Posted By Arran Linton - Smith
Although details of the Baker Report have leaked in the press since Sunday, I am surprised that this has not yet been examined or discussed on this forum.

I am sure this report will be raised in many future exam papers.

See: http://news.bbc.co.uk/1/hi/business/6265535.stm
http://business.guardian...story/0,,1989712,00.html

Posted By Chas
I was interested in the following quote from the BBC article...

"......The report found that prior to the Texas City tragedy, BP emphasised personal safety but not process safety...."BP mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance at its US refineries," said the report...."

I wonder how many other organisations rely on personal safety stats to justify their good (safe) performance?

Posted By Pugwash
Arran expresses surprise that the report has not yet been examined or discussed on this forum.

We in the UK do not usually take much interest in health and safety matters in the USA. As regards health and safety management, we perceive it as a rather distant place where they do things differently. (Anyone care to take issue with me on this point?)

I would like to suggest that the only reason that the accident and subsequent investigations are receiving any coverage at all in the UK media (and in this forum) is because of the link to BP, a global company which just happens to have its headquarters in London.

It is a rare occurrence when we in the UK feel that we have much to learn from the USA as regards health and safety. It is not often that you see matters in the USA being discussed here. I would be very surprised indeed to find the findings in this report being the subject of exam questions in the UK.

Nevertheless, having read the executive summary, I think it is probably a report which is worth reading by any health and safety practitioner. There are lessons to be learned here which could have applications in many industries.

Posted By Andy Brazier
The key findings are summarised here

http://andybrazier.blogs...report-key-findings.html

Posted By garyh
The report apparently noted the fact that BP did not really pass on the learning from UK (Grangemouth etc) incidents to it's US operations.

This (not passing on learning) has happened many times across organisations.

Posted By LIM BOON KHOON
Dear David,

Would appreciate if you could e-mail a copy of the MPEG report on the texas city oil refinery accident so that lessons can be learnt from them

My e-mail address is helpc@helpc.com.sg

Thank you.



Lim Boon Khoon

Posted By Andrew Lochlyn Ure
Pugwash makes the point "We in the UK do not usually take much interest in health and safety matters in the USA. As regards health and safety management, we perceive it as a rather distant place where they do things differently" - Speaking for myself, and I daresay others, a very great deal of interest will be shown. BP is one of the biggest listed British companies, and the Baker report will have a profound effect in the petrochem and oil and gas industries (both upstream and downstream) all over the world, particularly since it will have a bearing on the organisation's license to operate. In the era of globalisation any company that operates internationally ignores developments affecting OHS/Environmental Protection outside of the UK at it's peril. Anyone remember Bhopal and Union Carbide?

Posted By Pugwash
The Baker will have a profound effect on BP in the USA - I would not dispute that. But elsewhere in other countries, I wonder. I would like to think that it would but Gary makes the point above that "the report apparently noted the fact that BP did not really pass on the learning from UK (Grangemouth etc) incidents to it's US operations". Why will it necessarily then work the other way round.

The Baker report might be of interest to those in the petrochemical industry but it really should be of interest to those outside it too. The deficiencies which it identifies should translate to other industries. The point I am making is that is that most people outside the petrochemical industry outside the USA will ignore it...and that is a sad thing.

We are very insular in the UK when it comes to looking at health and safety management practices. We very rarely compare ourselves with others abroad. I wonder why that is?

Posted By Andy Brazier
In some ways I agree with Pugwash because I can think of numerous UK accidents that have had an impact but can't say the same about US accidents. Three Mile Island certainly had a major impact across the world.

However, I wonder if it is quite the issue that Pugwash suggests. Safety knowledge is continually evolving. The reality is that accident investigators tend to reflect the latest thinking regarding the cause of accidents, largely because they are unlikely to come up with completely new theories on the basis of one accident. There is nothing in the Baker report that has not been said before, and this is pretty much the case for all accident reports.

An example that springs to mind is shift handover. In the early 90's I looked into the Piper Alpha disaster in some detail as part of my PhD studies. At the time I concluded that shift handover was a major issue. However, because it was not a subject that had received attention previously it did not get much attention in the inquiry.

When I started work as a consultant I raised shift handover a number of times but clients were not interested. Shift handover has now been highlighted following the Buncefield explosion. This time companies are taking note, and I know for a fact that many are doing some significant work in the area. My feeling is that understanding of human factors has increased greatly in the years since Piper Alpha and so it is something that is expected to be covered in accident reports because industry is now in a position to act.

It is interesting to hear from John in Oz. The Longford gas plant accident has certainly had an impact in the UK. I don't think it is because the accident was any more interesting than any other, but a number of the issues (especially around organisational change) were already being discussed and so the accident has been useful in reinforcing the messages.

I'm not sure how much sense this all makes. My view is that it is not such a shame that we don't always learn all we could about major accidents around the world. Rather, that we don't learn enough about the smaller events that are happening all the time that indicate we have problems.

Posted By jom
Andy,

"It is interesting to hear from John in Oz. The Longford gas plant accident has certainly had an impact in the UK"

Case in point.

Question, test and challenge what is published.

Never happened with Longford.

John in OZ.

