"The Texas City disaster was caused by organizational and safety deficiencies at all levels of the BP Corporation. Warning signs of a possible disaster were present for several years, but company officials did not intervene effectively to prevent it. The extent of the serious safety culture deficiencies was further revealed when the refinery experienced two additional serious incidents just a few months after the March 2005 disaster. In one, a pipe failure caused a reported $30 million in damage; the other resulted in a $2 million property loss."
12.1 Root Causes
"BP Group Board did not provide effective oversight of the company’s safety culture and major accident prevention programs.
• inadequately addressed controlling major hazard risk. Personal safety was measured, rewarded, and the primary focus, but the same emphasis was not put on improving process safety performance;
• did not provide effective safety culture leadership and oversight to prevent catastrophic accidents;
• ineffectively ensured that the safety implications of major organizational, personnel, and policy changes were evaluated;
• did not provide adequate resources to prevent major accidents; budget cuts impaired process safety performance at the Texas City refinery.
BP Texas City Managers did not:
• create an effective reporting and learning culture; reporting bad news was not encouraged. Incidents were often ineffectively investigated and appropriate corrective actions not taken.
• ensure that supervisors and management modeled and enforced use of up-to-date plant policies and procedures.
• incorporate good practice design in the operation of the ISOM unit. Examples of these failures include: no flare to safely combust flammables entering the blowdown system;
lack of automated controls in the splitter tower triggered by high-level, which would have prevented the unsafe level; and inadequate instrumentation to warn of overfilling in the splitter tower.
• ensure that operators were supervised and supported by experienced, technically trained personnel during unit startup, an especially hazardous phase of operation; or that
• effectively incorporated human factor considerations in its training, staffing, and work schedule for operations personnel.
12.2 Contributing Causes
BP Texas City managers:
• lacked an effective mechanical integrity program to maintain instruments and process equipment. For example, malfunctioning instruments and equipment were not repaired prior to startup.
• did not have an effective vehicle traffic policy to control vehicle traffic into hazardous process areas or to establish safe distances from process unit boundaries.
• ineffectively implemented their PSSR policy; nonessential personnel were not removed from areas in and around process units during the hazardous unit startup.
• lacked a policy for siting trailers that was sufficiently protective of trailer occupants."