driving a car on the site at speeds in excess of 100 kilometers per hour.  This serious infraction would justify termination of employment from most companies with strong safety records.  However, we learned that the employee was disciplined and returned to work, sending a message that weakened the safety culture.

Operating Discipline

BP has a strong entrepreneurial culture.  A “can do” spirit has many benefits in workplaces that require creativity and initiative.  But this attitude can also challenge the management processes in environments where operations are complex and materials are hazardous. 

If you haven’t got a line in the sand, you’ll lose a strong principle of process safety management – operating discipline.  In fact, there were few problems with the procedures and systems at BP, but management did not enforce clear consequences.   The speeding driver is just one of several observations that caused me to conclude that the underlying safety culture at the BP U.S. refineries varied from site to site and lacked the discipline to meet a goal of zero.

Leading and Lagging Indicators

BP senior management reviewed safety metrics, but these metrics were primarily focused on personal safety, rather than process safety.  It was even rarer to find leading indicators that could predict a risk for future incidents, such as loss of containment incidents or overdue inspections.  At Texas City, loss of containment incidents increased rapidly each year, and in 2004 there were over 1,700 overdue inspections for pressure safety valves and similar areas.  These metrics could have gauged the risk that Texas City faced leading up to the explosion.

Following the explosion, BP now tracks a broader set of metrics that help assess what might happen, such as number of overdue inspections, completion of major accident risk assessments and closure of recommendations.  But the Panel members agree that more attention to leading indicators is still needed across the industry. 

These four areas are the focal points for a strong safety management system.  At the foundation of a safety culture is leadership with consistent expectations, behavior and actions.  Safety accountability and operating discipline must reside in the line organization, so that procedures and consequences are clearly defined and followed.  And metrics that predict potential failure will better prepare our industry to avoid future incidents.  The tragedy witnessed at Texas City must never happen again.