As George Bush might ask: "Rarely is the question asked, is our refineries learning?"

Well, the US Chemical Safety and Hazard Investigation Board is asking. Today the CSB issued an urgent recommendation to BP Amoco to commission an independent panel that would review a range of safety management and culture issues stemming from the March 23 Texas City explosion that killed 15 and injured 170, as well as a number of other incidents at BP facilities in the United States. It's the first time in the CSB's history that the Board has issued an urgent recommendation.

CSB Chairman Carolyn Merritt

cited the Columbia Accident Investigation Board, which investigated in the 2003 Space Shuttle reentry disaster, as one of the models for the independent panel.

She said the CSB was requesting that BP develop an implementation plan for the recommendation within 30 days and complete all work within six to twelve months. The CSB will not serve on the panel but will track and evaluate progress in implementing the recommendation, with periodic reporting to the public.

The Board recommended that the panel appoint an independent chairperson and include a diverse membership, including employee representatives, as well as experts from aviation, space exploration, nuclear energy, and the undersea navy, as well as the process industries.

BP owns five refineries in the U.S., two of which, like Texas City, were acquired in the late 19990's when the company purchased Amoco and Atlantic Richfield Co. Since the March explosion, BP's Texas City plant suffered two other serious incidents which caused no injuries or deaths, but the CSB maintains that all three incidents, as well as a fatal incident that occurred before the March explosion raised questions about the adequacy of BP's safety systems.

BP has announced that it would accept the recommendation. BP Group chief executive John Browne stated that

Today’s recommendation from the CSB is a welcome development and we take it seriously.

"We will move speedily to appoint an independent panel and offer it every help to do its job. When it reports, we will act with equal speed to deal with its recommendations."

BP cautioned, however, that its acceptance of the recommendation "does not mean the company agrees with all of the information or conclusions contained in the preamble to the CSB recommendation.”

The preamble that Lord Browne is having problems with contained several findings by the CSB investigative team, some of which had been presented previously, including the finding announced by the CSB at the end of June that key alarms and a level transmitter failed to operate properly and to warn operators of unsafe and abnormal conditions within the raffinate tower and the blowdown drum. Highly flammable hydrocarbons had escaped from the tower into the blowdown drums where they overflowed and ignited, causing the explosion, but the indicators and alarms that should have warned the workers were not functioning properly.

In addition, BP admitted that it knew the blowdown drums weren't safe and had bypassed numerous opportunities to replace them with safer flare systems. Nevertheless, BP, blamed the explosion on "surprising and deeply disturbing" mistakes made by plant workers who did not follow proper procedures, instead of poor maintenance or malfunctioning pumps, indicators and alarms that caused the problem.

New findings announced today in the preamble of the CSB's recommendation included evidence that BP had known since at least two weeks before the March 23 incident that the alarms and transmitters weren’t functioning and that a critical pressure-control valve did not function in pre-startup equipment checks. The CSB also revealed in the preamble of the recommendation that BP had been having problems with the process for five years before the explosion.

The majority of 17 startups of the raffinate splitter tower from April 2000 to March 2005 exhibited abnormally high internal pressures and liquid levels – including several occasions where pressure-relief valves likely opened – but the abnormal startups were not investigated as near-misses and the adequacy of the tower’s design, instrumentation, and process controls were not re-evaluated.

Gary Beevers, Director of United Steelworkers Region 6 that represents the workers at the Texas City refinery, announced that the

"urgent" call leaves little doubt that BP’s firing of three union members in the aftermath of the March 24 explosion that killed 15 contract workers “was little more than a shameless ploy to cover up its corporate-wide failure to deal with safety issues that routinely put our members in harms way.”

What Are Safety Management Systems and Workplace Culture?

The CSB recommended that BP “assess and report on the effectiveness of BP North America’s corporate oversight of safety management systems at its refineries and its corporate safety culture.”

So what does this mean for BP, especially considering that the company has announced that they have already made quite a few “corrective actions ” at the Texas City plant? Since the March explosion, BP has replaced a number of managers (and fired several line workers, an action not mentioned in BP’s report), re-emphasized who’s responsible for what, announced that it would replace the blow-down drums with a safer flare system, and prohibited the occupancy of office trailers within 500 feet of blowdown drums or flares. (All 15 workers killed were contractors working in or near the trailers.)

Among the references cited in its recommendation, the CSB cites the 2003 Report of Columbia Accident Investigation Board. Chapter 7 of that report, “The Accident’s Organizational Causes” leads one to believe that BP may be missing the boat in addressing the root causes of the incident and appropriate responses. It warns that

Many accident investigations make the same mistake in defining causes. They identify the widget that broke or malfunctioned, then locate the person most closely connected with the technical failure: the engineer who miscalculated an analysis, the operator who missed signals or pulled the wrong switches, the supervisor who failed to listen, or the manager who made bad decisions. When causal chains are limited to technical flaws and individual failures, the ensuing responses aimed at preventing a similar event in the future are equally limited: they aim to fix the technical problem and replace or retrain the individual responsible. Such corrections lead to a misguided and potentially disastrous belief that the underlying problem has been solved.

Regarding BP's personnel changes and firings, Chapter 8, "History as Cause: Columbia and Challenger

Changing personnel is a typical response after an organization has some kind of harmful outcome. It has great symbolic value. A change in personnel points to individuals as the cause and removing them gives the false impression that the problems have been solved, leaving unresolved organizational system problems.

So what is “organizational culture?”

The Columbia report defines it as

the values, norms, beliefs, and practices that govern how an institution functions. At the most basic level, organizational culture defines the assumptions that employees make as they carry out their work. It is a powerful force that can persist through reorganizations and the reassignment of key personnel.

Experts in organization safety culture note, however, that "assumptions that employees make when they carry out their work" should not be confused with "behavioral safety," which assumes (as BP has suggested) that most accidents are caused by the improper behavior of employees. Organizational culture, on the other hand, explores why, for example, employees don't follow written procedures (outdated, poorly written, inaccurate?) and how management responds to employee complaints about unsafe conditions.

As an example taken from NASA, Vaughn notes that “NASA culture allowed flying with flaws when problems were defined as normal and routine” and that NASA was operating like a business, with “schedules, production pressures, deadlines, and cost efficiency goals elevated to the level of technical innovation and safety goals."

At the same time that NASA leaders were emphasizing the importance of safety, their personnel cutbacks sent other signals. Streamlining and downsizing, which scarcely go unnoticed by employees, convey a message that efficiency is an
important goal.

All of this makes particularly chilling reading considering the pressures and temptations that rising gas prices (and windfall profits) put on the refinery business. Acording to the Financial Times

With oil prices at record highs, refineries are running at full capacity, and many other oil companies have suffered accidents and disruptions at their plants. Analysts warn that it is tempting to skip routine maintenance on ageing facilities at the top of the cycle.

"It's not surprising that you run into more accidents, explosions, outages when things are running full-out," says John Thieroff from Standard & Poor's, the ratings agency.

BP may have a lot to learn from the investigation. A recent article in the Wall St. Journal, describing previous cost cutting at BP facilities, noted that

BP has denied any connection between cost-cutting and plant fatalities. It contends that overall safety at its American refineries has improved since it acquired them.

"I think the culture of safety, in terms of policies and procedures, was there," said Ross Pillari, president of BP Products North America. "But the implementation of these policies and procedures was clearly not there, because if it was, the accidents wouldn't have happened."

Why it's not possible to have a well-functioning safety culture when your policies and procedures aren’t being implemented is a puzzle that the new panel will hopefully clarify for BP management.

More BP Stories from Confined Space here.

Labels: BP, Chemical Safety Board