As reported earlier, a preliminary CSB report of the investigation at the BP Texas City Plant where a March 23 explosion killed 15 workers could have been prevented if the refinery had installed a flare system years before, as OSHA had recommended, and heeded past warnings of previous "close calls" and malfunctioning alarms, indicators and other equipment.
Some health and safety activists have questioned what the Board means by "safety culture," and what issues the panel will be looking into. To clarify some of those issues, check out the following sections from the statement of CSB Chairman Carolyn Merritt at the opening meeting of the panel.
A good safety culture is the embodiment of effective programs, decision making and accountability at all levels. It is a much different concept from simply having good procedures on paper.Merritt also noted some other areas that she wanted the panel to look into.
There is a widespread misperception that safety culture can be improved solely through modifying unsafe worker behaviors. While human errors contribute to most major incidents including this one, they are rarely the root cause. The mistakes that were made in Texas City have their roots in decisions made by managers at the facility and the corporate level, sometimes years earlier.
Thus when we talk about safety culture, we are talking first and foremost about how managerial decisions are made, about the incentives and disincentives within an organization for promoting safety. Are production and cost control being rewarded at the expense of safety and risk management?
One thing I have often observed is that there is a great gap between what executives believe to be the safety culture of an organization and what it actually is on the ground. Almost every executive believes he or she is conveying a message that safety is number one. But it is not always so in reality.
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- One is management of fatigue. Our information indicates that on the day of the incident, some BP operators had worked 30 days straight, 12 hours per day, some with two-hour commute times.
- Another is the downsizing of both supervision and training. For example, BP Texas City went from 38 trainers in 1998 to just nine in 2005. And on the day of the incident there was no supervisor with appropriate experience overseeing key phases of the startup operation.
- Another concern is workload management. On March 23, a single board operator was responsible for simultaneously running the controls of three different complex process units, including the isom unit that was starting up.
- Finally, there is the issue of how obsolete equipment is managed. The blowdown drum and stack in Texas City was half-century old technology. Yet in the 1990s it was completely rebuilt according to its original design, which was by then recognized as antiquated and unsafe. How does BP’s management assure they are using current safety equipment that is appropriate for the risks involved?