safety board says major deficiencies caused bp disaster

7/28/2019 Safety Board Says Major Deficiencies Caused BP Disaster

1/12

Safety board says major deficiencies caused BP disaster

-Author: RP news wires-

In a 335-page final report released on March 20, federal investigators from theU.S. Chemical Safety Board (CSB) conclude that "organizational and safetydeficiencies at all levels of the BP Corporation" caused the March 23, 2005,explosion at the BP Texas City refinery, the worst industrial accident in theUnited States since 1990. The report calls on the U.S. Occupational Safety andHealth Administration (OSHA) to increase inspection and enforcement at U.S.oil refineries and chemical plants, and to require these corporations to evaluatethe safety impact of mergers, reorganizations, downsizing and budget cuts.

CSB chairman Carolyn W. Merritt said, "It is my sincere hope and belief that ourreport and the recent Baker report will establish a new standard of care for

corporate boards of directors and CEOs throughout the world. Process safetyprograms to protect the lives of workers and the public deserve the same levelof attention, investment, and scrutiny as companies now dedicate to maintainingtheir financial controls. The boards of directors of oil and chemical companiesshould examine every detail of their process safety programs to ensure that noother terrible tragedy like the one at BP occurs."

The CSB report calls on BP to appoint an additional member of the board ofdirectors with expertise in process safety, and calls for BP senior executives toestablish an improved incident reporting program and use new indicators tomeasure safety performance.

The independent Baker panel, formed and funded by BP in response to anurgent CSB safety recommendation, issued its final report in January 2007. Itfound "material deficiencies" in the safety of BP's five U.S. refineries in Texas,California, Indiana, Ohio and Washington. The 11-member panel also issued 10safety recommendations, including calling on BP's corporate board to closelymonitor safety performance at its facilities. The Baker panel was not chargedwith determining the root causes of the March 2005 explosion.

CSB Investigation Background

Merritt said, "Our investigation of BP was the largest and most complexundertaking in the agency's nine-year history. Under the leadership ofsupervisory investigator Don Holmstrom, the team interviewed 370 witnesses,reviewed more than 30,000 documents, and conducted a far-reaching programof equipment, instrumentation, and chemical testing." The final report isscheduled to be presented at a CSB public meeting beginning at 6 p.m. tonightat the Nessler Center, Wings of Heritage Room, located at 2010 5th AvenueNorth in Texas City. The report and recommendations are subject to approvalby the full board at the public meeting.

BP cooperated with the investigation, furnished documents and interviews on avoluntary basis, and committed to widespread safety improvements and

1


2/12

investments following the accident. BP published its own report on theexplosion in December 2005, pledged the total elimination of the kind of unsafedisposal equipment that led to the explosion, and developed a new siting policyto remove trailers from hazardous process areas. All 15 fatalities occurred in ornear trailers that were sited as close as 121 feet from a blowdown drum that

vented flammable liquid and vapor directly to the atmosphere.

Safety Harmed by Cost-Cutting, Production Pressures and Failure toInvestBP acquired the Texas City refinery when it merged with Amoco in 1999. TheCSB report found that "cost-cutting in the 1990s by Amoco and then BP left theTexas City refinery vulnerable to a catastrophe." Shortly after acquiring Amoco,the BP Group Chief Executive ordered an across-the-budget 25 percent cut infixed spending at the corporation's refineries. The impact of the cost cuts isdetailed in many of the more than 20 key investigative documents the CSBmade public today, including internal BP safety audits, reviews, and emails.

Among other things, cost considerations discouraged refinery officials fromreplacing the blowdown drum with a flare system, which the CSB previouslydetermined would have prevented or greatly minimized the severity of theaccident.

Merritt said, "The combination of cost-cutting, production pressures, and failureto invest caused a progressive deterioration of safety at the refinery. Beginningin 2002, BP commissioned a series of audits and studies that revealed serioussafety problems at the Texas City refinery, including a lack of necessarypreventative maintenance and training. These audits and studies were sharedwith BP executives in London, and were provided to at least one member of theexecutive board. BP's response was too little and too late. Some additionalinvestments were made, but they did not address the core problems in TexasCity. In 2004, BP executives challenged their refineries to cut yet another 25percent from their budgets for the following year."

