By OGJ editors
HOUSTON, Dec. 9 -- BP Products North America Inc. Dec. 9 released its final incident investigation report on the Mar. 23 Texas City, Tex., refinery explosion and fire (OGJ Online, Mar. 23, 2005). The company said it plans to invest about $1 billion to improve and maintain the site over the next 5 years.
While many of the actions recommended by investigators are under way, some actions have been completed. Among the work, the company will install modern process-control systems on major units, transition to a more powerful maintenance management system, improve worker training, and remove blowdown stacks, the report said.
BP said that the investigation team "found no evidence of anyone consciously or intentionally taking actions or decisions that put others at risk." However, "the team found many areas where procedures, policies, and expected behaviors were not met."
According to the report, BP found that the "underlying reasons for the behaviors and actions displayed during the incident are complex" and that it was "evident that they had been many years in the making. . .."
Critical factors that led to the explosion were identified in an interim report published May 17 (OGJ Online, May 18, 2005). The final report also identifies the following underlying causes:
-- "Over the years, the working environment had eroded to one characterized by resistance to change, and lacking of trust, motivation, and a sense of purpose. Coupled with unclear expectations around supervisory and management behaviors this meant that rules were not consistently followed, rigor was lacking, and individuals felt disempowered from suggesting or initiating improvements.
-- "Process safety, operations performance and systematic risk reduction priorities had not been set and consistently reinforced by management.
-- "Many changes in a complex organization had led to the lack of clear accountabilities and poor communication, which together resulted in confusion in the workforce over roles and responsibilities.
-- "A poor level of hazard awareness and understanding of process safety on the site resulted in people accepting levels of risk that are considerably higher than comparable installations. One consequence was that temporary office trailers were placed within 150 ft of a blowdown stack, which vented heavier than air hydrocarbons to the atmosphere without questioning the established industry practice.
-- "Given the poor vertical communication and performance management process, there was neither adequate early warning system of problems, nor any independent means of understanding the deteriorating standards in the plant."