Posted By Andy Brazier
John in Oz

The key message seems to be that BP thought a good safety record meant they were safe. Unfortunately, normal safety performance measures (e.g. injury rates etc.) tell you very little about process safety. Interestingly the same point came out following Longford. The example from Andrew Hopkins being that an airline would not judge its safety on injury rates because most injuries happen to baggage handlers, which has nothing to do with aircraft crashing.

Posted By Ian Waldram
The Baker Report is long and not easily digested. However it has the merit of summarising the specific evidence they collected from all 5 of BP's US refineries, and drawing conclusions from this additional evidence, not just using 'expert opinion'.

The Panel are very clear on several issues, not covered in the postings above:
- They are not re-considering the original accident, which has been well investigated by others;
- They are recommending how to achieve excellence, not compliance. They do not expect 'quick fixes';
- They do not believe BP are alone in their deficiencies. All credit to BP, as others have already said, for making the full report freely available just a few days after they received it.

They do not mention anything about the following aspects:
- US enforcement practices, which I personally suggest may also be linked to the balance of effort BP had between process and personal safety;
- The lack (I'm told, by someone from the organisation that suffered 11 or the fatalities) of any prior thoughtful regulator or industry guidance on the siting of temporary cabins in major hazard facilities. The same source told me that it was several months before there was even an official message to others that they should urgently review such sitings (apologies if I'm wrong, but my source seemed to know the details accurately).

They are also silent on the issue of anything BP should have ceased doing on personal safety (or health, or environment, or driving, or ...) so as to devote more effort to process safety. Part of the answer may be that BP needed more resources, and some of that has been done, but that isn't a complete answer. Also they seem to believe that the two types of effort are quite separate, whereas some of the key 'soft' elemeents (such as leadership from the top and worker commitment) seem identical to me.

I've still to read the whole report in detail, and I'm certainly not suggesting that BP, and others with major hazard sites, have nothing to learn - but I do think that its fairly easy to be wise after the event, especially when you've had 22 months to think about it.

Posted By Ian Waldram
As I said, the Baker Panel did not re-investigate the original incident. If you wish to understand the saga of the cabins, see the Mogford Report, BP's internal investigation.

The point is that no one at site, in either BP or the contractor organisation, apparently appreciated why the cabins should not be there. There was a site procedure for approving where temporary cabins were placed, but the Mogford team did not find evidence that it was followed. This is one example of widespread lack of competence in process safety, the Baker report has additional evidence.

Posted By jom
"If you wish to understand the saga of the cabins, see the Mogford Report"

That's section 5.12 - alot said about the trailer location approval process.

The question stands - is the fundamantal principle trailer location or personnel location? We need to know the tasks these people were doing and why they needed to be at that location.

"This is one example of widespread lack of competence in process safety"

Hey, that's a big statement -"widespread lack of competence"?

Petrochem plants worldwide operate round the clock without Major Accidents occurring. That's a result of widespread competence in Process Safety. Is that a fair comment?

J.

Posted By jom
Hi Bob.

"Is it really a lack of process safety when a plant fails?"

Yes, it is.

That's exactly what Process Safety is about - prevention of loss of containment of dangerous chemicals. If loss of containment occurs then Process Safety has failed.

Process Safety failed at both Texas City and Buncefield.

J.

Posted By jom
Andy made the following point in an early post:-

"I think most organisations rely on personal accident data at the expense of process safety. This point was made very clearly in the investigation to the Esso Longford gas plant fire."

Actually, Andy, with respect to Longford, I don't believe there was any evidence revealed that reliance was placed on personal safety "at the expense of process saftey".

Does anyone know of any such evidence?

J.

Posted By Pete48
Ian, I agree completely. I would use the term "mutually supportive". I have also witnessed this concentration on hearts and minds to the detriment of engineering based controls. There is, I think, a link to the change from control and command management to the modern mantra of devolve to evolve.

The management of change is the critical matter in my view. This is so often where the systems fail. Whether we are talking changes to equipment, materials, environment, working practice or people, it is the lack of proper assessment regarding change that catches out far too many, far too often. The first link in the chain of many major accidents starts many months and many miles away from the actual incident.

The most chilling recollection that came to my mind after reading the BP report was a response from a senior executive being questioned at the Piper Alpha enquiry. In answering how he knew that the state of safety on the rig just before the incident was OK, he replied "becaus no-one told me it wasn't".

The more things change, the more they stay the same???

Posted By jom
Andy,

I have the Commission's report and have carefully gone through the ten pages of their "Conclusions and Recommendations".

I cannot find anything there referring to "personal safety", let alone anything suggesting that there was a "focus on personal safety at the expense of process safety".

So what is the evidence that personal safety took precedence over process safety?

Regards,
J.

Posted By Ian Waldram
I concur with most of the comments posted above. But one point to bear in mind is that BP is also the source of the leading suite of Process Safety handbooks from IChemE. The Baker report took evidence from US refineries only - care is needed when applying conclusion to wider BP. From my experience, the concentration on injury data rather than leaks, process trips, overdue inspections, etc. is more prevalent in downstream hydrocarbon processing than upstream - but the tendency is always present.

There are some people in IOSH with both a strong engineering and a strong personal safety background. Sometimes we feel a bit like voices in the wilderness - particularly in discussions about what is a 'relevant degree'. The new Hazardous Industries SG should help to redress the balance, and also to forge partnerships with other bodies who are strong in this area.

Posted By jom
The Chemical Safety Board will be presenting its final report on the TC accident next week.