Blast Modeling Shows Vulnerability of Temporary TrailersThe March 23 accident occurred during the startup of the refinery's octane-boosting isomerization (ISOM) unit, when a distillation tower and attachedblowdown drum were overfilled with highly flammable liquid hydrocarbons.Because the blowdown drum vented directly to the atmosphere, there was a

geyser-like release of highly flammable liquid and vapor onto the grounds of therefinery. A diesel pickup truck that was idling nearby ignited the vapor, initiatinga series of explosions and fires that swept through the unit and the surroundingarea. Fatalities and injuries occurred in and around occupied work trailers,which were placed too close to the ISOM unit and which were not evacuatedprior to the startup.

CSB investigator Mark Kaszniak, who led the CSB's vapor and blast modelingeffort, stated, "The CSB was able to calculate that approximately 7,600 gallonsof flammable liquid hydrocarbons nearly the equivalent of a full tanker truck ofgasoline were release from the top of the blowdown drum stack in just under

two minutes." The ejected liquid rapidly vaporized due to evaporation, winddispersion, and contact with the surface of nearby equipment. High

2


3/12

overpressures from the resulting vapor cloud explosion totally destroyed 13trailers and damaged 27 others. People inside trailers were injured as far as479 feet away from the blowdown drum, and trailers nearly 1,000 feet awaysustained damage.

"Industry trailer siting guidelines did not predict the level of trailer damage thatwe actually saw," Kaszniak stated.

In October 2005, the CSB issued an urgent recommendation to the AmericanPetroleum Institute to develop new guidance to prevent trailers from being sitednear hazardous areas of refineries and chemical plants, where occupants couldbe injured or killed.

"A human being is more likely to be injured or killed inside a trailer which canshatter during an explosion than if he is standing in the open air. For thatreason, occupied trailers have no place near hazardous process areas of

refineries and chemical plants," Kaszniak said.

Human Factors Analysis: Fatigue, Other Conditions Made Errors MoreLikelyThe tower overfilled because a valve allowing liquid to drain from the bottom ofthe tower into storage tanks was left closed for over three hours during thestartup on the morning of March 23, which was contrary to unit startupprocedures. The CSB investigative team examined various conditions andhuman factors that led to this error.

"BP relied on operators taking correct and timely actions and followingprocedures to prevent excessive liquid levels in the tower. While procedures areessential to any process safety program, they are the least reliable safeguard toprevent process accidents," Kaszniak said. "Modern control systems utilizeautomatic safety controls to shut down liquid flow to a tower and preventdangerous overfilling."

According to a definition by U.K. safety authorities, human factors are thoseenvironmental, organizational, and job-related factors that influence behavior atwork and can impact safety performance. CSB investigator Cheryl MacKenzie,who led the human factors analysis, said, "Although errors and procedural

deviations occurred during the startup, it is important to recognize thatindividuals do not plan to make mistakes. They are doing what makes sense tothem at the time, given the work environment, the organization's goals, andother job-related factors. Understanding and correcting these factors will helpprevent future accidents at BP and throughout the industry."

In particular, the investigation found that procedural deviations, abnormally highliquid levels and pressures, and dramatic swings in tower liquid level were thenorm in almost all previous startups of the unit since 2000. Operators typicallystarted up the unit with a high liquid level inside and left the drain valve inmanual not automatic mode to prevent possible loss of liquid flow and

resulting damage to a furnace that was connected to the tower. Theseprocedural deviations together with the faulty condition of valves, gauges and

3


4/12

instruments on the tower made the tower susceptible to overfilling,investigators said.

None of the previous abnormal startups was investigated by BP, nor wereoperating procedures updated to reduce the likelihood or consequences of

flooding the tower. As American Petroleum Institute safety guidance notes,when operating procedures are not updated or correct, "workers will create theirown unofficial procedures that may not adequately address safety issues." Atthe Texas City refinery, "Procedural workarounds were accepted as normal,"MacKenzie said.

On March 23, the control board operator's decision to keep the drain valveclosed was influenced by ineffective communication and by false instrumentreadings from the tower. Alarms and gauges that should have warned of theoverfilling equipment failed to operate properly. In addition, the operatorbelieved he had been instructed not to send any liquid from the bottom of the

tower to storage tanks, and the CSB determined that these storage tanks werein fact noted as nearly full.

"BP had no policy for effective shift communication or requirements for shiftturnover," MacKenzie said. "This important instruction to the operator was givenover the phone and was not contained in the log book or the startup procedure."

Although a high tower liquid level alarm did activate in the control room in theearly morning hours, a second high-level alarm malfunctioned and the faultytower level transmitter later indicated that the liquid level was below nine feetand falling. The normal liquid level in the tower was six-and-a-half feet.Unknown to operators, the level was actually rising rapidly, reaching 158 feet by1 p.m. on March 23, 20 minutes before the explosion. The CSB determined thatthe level transmitter was miscalibrated, using a setting from outdated datasheets that likely had not been updated since 1975.

