Much of the information Miles discussed regarding outdated equipment and malfunctioning gauges and alarms was similar to information previously revealed by the US Chemical Safety Board:
Miles said OSHA found plenty of evidence that BP managers also ignored glaring maintenance problems for years before the blast.Miles said that OSHA had not yet decided whether or not to file criminal charges, but there is a five-year statute of limitations.
"We found that when they had a turnaround in 2003, they noticed that there were baffles rusted out and lying in the bottom of the blowdown unit. But instead of fixing it, employees mentioned it in their report, closed up the unit and said they would get to it in the next turnaround in 2005. But they didn't fix it then either."
In fact, on at least six separate occasions, BP managers considered getting rid of the vent stack entirely, and connecting the system to a safer flare, but the work was always delayed or dropped, he said.
Inspectors also found that employees operating the unit on the day of the accident were "flying blind" without updated training and procedures and were operating equipment with faulty gauges and alarms. "When the instruments are not working, you obviously don't know what is happening, and they overfilled the unit," Miles said.
Miles was also asked if the lack of OSHA enforcement previous to the disaster had made it possible for the accidetn to happen. The response was a bit frightening, though not surprising: A:
True, the OSHA Act, like every other law on the books, is based on people complying with the law. But society's laws are also based on the presumption that if people break that faith and don't comply with the law, there is a reasonable likelihood that they will be caught and punished. We shouldn't need (and can never afford) enough enforcers to monitor everyone's behavior all the time. On the other hand, unless we have enough enforcers to establish a credible deterrent for those who are tempted to break the law, then the law is pretty worthless.
I think when (the Texas City refinery) was Amoco, there was a lot of enforcement
history. Under BP ownership, we had only been out there a couple of times before
two pipefitters were killed in September 2004.
You'd like to say we should have done more enforcement, but the OSHA Act is based on employers complying with safety and health requirements.
Nationwide, OSHA has only one team of inspectors who specialize in process safety management (the specialized safety rules that apply to facilities such are refineries). That six-member team is based at the Houston South office.
And with so few OSHA inspectors, and even fewer who are experts in Process Safety Management, most employers probably figure -- correctly -- that their chance of being caught by OSHA for not complying with health and safety requirements is pretty slim -- unless they happen to kill someone.
Finally, one other answer that bothered me:
Q: You have said that BP had a cultural safety problem at the Texas City refinery. What are the causes of this, in your opinion?As I discussed after the US Chemical Safety Board issued an urgent recommendation to BP to commission an independent panel that would review a range of safety management and culture issues stemming from the March 23 explosion, the report into the Columbia space shuttle accident, defined "organizational culture" as
A: They need to do a complete overhaul with supervisors and with units. They have a new plant manager and a new safety guy, and that's a good start if those people follow through on what they need to do.
Maintenance was deferred, and equipment was in poor condition. They have to put employee safety ahead of production, and they need to send the message they will not tolerate people who do not follow procedures.
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.In making its recommendation, the CSB was focusing on effective corporate oversight of safety management systems, not just replacing bad manager with good managers. Good managers come and good managers go, but effective safety management systems -- and a good organizational culture -- will survive through managers good or bad.