The U.S. Chemical Safety Board says the accident was caused by organizational and safety deficiencies at all levels of BP. The report calls for safety improvements. CSB chair Carolyn Merritt says energy companies need to pay attention to process safety, which focuses on the prevention of mishaps rather than personal safety issues like slips, trips and falls.
"Process safety programs to protect the lives of workers and the public deserve the same level of attention, investment and scrutiny as companies now dedicate to managing their financial records. The boards of directors of oil and chemical companies should examine every detail of their process safety program to ensure that another terrible tragedies like the one at BP never occurs again."
The CSB report also finds fault with the Occupational Safety and Health Administration, saying regulatory oversight of refinery workers needs to be improved. Don Holmstrom is lead investigator for the CSB report.
"The investigation found that OSHA conducted only one planned process safety management inspection at the Texas city refinery--in 1998--although the refinery experienced numerous fatal incidents from 1985 to 2005. OSHA's national focus is on inspecting facilities with high injury rates. While that is important, it has resulted in reduced attention to preventing less frequent, but catastrophic, process safety incidents such as the one at Texas City."
Holmstrom says cost-cutting, production pressures and insufficient investment caused a progressive deterioration of safety at the refinery. Holmstrom also puts some blame on fatigue.
"By March 23rd, operators had been working 12-hour shifts for 29 or more consecutive days. Fatigue causes cognitive fixation and impaired judgment and could lead operators to fix on one operational parameter to the exclusion of other indicators. The ability to solve complex problems diminishes."
The CSB recommends an additional appointment to the BP board with expertise in refining operations and process safety. Evaluate all process units and all instrumentation. And require that knowledgeable supervisors be present during hazardous operations such as unit start-ups. Merritt says the March 23rd, 2005 mishap was avoidable.
"In my view, it was the inevitable result of a series of actions by the company: among these things, they cut costs that affected maintenance and safety, they ignored the implications of previous incidents that were red warning flags. There was a broken safety culture at BP."
Ed Mayberry, Houston Public Radio News.