a 21st century safety solution based on an integral approach

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® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608

Rick Strycker, Director of Development, JMJ Associates

May 2007

A JMJ Response to the Baker Panel Report

A 21st Century Safety Solution Based on an Integral Approach

Executive Summary

The March 2005 explosion that occurred at BP’s Texas City refinery led to The Report of the BP U.S.

Refineries Independent Safety Review Panel (a.k.a. the Baker Panel Report or the Report) issued in January

20071. This report provides an analysis of and recommendations regarding this disaster as well as BP’s overall

corporate and site-level safety practices.

We strongly commend the important work of the Baker Panel, and sincerely hope it forwards the collective

mission to eliminate injury among workers worldwide; at the same time we suggest that the recommendations

therein, while valid, are limited. The recommendations should indeed be acted upon; however, not to the

exclusion of addressing other important safety perspectives as well.

In its 20 years of experience assisting companies to create Incident and Injury-Free® workplaces,

JMJ has found that an integral approach that addresses process safety, as described in The

Baker Panel Report, as well as the personal, cultural and system-wide aspects of safety is

required to create an environment that is sustainably incident and injury free.

The specific set of recommendations that JMJ offers to build on the Baker Panel’s recommendations include:

• Think integrally to promote more effective safety solutions. Design a safety program that

addresses both the people and process aspects that together impact safety performance and

apply safety engineering in a way that integrates all perspectives, as well.

• Commit to the elimination of all worker injury and then intentionally speak and interact in

ways that elevate the human spirit in service of this commitment. Experience has shown that

sustainable change begins when people take responsibility for what they want.

• Embrace the ongoing, adaptive nature of safety—it is a journey, not a destination. Its adaptive

nature requires that organizations continuously learn from their successes and mistakes. It

requires vigilance and the willingness to continually think anew by recognizing that many safety

situations do not have technical fixes.

1 Baker, Bowman, Erwin, et al. (2007). The Report of the BP U.S. Refineries Independent Safety Review Panel.



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Purpose The recent release of the Baker Panel Report creates an opportunity for expanding the practice of Incident and Injury-Free® (IIF®) safety worldwide.

While the findings of the Baker Panel focused specifically on the BP Texas City Refinery and BP’s other U.S. refineries, the implications of the Report are already reverberating beyond Texas City and throughout industry. We are concerned that a misinterpretation of the Report may obscure other important dimensions of safety that are underemphasized by the report writers. While acknowledging the significant contribution made by the Baker Panel, we believe it is important to expand the inquiry to include those underemphasized factors. Including these factors will lead to a more integral approach to safety— an approach we feel is essential for creating and sustaining an Incident and Injury-Free workplace.

The purpose of this paper is to build on the work of the Baker Report so that their work and the tragedy that spurred it can accelerate the movement toward all workplaces creating being Incident and Injury-Free results.

Context for the Baker Panel ReportBP’s Texas City Refinery in Texas City, Texas, is the second-largest oil refinery in the state and the third-largest in the United States. A major explosion occurred in an isomerization unit at the site on March 23, 2005, killing 15 people and injuring over 170 others.

Following two additional serious safety incidents during July and August of 2005, the U.S. Chemical Safety and Hazard Investigation Board (CSB) recommended that BP Global commission an independent panel to investigate the safety situation within BP North America’s refineries. The panel was lead by former U.S. Secretary of State James Baker III. The Baker Panel Report, as it is now widely called, was released on January 16, 2007.

The Baker Panel’s Findings and RecommendationsWorking within the commissioning guidelines given by the CSB and BP, the panel conducted an extensive assessment of the conditions at BP’s Texas City refinery, as well as other major U.S. refineries. The panel’s principal finding was that BP management had not distinguished between personal safety (i.e., slips-trips-and-falls, driving safety, etc.) and process safety (i.e., design for safety, hazard analysis, material verification, equipment maintenance, process upset reporting, etc.).

Specifically, the panel asserted that the metrics, incentives and management systems at BP focused on measuring and managing personal safety while ignoring process safety. In addition, BP had confused improving trends in occupational safety statistics for a general improvement in all types of safety. (See the Appendix to this paper for a summary of the Baker Panel’s findings and recommendations).

From the Baker Panel’s Report: The Panel has focused on process safety rather than personal safety. The Panel believes that its charter and the CSB’s August 2005 urgent recommendation require this focus.

In its request for an independent investigation, the CSB was particularly concerned about:

• The effectiveness of the safety management system at BP Texas City refinery,

• The effectiveness of BP North America’s corporate safety oversight of its refining facilities, and

• A corporate safety culture that may have tolerated serious and long standing deviations from good safety practice.