The tower lacked basic process indicators, such as a bottom pressure indicator,that could have provided operators with an accurate picture of the high levelinside the tower. The control panel also did not display the flows in and out ofthe tower on the same screen, and did not automatically calculate how muchtotal liquid was in the tower, even though it could have been configured to do

so.The CSB team used an NTSB methodology to conclude that ISOM unitoperators were likely fatigued when the startup occurred. By March 23,operators had been working 12-hour shifts for 29 or more consecutive days.

"Fatigue causes cognitive fixation and impaired judgment and could leadoperators to fixate on one operational parameter such as the apparentlydeclining liquid level to the exclusion of other indicators," MacKenzie said.

Fatigue has been recognized as a cause of major accidents in the

transportation sector. Fatigue prevention regulations have been developed for

4


5/12

aviation and other transportation sectors, but there are no fatigue preventionguidelines that are widely used and accepted in the oil and chemical sector.

The report recommends that the American Petroleum Institute, a leading tradeorganization, and the United Steelworkers International Union (USW), the

largest union representing refinery workers, work together to develop a newconsensus standard for fatigue prevention in the oil and chemical industry.

The investigative team also pointed to a significant downsizing that occurred inoperations and training at the refinery. Following BP's global 25 percent cut tofixed costs in 1999, the Texas City Refinery halved the number of control boardoperators in the ISOM area, from two to one. Then in 2003, the sole remainingoperator was given a third process unit to control. Each refinery unit is acomplex network of equipment, piping, valves, and instruments. The ISOM unititself, one of the smaller units of the refinery, was the size of a city block andcontained four major subunits. A 2003 BP hazard review recommended that a

second operator be present during startups, but this recommendation wasnever implemented. The 25 percent budget cut from 1999 also resulted insignificant training reductions for operators, and cost pressures prevented therefinery from using simulators to train operators for handling abnormal situationsand process upsets.

Refinery Had Longstanding Process Safety DeficienciesLike other refineries and chemical plants that handle highly flammable, toxic, orhazardous substances, the Texas City Refinery is regulated under the ProcessSafety Management (PSM) standard of the U.S. Occupational Safety andHealth Administration (OSHA). The standard was promulgated in 1992 as aresult of provisions in the 1990 Clean Air Act, which responded to majorchemical accidents in the U.S. and overseas. The PSM standard requirescovered facilities to implement 14 specific management elements to preventcatastrophic releases of hazardous substances. These include hazard analysis,operator training, preventative maintenance programs (mechanical integrity),and management of change reviews.

Investigator Mark Kaszniak stated, "If the Process Safety Management standardhad been thoroughly implemented at the refinery, as required by federalregulations, this accident likely would not have occurred."

Kaszniak said that numerous requirements of the standard were not beingfollowed in Texas City and cited ineffective incident investigations, lack ofeffective preventative maintenance, lack of change reviews and pre-startupreviews, and incomplete hazard analyses.

OSHA rules require internal investigations and corrective actions for any seriousprocess incidents or near-misses. But the CSB found that the refinery onlyinvestigated three of the eight known previous ISOM blowdown releaseincidents, where flammable and potentially explosive vapor was released fromthe same blowdown drum involved in the March 23 accident. In 2004, an

internal BP audit graded the refinery's analysis of incident information as "poor."

5


6/12

The CSB also determined that both the blowdown drum and the relief valvedisposal piping were undersized, which led to the blowdown drum overflowingwith liquid. Under the PSM standard, BP was required to conduct a study of thetower's pressure relief system to ensure its safety. Despite the federalrequirement, BP was not able to produce any documents indicating the study

had even been done.

"By 2005, the required relief valve study was 13 years overdue," Kaszniak said."Without the study, there was no assurance that the equipment could handle allthe credible relief scenarios, including the one that actually occurred on March23." The report noted that an internal BP audit from 2004 found that designcalculations did not exist for many relief valves at the refinery and that theproblem had existed for nearly 10 years.

In October 2006, the CSB issued recommendations to OSHA and API aimed ateliminating similar atmospheric blowdown systems from U.S. refineries and

chemical plants in favor of safer alternatives, such as flare systems.

