2007 Baker The report of the BP U.S. Refineries independent safety review panel

Process safety accidents can be prevented.
On March 23, 2005, the BP Texas City refinery experienced a catastrophic process accident.
It was one of the most serious U.S. workplace disasters of the past two decades, resulting in 15 deaths and more than 170 injuries.
In the aftermath of the accident, BP followed the recommendation of the U. S. Chemical Safety and Hazard Investigation Board and formed this independent panel to conduct a thorough review of the company’s corporate safety culture, safety management systems, and corporate safety oversight at its U.S. refineries. We issue our findings and make specific and extensive recommendations. If implemented and sustained, these recommendations can significantly improve BP’s process safety performance.
Throughout our review, we focused on being thorough and then letting the chips fall where they may. As our charter contemplates, we allowed BP to comment on our report to ensure its factual accuracy. However, we are solely responsible for our report’s final content.
Although we necessarily direct our report to BP, we intend it for a broader audience. We are under no illusion that deficiencies in process safety culture, management, or corporate oversight are limited to BP. Other companies and their stakeholders can benefit from our work. We urge these companies to regularly and thoroughly evaluate their safety culture, the performance of their process safety management systems, and their corporate safety oversight for possible improvements. We also urge the same companies to review carefully our findings and recommendations for application to their situations.
Preventing process accidents requires vigilance. The passing of time without a process accident is not necessarily an indication that all is well and may contribute to a dangerous and growing sense of complacency. When people lose an appreciation of how their safety systems were intended to work, safety systems and controls can deteriorate, lessons can be forgotten, and hazards and deviations from safe operating procedures can be accepted.
Workers and supervisors can increasingly rely on how things were done before, rather than rely on sound engineering principles and other controls. People can forget to be afraid. When systems and controls deteriorate, everything can come together in the worst possible way. Equipment malfunctions and controls fail. An explosion and fire occur. People lose their
lives or suffer horrible injuries. Families and communities are devastated.
The burden of these catastrophes is uniquely and unfairly borne by the victims, their families, and their friends. This was the case for the Texas City victims—men and women who were providing a livelihood for themselves and their families. These victims were fathers and mothers, husbands and wives, sons and daughters, and friends. We dedicate our report
to the survivors of this tragedy and the memory of those who lost their lives.



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