As directed, the Baker Panel addressed each of these areas of concern through the lens of process safety—in our view, a much narrower lens than was required or desirable. In addition, the panel addressed issues of leadership, culture and safety management but did so exclusively from the perspective of process safety.

Thus, the panel discusses process safety leadership, rather than safety leadership in general, and process safety culture, rather than safety culture in general. Although this process safety focus is warranted in the Texas City context, it is our opinion that it may inadvertently create an overly narrow lens for safety in general. In the remainder of this paper, we offer what we believe is a fuller, more comprehensive approach for those industries that have committed to Incident and Injury-Free performance.

Expanding the FocusThe distinction between personal (occupational) safety and process safety is important. However, the resulting focus on process safety alone leads the Baker Panel to underemphasize both personal safety and the implicit connections between personal and process safety. Later, we will point to other limitations, as well. The following quote clarifies this distinction and the rationale behind the report.



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Not all refining hazards are caused by the same factors or involve the same degree of potential damage. Personal or occupational safety hazards give rise to incidents—such as slips, falls, and vehicle accidents—that primarily affect one individual worker for each occurrence. Process safety hazards can give rise to major accidents involving the release of potentially dangerous materials, the release of energy (such as fires and explosions), or both. Process safety incidents can have catastrophic effects and can result in multiple injuries and fatalities, as well as substantial economic, property, and environmental damage. Process safety refinery incidents can affect workers inside the refinery and members of the public who reside nearby. Process safety in a refinery involves the prevention of leaks, spills, equipment malfunctions, over-pressures, excessive temperatures, corrosion, metal fatigue, and other similar conditions. Process safety programs focus on the design and engineering of facilities, hazard assessments, management of change, inspection, testing, and maintenance of equipment, effective alarms, effective process control, procedures, training of personnel, and human factors. The Texas City tragedy in March 2005 was a process safety accident.

The Panel has focused on process safety rather than personal safety. The Panel believes that its charter and the CSB’s August 2005 urgent recommendation require this focus.

In its report, the Baker Panel concludes that BP has: …emphasized personal safety in recent years and has achieved significant improvement in personal safety performance, but BP did not emphasize process safety. BP mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance at its U.S. refineries. BP’s reliance on this data, combined with an inadequate process safety understanding, created a false sense of confidence that BP was properly addressing process safety risks.

By placing attention on process safety, we commend the panel for its useful recommendations, which should be taken seriously and acted upon. From the perspective of JMJ’s consulting experience, however, these findings while addressing significant problems and failings in the Texas City operation, do not adequately address other important issues required to produce a breakthrough in safety performance and which may have also played a part in the accident. Following

is a list of areas of focus that are either missing from the Baker Panel Report or that need more emphasis:

• The exclusive focus on process safety as the context of the report misses a potentially more powerful context—the elimination of worker injury for both personal and process safety approaches.

• The Report’s exclusive process safety focus underemphasizes the role of personal responsibility, commitment and behavioral change in creating a safe workplace

• The report addresses safety culture but only in the context of process safety and therefore underestimates the importance of a strong safety culture that supports both personal and process safety.

• The Report collapses elements of safety into the process safety domain (i.e., human factors, design and engineering) that are best kept separate and held as components of the whole safety situation.

A JMJ Response It is our experience that safety, and in particular the creation of a sustainable Incident and Injury-Free workplace, is a complex adaptive problem that cannot be addressed with technical solutions. The overemphasis on process safety in the report, and the manner in which the issues are addressed there, does not sufficiently address the complexity of the whole safety situation.

Following are a few critical aspects—perspectives on safety performance—that we believe must be considered to complement the findings of the Baker Panel Report and ensure positive, sustainable safety outcomes.

• Think integrally to promote more effective solutions.

• Commit to the elimination of all worker injury and speak and interact in ways that elevate the human spirit in service of this commitment.

• Distinguish adaptive situations from technical fixes to open new opportunities for learning.



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Think integrally to promote holistic solutionsBased on JMJ’s experience in safety consulting, we have found that the Four Quadrants Model2 is the most useful tool for promoting integral thinking as it provides a way of explaining the complexity of life in a very simple and elegant framework. This model, which at first seems quite abstract, becomes quite practical when used to determine if we are thinking about all aspects of a problem, issue or challenge.

First, the abstract explanation. Each unit of reality can be described as being both a whole system in itself, and a part of a larger whole system, with interior and exterior aspects. Each unit also has individual and collective aspects. Observing reality from the outside constitutes an exterior perspective. Observing it from the inside is the interior perspective, and so forth. If you map these four perspectives into quadrants, you have the four dimensions of any unit of reality as seen in this Four Quadrants Model:

To give an example of how this works, consider four schools of social science. Freudian psychoanalysis, which interprets people’s interior experiences, is an account of the interior individual, or the upper-left quadrant of the Four Quadrants Model. Meanwhile, B. F. Skinner’s behaviorism, which limits itself to the observation of the behavior of organisms,is an exterior individual, or upper-right quadrant, matter.