The investigative team also noted a number of problems with the facility'spreventative maintenance program that were causally related to the March 23accident. The report concluded that BP supervisory personnel were aware ofthe equipment problems with the level transmitter before the March 23 startupbut still had signed off on equipment checks as if they had been done, which thereport said reflected the prevalence of production pressures at the refinery.

In addition, there was no documented test method for the blowdown drum high-level alarm, which failed to sound on March 23, and the testing method in actualuse was contrary to the manufacturer's recommendations. The refinery'scomputerized maintenance management system allowed maintenance workorders to be closed even if no repair had been done. Many action items fromprevious hazard analyses and incident investigations such as a 1994 actionitem to review the adequacy of the ISOM blowdown system following twoserious incidents that year were never completed.

Dysfunctional Safety Culture Existed at All Levels of BPFor the first time in its nine-year history, the CSB conducted an examination ofcorporate safety culture.

"As the science of major accident investigations has matured, analysis hasgone beyond technical and system deficiencies to include an examination oforganizational culture," supervisory investigator Don Holmstrom said. "Effectiveorganizational practices such as encouraging the reporting of incidents andallocating adequate resources for safe operation, are required to make safetysystems work successfully."

Holmstrom pointed to the unusual history of fatal incidents at the Texas CityRefinery. Over a 30-year period spanning Amoco and BP's ownership, 23workers died at the facility not counting the 15 workers killed in March 2005.

6


7/12

"Many of the safety issues that led to the March 2005 accident were recurringsafety problems that had been previously identified in internal audits, reports,and investigations. Our findings show that both BP Group executives and TexasCity managers became aware of serious process safety problems at the refinerybeginning in 2002 and continuing through March 2005," Holmstrom said.

Holmstrom also cited a series of three serious incidents at the BP refinery inGrangemouth, Scotland, in 2000, which were investigated by the U.K. Healthand Safety Executive. BP officials wrote that meeting "cost targets" played arole in the Grangemouth incidents and stated that "there was too muchemphasis on short term cost reduction HSE [health, safety, and environment]was unofficially sacrificed to cost reductions, and cost pressures inhibited thestaff from asking the right questions." The lessons from the Grangemouthinvestigation were not effectively implemented at the Texas City Refinery,however.

Holmstrom stated that in each year from 2002 to 2005, BP made its ownsignificant findings about the culture and safety of the Texas City site. In 2002,the new refinery manager found the infrastructure and equipment to be "incomplete decline." A follow-up study by BP found "serious concerns about thepotential for a major site accident" due to mechanical integrity problems. Laterin 2002, another internal report explicitly connected the safety problems toearlier cost-cutting, stating, "the current integrity and reliability issues at TCR[Texas City Refinery] are clearly linked to the reduction in maintenancespending over the last decade." The prevailing culture at the Texas City refinerywas to accept cost reductions without challenge and not to raise concerns whenoperational integrity was compromised."

Similar findings were made in 2003, when a study of maintenance found that"cost-cutting measures have intervened with the group's work to get things right- usually reliability improvements are cut." An external BP safety audit foundinadequate training, a large number of overdue action items, and a concernabout "insufficient resources to achieve all commitments." The report stated that"the condition of the infrastructure and assets is poor."

The year 2004 was marked by three major accidents at the refinery, including a$30 million process fire and two other accidents that caused three deaths.

Meanwhile, an analysis conducted by BP's internal audit group in London foundcommon safety deficiencies among 35 BP business units around the world,including widespread tolerance of non-compliance with basic health, safety, andenvironment rules and poor implementation of safety management systems.

"In 2004, BP documents do show that maintenance spending increased, but wefound that the increases were largely due to complying with environmentalrequirements and responding to major accidents and outages. There was stillnot an adequate focus on preventative maintenance before accidentsoccurred," Holmstrom said. The investigation found that BP's executives reliedunduly on injury statistics in assessing the safety of their facilities.

7


8/12

He added, "BP managers and executives attempted to make improvementsfrom 2002 to 2005 but they were largely focused on personal safety such asslips, trips, falls, and vehicle accidents rather than on improving processsafety performance, which continued to deteriorate."

The report calls on API and the USW to develop a new consensus standarddefining performance indicators for process safety. The consensus processshould draw on representatives from industry, labor, government, publicinterest, and environmental organizations.

Later in 2004, a safety culture survey of the refinery was conducted andendorsed by the site leadership. The study, known as the Telos report, pointedto "an exceptional degree of fear of catastrophic incidents" among otherconclusions, and it stated respondents' belief that "production and budgetcompliance gets ... rewarded before anything else." Finally, a safety businessplan for 2005 cited as a "key risk" the possibility that "Texas City kills someone

in the next 12 to 18 months."

