March 23, 2023 | Mark Paradies

Failure to Learn Costs 11 Lives – How Many More Will Die?

Lessons Learned NOT

BP Texas City Blast Kills 15

On March 23, 2005 (eighteen years ago), a blast shook the BP Texas City Refinery and killed 15 people. There were major accident investigations by OSHA, the EPA, the CSB, and BP. There were many court cases, and by June of 2007, the whole refining chain of command, from the Refinery General Manager to the CEO, were fired or left their jobs.

In June 2007, Tony Hayward became the new CEO.

He said that BP shines when it comes to finding oil and gas or amassing an impressive portfolio of energy assets. In a video produced by the BBC (no longer available online) about Hayward’s leadership, the CEO was praised for his commitment to “no dry holes” when BP drilled for oil. This was making the company more efficient and would be good for profits and shareholders.

Also, Tony Hayward said he was committed to improving BP’s safety and safety culture in a July 15th interview with the Houston Chronicle. The article quotes Hayward as saying that BP:

“… has learned from its mistakes and has embraced an extensive report
from an investigative panel headed by former Secretary of State James
Baker III as a road map for righting safety wrongs at U.S. refineries.”

This was just six weeks into his tenure as CEO.

The article quoted him as saying:

“You earn your reputation through performance, through being
clear about what you’re going to do and then doing it.”

Then, the article became prophetic:

Investors and the Texas City community have heard such promises already.
Robert Kessler, an analyst with Simmons & Co. International, said he’s
watching for action, not words.

“The jury is still out in the BP story from an execution standpoint,” Kessler said.
“We just need to see good intentions translate into results for the company.”

CEO Hayward said improvement efforts could take up to five years. But the Baker panel’s report, which he called a “real gift for BP,” can guide the company in setting a new benchmark for industrial safety.

Five Years Later – Deepwater Horizon Accident Kills 11

Five years and a few days after the BP Texas City Explosion, BP had another tragedy – The BP Deepwater Horizon well blowout and explosion in the Gulf of Mexico.

The exploration side of BP had not learned the process safety lessons from the refinery accident.

This accident cost 11 lives and would eventually cost Tony Hayward his job as CEO.

There Has Never Been a Clearer Case of Failure to Learn Lessons

Lesson 1 – Cost-Cutting Impacts Safety

The Chemical Safety Board’s investigation found that cost-cutting by BP (and prior refinery owner Amoco) directly contributed to the blast at the Texas City refinery. Dan Horowitz, CSB spokesman, said:

“There was a clear linkage between budget cuts and inadequate
and the serious safety lapses in Texas City.”

But what did Tony Hayward have to say about the cost-cutting contributing to the accident:

“We spent a lot of time looking at that, and there is
no way you can say there is a direct correlation.”

I believe the CSB’s argument for cost-cutting being a cause was clear and direct. Let’s call that Lesson 1, which was not learned. Cost-cutting contributed to the Deepwater Horizon accident because the lesson about cost-cutting impacting safety was not learned.

Cost-cutting was part of why they were removing the drilling mud (under-balancing the well) when getting ready to take this rig away and bring in a cheaper rig to finish this well.

Cost-cutting was part of the hurry to complete the cement job.

Hurrying (cost-cutting) may have caused the operators to start testing the cement before it had completely cured (and contributed to the cement job failure).

Hurrying (cost-cutting) may have been why the personnel didn’t run a cement log, which could have detected a failed cement job.

And there are more examples of cost-cutting reducing the safety margin for this well. I won’t go through the examples here.

But that lesson, Lesson 1, isn’t just for BP. That lesson still hasn’t been learned by many CEOs.

Lesson 2 – Bad Human Factors Design Causes Human Errors

But Lesson 1 wasn’t the only failed lesson learned that contributed to the Deepwater Horizon accident.

In the Texas City Accident, the control panel for the unit was poorly designed (from a human factors perspective). Only a fraction (about 15 feet) of the total height of the column was shown on the display. Plus, when the range was exceeded, the indicated range seemed to decrease, indicating a lower level than the 15-foot mark.

On the Deepwater Horizon, I believe that the operator observing the pressure at the wellhead either didn’t have the pressure indicator set so that he could detect a kick or was so overwhelmed by his duties that he didn’t notice the subtle indications of the kick until it was too late. This, too, is a human factors issue. Although BP didn’t own the rig or the instrumentation, they were responsible for the actions taken (or not taken).

Many industries haven’t learned the importance of excellent human factors design to prevent accidents. This lesson is even more important when using digital controls and displays, and automation. (CLICK HERE for an explanation of why.) Thus, improved human factors need to be engineered into all high-risk systems.

Lesson 3 – Bad Procedures Can Cause Human Errors

Of the three procedures for the startup of the unit at the Texas City refinery, none were being used properly, and none could be used as written to start up the unit. In fact, for over a decade, these procedures were misused because they were not written so that the plant could be started up using the procedures.

The procedure Deepwater Horizon was trying to use to isolate the well did not have a clear process for testing the well seal. Thus, a pressure gauge that was plugged was selected to be used for the test rather than the normal pressure indication that seemed to indicate a failed test. (They chose the indication they liked rather than the one that was most conservative with an out-of-spec reading because the indicator to use was not specified.)

The lesson to have well-written, reviewed, accurate, and optimized procedures still hasn’t been learned. Many assume that industry procedures aren’t written clearly and accurately and probably can’t be. Thus, some believe that operators deviating from procedures and finding a “better way” to do the job is a natural (and perhaps desirable) way to perform work.

Lesson 4 – Inadequate Training Reduces the Safety Margin

The operator starting up the Texas City unit had never performed a startup before – not in real life and not on a simulator. Certainly, this is inadequate training.

The personnel on the Deepwater Horizon had never performed an abandonment of a well like they were performing before (according to Mike Williams). No special training was provided for the crew performing the work. And one of the Company Men (who worked for BP) had only been aboard the rig for 24 hours to fill in for the normal Company Man who was off for refresher training.

If the crew and BP Supervisors had been adequately trained, perhaps they would have been more cautious with their approach to the work and watched more closely for a kick.

How many other industries or companies have poorly trained personnel (supervisors and contractors) performing tasks for the first time with little or inadequate supervision? I think the answer is many.

Lesson 5 – Failure to Learn from Precursor Incidents Due to Poor RCA

The Baker Report about the Texas City refinery explosion pointed to the failure of BP to learn from precursor events due to poor root cause analysis.

The CSB report about the Deepwater Horizon accident pointed to similar failures.

Thus, even though Tony Hayward said that the Baker Report was a:

“…road map for righting safety wrongs…”

It doesn’t seem that BP learned that lesson across the company. And it seems that their contractor didn’t learn the lesson either.

And how many other companies have inadequate root cause analysis? Techniques like 5-Whys or Cause-and-Effect? Techniques that don’t get investigators beyond their current knowledge. I think the answer is far too many.

Time to Learn These Lessons

It’s been 18 years since the BP Texas City explosion. It’s been almost 13 years since the Deepwater Horizon accident. Isn’t time these lessons are learned?

If you need advanced root cause analysis, root cause analysis that:

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Attend one of our public root cause analysis courses. See the dates and locations of upcoming courses HERE.

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