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Case Study: BP Texas City Explosion 23 March 2005

Analysis of BP’s Safety Culture

The BP Texas City tragedy is an accident with organizational causes embedded in the refinery’s culture. The CSB investigation found that organizational causes linked the numerous safety system failures that extended beyond the ISOM unit. The organizational causes of the March 23, 2005, ISOM explosion are

BP Texas City lacked a reporting and learning culture. Reporting bad news was not encouraged, and often Texas City managers did not effectively investigate incidents or take appropriate corrective action.

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A BP Group 2002 report on the Group Fatal Accident Investigation Process found that “critical factors and hence root causes [were] not identified” and that “corrective actions [were]sometimes vague and impractical.”

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The 2003 South Houston GHSER audit found that “a coordinated, self monitoring and self assessment process is not evident throughout the organization.”

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The 2004 GHSER assessment graded Texas City as “poor” because investigation information was not analyzed to monitor trends and develop prevention programs. The assessment found little use of the GHSER audit/assessment results to drive plant goals.

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The 2004 Group Internal Audit report found poor plant monitoring and lessons learned processes at 35 BP Group business units: “[i]nformation on incidents is circulated from Group HSE. Some entities do not have robust processes for assessing the implications of these and initiating actions to manage their risks of a similar occurrence.”

BP Group lacked focus on controlling major hazard risk. BP management paid attention to, measured, and rewarded personal safety rather than process safety.

BP Group and Texas City managers provided ineffective leadership and oversight. BP management did not implement adequate safety oversight, provide needed human and economic resources, or consistently model adherence to safety rules and procedures.

BP Group and Texas City did not effectively evaluate the safety implications of major organizational, personnel, and policy changes.

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