"The investigation found that BP executives made spending cuts withoutassessing the safety impact of those decisions," Holmstrom said.

The report recommends that OSHA amend its Process Safety Managementstandard to require companies to perform a management-of-change safetyreview on organizational changes including mergers, acquisitions,reorganizations, personnel changes, policy changes and budget reductions.The CSB report cited previous good-practice guidance from the AmericanChemistry Council, then known as the Chemical Manufacturers Association,calling for such safety reviews. The report also included a new recommendationto the Center for Chemical Process Safety to develop guidelines for how toconduct the organizational management-of-change reviews envisioned in therecommendation to OSHA.

OSHA Should Increase Petrochemical Inspections, EnforcementAs part of its investigation, the CSB looked at the role of OSHA in inspectingand enforcing safety regulations at refineries and chemical plants. Although therefinery had experienced numerous fatal incidents from 1985 to 2005, theinvestigation found that OSHA conducted only one planned PSM inspection at

the Texas City Refinery, in 1998. Other, unplanned OSHA inspections of theTexas City Refinery occurred in response to accidents, complaints, or referrals;the report said that unplanned inspections are typically narrower in scope andshorter than planned inspections. Proposed OSHA fines during the 20 yearspreceding the March 2005 disaster a period when ten fatalities occurred at therefinery totaled $270,255; net fines collected after negotiations totaled$77,860. Following the March 2005 explosion, OSHA issued the largest penaltyin its history to BP, over $21 million for more than 300 egregious and willfulviolations.

"OSHA's national focus on inspecting facilities with high injury rates, while

important, has resulted in reduced attention to preventing less frequent, butcatastrophic, process safety incidents such as the one at Texas City," the report

8


9/12

reads. The report found that when the PSM standard was created, OSHA hadenvisioned a highly technical, complex, and lengthy inspection process forregulated facilities, called a Program Quality Verification or PQV inspection. Theinspections would take weeks or months at each facility and would beconducted by a select, well-trained, and experienced team.

The CSB investigation found that few PQV inspections were done between1995 and 2005. Federal OSHA conducted only nine such inspections in thetargeted industries over that ten-year period, and none in the refining sector.State agencies in the 26 states that operate their own workplace safetyprograms conducted a total of 48 PQV inspections, including six at refineries.However, a number of states including Texas, Louisiana and New Jersey,where much of the U.S. oil and chemical industry is concentrated rely uponfederal OSHA to enforce workplace safety rules.

"On average from 1995 to 2005, only 0.2 percent of the approximately 2,816

facilities in targeted, high-hazard industries received a planned OSHA processsafety inspection each year. That's about one planned inspection per 500facilities," Holmstrom said.

The total number of U.S. facilities covered under the PSM standard is notknown, since covered facilities are not required to identify themselves to thegovernment; however, a similar regulatory program administered by theEnvironmental Protection Agency covers an estimated 15,000 sites.

The report noted that California's Contra Costa County, which has its ownindustrial safety ordinance, inspects each covered facility every three years. Acounty staff of five engineers performs an average of 16 inspections per year.The U.K. Health and Safety Executive, which oversees a much smaller oil andchemical industry than do U.S. authorities, has 105 inspectors for high-hazardfacilities; each covered facility in the U.K. is inspected every five years.Although OSHA did not provide requested information to the CSB investigation,available evidence indicates that OSHA has an insufficient number of qualifiedinspectors to enforce the PSM standard at oil and chemical facilities.

The report calls on OSHA to "identify those facilities at the greatest risk of acatastrophic accident" and then to "conduct comprehensive inspections" at

those facilities. The report also recommends that OSHA hire or develop new,specialized inspectors and expand the PSM training curriculum at its NationalTraining Institute.

"Rules already on the books would likely have prevented the tragedy in TexasCity," chairman Merritt said. "But if a company is not following those rules, year-in and year-out, it is ultimately the responsibility of the federal government toenforce good safety practices before more lives are lost. OSHA should obtainand dedicate whatever resources are necessary for inspecting and enforcingsafety rules at oil and chemical plants. These facilities simply have too manypotentially catastrophic hazards to be overlooked."

9


10/12

The CSB is an independent federal agency charged with investigating industrialchemical accidents. The agency's board members are appointed by thepresident and confirmed by the Senate. CSB investigations look into all aspectsof chemical accidents, including physical causes such as equipment failure aswell as inadequacies in regulations, industry standards, and safety

management systems.

