May 21, 2007 | Mark Paradies

Monday Accident & Lessons Learned: Can BP Learn from Texas City and Alaska Pipeline Failures

In the “Continue reading …” section below is a Press Release from the CSB that says there are “striking similarities” between the root causes discovered by the CSB’s investigation of the BP’s Texas City Refinery Explosion and the causes of the pipeline leak at BP’s Prudhoe Bay oil field as outlined in a study by Booz Allen Hamilton.

With the considerable turnover among BP’s senior management ranks, it leaves one to wonder, can BP learn from these accidents, or will the senior management turnover just lead to a new culture without any real learning from the accidents?

Some may say that the disciplinary documents released recently point to a culture of blame – not a learning culture. If after a year and a half after the tragedy in Texas City, BP executives are still looking higher and higher in the corporation for people to blame, perhaps they haven’t learned that they need to put strict systems in place rather than relying on managements’ changing priorities to manage safety at highly hazardous workplaces.

You may consider this to be a harsh evaluation, but getting beyond blame and putting effective systems in place – systems that are supported by management – is the only way to stop the kind of unwise cost-cutting that lead to unsafe conditions at the BP Texas City Refinery and the BP Prudhoe Bay Oil Pipeline.

_ _ _ _ _

The following message is from the U.S. Chemical Safety Board, Washington DC.

CSB Chairman Carolyn Merritt Tells House Subcommittee of ‘Striking Similarities’ in Causes of BP Texas City Tragedy and Prudhoe Bay Pipeline Disaster

Washington, DC, May 16, 2007 – U.S. Chemical Safety Board (CSB) Chairman Carolyn W. Merritt today told members of a  U.S. House of Representatives subcommittee that she found ‘striking similarities’ between the causes of the fatal BP accident in Texas City, Texas, in 2005, and the company’s pipeline failure at Prudhoe Bay, Alaska, in 2006 which resulted in the leakage of more than 200,000 gallons of oil. The pipeline suffered extensive corrosion due to a lack of maintenance over several years.

While the CSB did not investigate the Prudhoe Bay accident, Chairman Merritt was asked by the House Committee on Energy and Commerce Subcommittee on Investigations and Oversight to review a BP internal audit of the accident completed by Booz Allen Hamilton.  Chairman Merritt told the subcommittee, ‘Virtually all of the seven root causes identified for the Prudhoe Bay incidents have strong echoes in Texas City.’  These included, she said, the ‘significant role of budget and production pressures in driving BP’s decision-making – and ultimately harming safety.’

The hearing, chaired by Rep. Bart Stupak (Michigan), was entitled ‘2006 Prudhoe Bay Shutdown: Will Recent Regulatory Changes and BP Management Reforms Prevent Future Failures?’  Other panel members included representatives from the Occupational Safety and Health Administration (OSHA), the Alaska Department of Natural Resources, and the pipeline and hazardous materials safety division of the U.S. Department of Transportation.  Featured on a second panel was Robert. A. Malone, Chairman and President of BP America, Inc.

Chairman Merritt told the committee of further comparisons of safety culture similarities at Texas City and Prudhoe Bay.  Both investigations, she said, found deficiencies in how BP managed the safety of process changes.  In Prudhoe Bay, Booz Allen Hamilton found ‘a normalization of deviance where risk levels gradually crept up due to evolving operating conditions.’  This compared, she said, to Texas City, where at BP’s refinery ‘Abnormal startups were not investigated and became routine, while critical equipment was allowed to decay. By the day of the accident, the distillation equipment had six key alarms, instruments and controls that were malfunctioning. Trailers had been moved into dangerous locations without appropriate safety reviews.’

Similarly, Ms. Merritt noted BP’s own internal audit findings concerning its Prudhoe Bay pipeline problems did not result in repairs or improved maintenance. Ms. Merritt quoted the company’s audit as saying the findings faced ‘long delays in implementation, administrative documentation of close-out even though remedial actions were not actually taken, or simple non-compliance.’

Other common findings at both Texas City and Prudhoe Bay included, the chairman said, ‘Flawed communication of lessons learned, excessive decentralization of safety functions, and high management turnover.  BP focused on personal safety statistics but allowed catastrophic process safety risks to grow.’

For more information, contact:

Sandy Gilmour 202-261-7614 or cell 202-251-5496, Public Affairs Specialist Kate Baumann 202-261-7612 or cell 202-725-2204, Public Affairs Specialist Jennifer Jones 202-261-3603 or cell 202-577-8448, or Director of Public Affairs Dr. Daniel Horowitz, 202-261-7613 or cell 202-441-6074.

Root Cause Analysis
Show Comments

Leave a Reply

Your email address will not be published. Required fields are marked *