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Catastrophic Texas
City Explosion Was Foreseen, Preventable
This month we feature an article on disaster preparedness that
acknowledges the fact that you can’t possibly prepare for every
disaster, whether imaginable of not. So, the question is how and
what do you prepare for? How do you prioritize your resources to
prepare for a wide variety of threats in as reasonable a manner as
possible? And once those threats have been identified, how do you
ensure that the risks they present have been reduced to an
acceptable level.
One option is to conduct a safety assessment as part of a risk
management plan. You’ll find information on how to do that in the
following pages, too. But conducting a risk assessment involves more
than figuring out how to prevent slips, trips and falls. Though that
is essential, there may be greater dangers lurking at your facility.
This was the finding of an investigation by the Chemical Safety and
Hazard Investigation Board into the BP refinery explosion that killed
15 people in Texas City, TX two years ago. The report was also
critical of OSHA, finding it lax in its enforcement and inspection of
petrochemical facilities.
The 335-page report determined that “a dysfunctional safety culture
existed at all levels of BP,” and cost cutting, production
pressures, and a failure to invest resulted in making the refinery
“vulnerable to catastrophe.”
This combination “caused a progressive deterioration of safety at
the refinery,” said CSB Chairman Carolyn W. Merritt. “Beginning in
2002, BP commissioned a series of audits and studies that revealed
serious safety problems at the Texas City refinery, including a lack
of necessary preventative maintenance and training.”
The report also calls on OSHA to increase inspection and enforcement
at U.S. oil refineries and chemical plants.
“OSHA’s national focus on inspecting facilities with high injury
rates, while important, has resulted in reduced attention to
preventing less frequent, but catastrophic, process safety incidents
such as the one at Texas City,” says the CSB.
As part of its investigation, the CSB conducted an examination of
corporate safety culture, the first in its nine-year existence. “As
the science of major accident investigations has matured, analysis
has gone beyond technical and system deficiencies to include an
examination of organizational culture,” said supervisory
investigator Don Holmstrom. “Effective organizational practices such
as encouraging the reporting of incidents and allocating adequate
resources for safe operation, are required to make safety systems
work successfully.”
“BP managers and executives attempted to make improvements from 2002
to 2005 but they were largely focused on personal safety — such as
slips, trips, falls, and vehicle accidents — rather than on
improving process safety performance, which continued to
deteriorate.” The report calls on the development of a new consensus
standard defining performance indicators for process safety.
In 2004, a safety culture survey of the refinery was conducted and
endorsed by the site leadership. The study, known as the Telos
report, pointed to “an exceptional degree of fear of catastrophic
incidents” among other conclusions, and it stated respondents'’
belief that “production and budget compliance gets ... rewarded
before anything else.”
Finally, CSB found that a safety business plan for 2005 cited as a
“key risk” the possibility that “Texas City kills someone in the
next 12-18 months.”
Rules already on the books would likely have prevented the tragedy
in Texas City, said CSB Chairman Merritt. “But if a company is not
following those rules, year-in and year-out, it is ultimately the
responsibility of the federal government to enforce good safety
practices before more lives are lost.”
OSHA needs to do whatever is necessary for inspecting and enforcing
safety rules at oil and chemical plants. There are just too many
potentially catastrophic hazards to be overlooked.
They also have too much to lose, especially the lives of their
workers.
Thanks and good luck.
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