The board does not issue citations or fines but does make safetyrecommendations to plants, industry organizations, labor groups, and regulatoryagencies such as OSHA and EPA. Please visit our website, www.csb.gov.

For more information, please contact a member of the CSB public affairs office:1) Daniel Horowitz, 202-441-6074 cell; 2) Sandy Gilmour 202-251-5496 cell; 3)Jennifer Jones 202-577-8448 cell; 4) Hillary Cohen 202-446-8094 cell; or 5)Kate Baumann 202-725-2204 cell.

A Chronology of the CSB Investigation

March 24, 2005 - CSB investigators arrive at the BP Texas City refinery

March 26, 2005 - The CSB team points out the hazard of placing trailers soclose to operating refinery units

April 1, 2005 - CSB investigators make initial entry into the damaged ISOM unitand identify the atmospheric blowdown drum as the likely source of the release

April 28, 2005 - CSB investigators say diminished outflow from an ISOM unitdistillation tower resulted in overpressurization and flooding and led to theflammable release during startup

June 28, 2005 - CSB Lead Investigator Don Holmstrom announces that areview of computer records shows that two alarms and a level transmitter,which could have warned operators of the flooded condition of ISOM unitequipment, failed to operate properly in the hours leading to the explosion

July 28, 2005 - The Texas City refinery experiences a serious hydrogen fire inthe Resid Hydrotreater Unit that causes $30 million in property damage andforces residents to take shelter

August 10, 2005 - Another incident related to mechanical integrity in therefinery's Gas Oil Hydrotreater forces another community shelter-in-place alert

August 17, 2005 - The Chemical Safety Board issues its first-ever urgent safetyrecommendation, calling on BP to convene an independent panel to assesssafety culture and oversight at all five of its North American refineries

October 24, 2005 - BP announces formation of the 11-member panel of experts,chaired by former U.S. Secretary of State James A. Baker III

10


11/12

October 25, 2005 - The Chemical Safety Board issues new urgent safetyrecommendations calling on the American Petroleum Institute to develop newsafety guidance for the placement of trailers away from hazardous processareas

October 27, 2005 - In preliminary findings released at a public meeting in TexasCity, CSB investigators describe a history of abnormal startups in the ISOMunit, previous vapor releases, and mechanical failures; they refer to the unit'sblowdown system as "outdated and unsafe"

November 10, 2005 - CSB Chairman Merritt testifies before the newlyestablished Baker panel, notes the role of worker fatigue and operatordownsizing in the accident

December 22, 2005 -The CSB releases a narrated computer animation of theevents leading to the accident; the video is viewed in refineries and chemical

plants worldwide

June 30, 2006 - The CSB releases blast damage information for 44 trailerslocated near the ISOM unit; notes serious damage to a distance of almost 600feet from the center of the explosions

October 15, 2006 - The CSB issues a safety bulletin based on the July 28,2005, hydrogen fire, calling for expanded use of positive material verification toprevent accidental releases

October 30, 2006 - CSB Chairman Merritt releases new preliminary findingsfrom the investigation, pointing to the role of organizational factors and cost-cutting in setting the stage for the accident

October 31, 2006 - The CSB issues new safety recommendations, calling onthe U.S. oil industry to eliminate the use of unsafe blowdown drums similar tothe one involved in the Texas City accident and calling on OSHA to establish arefinery special emphasis program to promote the replacement of the drumswith safer alternatives

January 16, 2007 - The independent refinery safety panel chaired by Secretary

Baker issues its final report at a news conference in Houston, revealingsystemic safety problems in BP's North American refineries

March 20, 2007 - At a public meeting in Texas City, the CSB releases its finalinvestigation report and recommendations, three days prior to the secondanniversary of the explosion

11


12/12

Taxa de freqncia (F): o nmero de acidentes ou acidentados (com e sem leso) por milhode horas-homem de exposio ao risco, em determinado perodo. calculada pela frmula:

F = N x 1.000.000H

Onde: N = nmero de acidentadosH = homens-hora de exposio ao risco1.000.000 = um milho de horas de exposio ao risco.

Taxa de gravidade (G): o tempo computado por milho de horas-homem de exposio aorisco. Deve ser expressa em nmeros inteiros e calculadas pela frmula:

G = T x 1.000.000H

Onde: T = tempo computado (dias perdidos + dias debitados);H = homens-hora de exposio ao risco;1.000.000 = um milho de horas de exposio ao risco

12

safety board says major deficiencies caused bp disaster

Documents