CSB Lead Investigator to Panel: 'All is Not Well at BP'

Taking issue with the "widespread misperception" that employers can improve safety simply by changing the unsafe behaviors of plant-level workers, U.S. Chemical Safety and Hazard Investigation Board (CSB) lead investigator Don Holmstrom said the March 23 BP refinery accident in Texas City, Texas, was the result of decisions made much higher up the corporate ladder.

"While human errors contribute to most major incidents including this one they are rarely the root cause," Holmstrom said. "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."

Holmstrom, speaking Nov. 10 to members of an independent safety panel that BP launched at CSB's urging to examine safety management in its five North American refineries, said many of CSB's finding from its investigation of the March 23 Texas City accident "are indicative of management culture issues at BP." The accident killed 15 workers and injured 170 others.

"The findings also raised serious concerns about the effectiveness of mechanical integrity programs, hazard analyses, management-of-change programs and incident investigation programs," Holmstrom said.

Other issues that Holmstrom identified as "harder to quantify" but nonetheless important included:

  • 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 2-hour commute times," Holmstrom said.
  • The downsizing of both supervision and training. For example, BP's Texas City refinery went from 38 trainers in 1998 to nine in 2005, Holmstrom pointed out. On the day of the incident there was no supervisor with appropriate experience overseeing key phases of the startup operation, Holmstrom added.
  • 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," Holmstrom said.
  • Management of obsolete equipment. "The blowdown drum and stack in Texas City was half-century-old technology," Holmstrom said. "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?"

Holmstrom's remarks to the independent safety panel came on the heels an Oct. 27 public meeting in which CSB unveiled the preliminary results of its investigation of the March 23 BP Texas City accident. Six major safety issues identified by CSB in its report including the unsafe placement of mobile trailers point to an incident that was, in the words of CSB Chairman and CEO Carolyn Merritt, "completely preventable."

"And so there are a great many important issues to look into, and that is why you are here, Mr. Secretary and members of the panel: to examine why BP evidently allowed serious deviations from good safety practice to exist and to persist," Holmstrom said Nov. 10. "More importantly, you are asked to recommend any needed changes in BP's governance, structure, management systems and organizational culture so that these facilities are safer in the future."

BP: CSB's Findings Inconsistent with Company Investigation

BP, which has placed much of the blame for the March 23 accident on "a series of failures by BP personnel before and during the startup of the isomerizatoin process unit in the Texas City refinery," acknowledged in an Oct. 27 statement that some of CSB's preliminary findings "appear to be inconsistent with the evidence and analysis gathered by our own incident investigation team."

BP's statement also said that the company plans to meet with CSB officials to "discuss their findings and any supporting information so that it can be fully considered in the preparation of our final investigation report."

BP spokesperson Ronnie Chappell said that the company had no comment on CSB's Nov. 10 presentation to the independent safety panel. Chappell said BP will address the issues raised by CSB in the company's final investigation report, which BP hopes to finish by the end of the year.

Holmstrom: Conduct Review 'In the Public Eye'

In his recommendations to the panel, Holmstrom said it should take into consideration how well BP's North American refineries have been assimilated into the corporation. Holmstrom noted that most of their North American refineries have been acquired through recent mergers.

Holmstrom urged the panel to establish benchmarks for the safety management systems and cultures of other high-risk sectors such as the nuclear industries, adding that it might help the panel to seek the counsel of at least one other oil or chemical company.

Holmstrom also encouraged the panel to conduct its review "in the public eye" and to hold public hearings.

"Mr. Secretary, you can see from our presentation that all is not well at BP," Holmstrom said. "The workers deserve better. The community deserves better. And at a time when petroleum supplies are in critical demand, the nation deserves better."

Both Merritt and Holmstrom framed their remarks by expressing their confidence in the panel, which is being chaired by former U.S. Secretary of State James Baker III and includes former CSB member Dr. Irv Rosenthal.

"I believe that your efforts can have a profound impact on many corporations who will be awakened and warned by your work," Holmstrom said.

Texas City Accident Spurred Panel's Creation

Prompted by its investigation of the March 23 Texas City refinery accident, CSB on Aug. 15 made an urgent recommendation to BP to form the panel "after our investigators uncovered evidence of serious management problems at the Texas City refinery," Merritt said Nov. 10.

The urgent recommendation was the first of its kind in the agency's 8-year history.

"We began to realize there might be systemic issues of management culture and oversight that are not localized to one site," Merritt said.

In October, CSB issued two additional urgent safety recommendations calling for the safer placement of trailers for workers at petrochemical facilities throughout the United States.

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