"too quick to stop at operator error as the root cause".
- Scroll down for a December 8, 2006 article that just surfaced in another web venue.What are the safety culture lessons to be learned?What are the root cause analysis lessons to be learned?Suppose they had done a Collective Significance Analysis on fires alone; what would have emerged?Take care,
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For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...BP disaster site 'held together with band aids'
· Refinery chief voiced concerns before explosionAndrew Clark in New York and Terry Macalister
· Plant had 23 deaths in 30 years, and a fire a week
Friday December 8, 2006
GuardianThe director responsible for running BP's Texas City oil refinery when it exploded last year killing 15 people has admitted that the site was held together by little more than "Band Aid" and "superglue" in the years running up to the disaster.
Newly disclosed documents yesterday shed fresh light on the flawed safety culture at the American arm of Britain's biggest oil company before the tragedy, in which a drumful of chemicals caught fire in the worst industrial accident in the US for a decade.
The year before the explosion, a worker was boiled alive at the refinery in the 23rd fatal accident in 30 years. That prompted the refinery's director, Don Parus, to call in external consultants. As part of the independent investigation, Mr Parus agreed to be interviewed and in an extraordinary series of comments that were intended to remain anonymous he admitted he was deeply troubled by safety standards and that he did not know if he "had the energy to single-handedly turn the site round".
He observed that "killing somebody every 18 months seems to be acceptable at this site" and questioned why his staff turned up for work: "Why would people take the risk, based on the risk of not going home?"
He added that when he inherited responsibility for the refinery in 2002, he found a culture of "keep it running with Band Aids and superglue", explaining that temporary clamps were used to patch up leaky pipes and valves instead of permanent repairs - a situation that continued until the disaster. According to the local fire brigade, there was an average of one blaze a week, 50 to 80 a year.
BP has reluctantly disclosed a mountain of internal documents about its safety practices as part of a legal settlement with a 22-year-old Louisiana woman, Eva Rowe, who lost both her parents in the Texas City blast.
An external consultants' safety report, called the Telos report, was presented to BP in January last year, two months before the explosion. It said there was "an exceptional degree of fear of catastrophic incidents" at the refinery.
Amid a range of shortcomings, the study said workers felt they were blamed by management when they got hurt and investigations were "too quick to stop at operator error as the root cause".
A focus on production, time pressure and understaffing were the root causes of a string of accidents. "Almost all interviewees say the quantity and quality of training at Texas City is inadequate, and prohibits the site from having a common understanding of the core [health and safety] management system."
Safety regulators have criticized a BP cost-cutting drive ordered from London, which demanded savings of 25%, which, they say, left local managers putting money ahead of safety.
Geoffrey Gioja, co-author of the study, told lawyers in a deposition: "I have been in many places where people have said 'I could die today', many places where they all knew it, but I was surprised by how many people volunteered that, as they go through the gate every morning, this is what they are thinking about and they are concerned about going home.
"They were very serious and very somber and the next moment they would say 'but I don't want to do anything to lose my job'."
In the wake of the accident, BP's internal investigators angered workers by overturning the confidentiality of the Texas City safety report and obtaining the details of which individuals said what in 100 interviews and 1,100 questionnaires.
The drip feed of disclosures is increasingly damaging to BP's reputation - particularly in America, where it is also under fire over Alaska pipeline leaks and alleged manipulation of propane prices.
BP has promised to clean up its act with a $7bn (£3.5bn) safety blitz on its US refineries.
It has recruited an independent ombudsman and appointed the former US secretary of state James Baker to chair a panel on improving its safety culture.
A BP spokesman said the company had accepted responsibility for the explosions and loss of life at Texas City. "We are spending $7bn improve the safety and integrity of our US plants."