Gadamer’s philosophical hermeneutics interprets the collective consciousness of a society, which makes it an interior collective, or lower-left quadrant, perspective. Finally, Marxist economic theory examines the external behavior of a society, which is a lower-right quadrant view. Together, all four pursuits—psychoanalysis, behaviorism, philosophical hermeneutics and Marxism—can offer complementary, rather than contradictory, perspectives. It is possible for each of these to be partially correct and necessary for a complete account of human experience. Each of these schools, taken separately, however, provides only a partial view of social science.

When the unit of reality we are discussing is a human system, or a human being, we can begin to fill in the quadrants with contents that correspond with the appropriate X and Y axes for that specific unit of reality. When we’re looking at people, for example, the upper-left quadrant includes feelings, personal values, commitments, attitudes, and so on. Many who use this model call this quadrant “intentions” which doesn’t do justice to all that might show up in that quadrant. The same is true for the remaining quadrants; we refer to the lower-left quadrant as “culture,” the upper-right as “behavior” and the lower-right as “systems” or “processes.” We use these terms as a shortcut, but we must always remember that this is a very compressed view of the reality that we are attempting to illustrate. The following Four Quadrants Model uses these shortcut terms.

Now for a practical use of the tool. Often, when we work with clients in safety, the first thing they notice when they are introduced to the Four Quadrants Model is that they have spent a disproportionate amount of time working on the right-hand (exterior) aspects of safety at the expense of the left-hand (interior) aspects. This is not unusual because we live in a society that tends to be obsessed with measurements, facts, objectives and goals—exterior, objective aspects. There is nothing wrong with this, unless it causes us to neglect other things that also are important to us. To balance the overemphasis on the right-hand aspects of safety, we often hold conversations about left-hand, interior aspects, which typically provide insights into values-based solutions to safety issues, like the value of human life, treating people with dignity and respect, and the desire to stay safe because of the love and care one has for family.

2 Adapted from Wilber, Ken (2001). A Theory of Everything. (Shambala: Boston)



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Integrating Personal and Process SafetyWe also gain insights into safety by examining the two upper quadrants of the Four Quadrants Model, those about the individual, as compared to the collective aspects found within the lower two quadrants. For example, if we accept the distinctions of the Baker Panel, we could say that personal safety encompasses the upper, or individual, quadrants (both interior and exterior), and process safety encompasses the lower, or collective, quadrants (both interior and exterior). To be technically accurate, we might say the lower quadrants are referring to the organizational aspects of safety as compared to the personal aspects of safety in the upper quadrants.

Following the Baker Panel, we would draw thedistinction as follows:

PRO

CESS

SAF

ETY

PERS

ONA

L SA

FETY

Thus, taken together, personal and process safety form a more complete safety picture. Let us now consider the left- and right-side integration, the subjective (interior) and objective (exterior) aspects of safety, as well.

The Subjective and Objective Aspects of SafetyIn our safety practice, when we speak about personal safety, for example, we distinguish both the importance of the value for safety (interior or subjective—left-hand side) and the actions required to demonstrate commitment to safety (exterior or objective—right-hand side). The combined left-hand and right-hand perspective is useful in helping people understand the importance of the subjective side to safety when they want to create an Incident and Injury-Free (IIF) workplace. It is useful because they see that IIF begins with commitments, values and beliefs (left-hand) and then moves into action (right-hand)3. Although the model separates these qualities, it is better to think about them as two sides of a coin, or the front and back of the

hand. The subjective and objective aspects of work, for example, are often occurring in the same time and space. In safety, we would be looking for values expressed in action, or attitudes reflected in behavior. In the lower quadrants, we look for the links between shared values and systems, or culture and processes.

GRO

UP A

LIG

NMEN

TIN

DIVI

DUAL

ALI

GNM

ENT

The Function of AlignmentIf we now return our attention to the upper and lower quadrants, the domains of personal and process safety, we can get an even clearer picture of the interconnections. The following chart illustrates possible relationships between the two subjective (left-hand) quadrants and the two objective (right-hand) quadrants. Notice how the upper quadrants are a function of the lower quadrants, and vice versa. The process of bringing these individual and collective aspects together is called “alignment.” On the left-hand side is an interior type of alignment having to do mostly with values; on the right-hand side is an exterior type of alignment having to do with observable behavior or performance.

SAFE

TY V

ALUE

S AL

IGNM

ENT

SAFETY PERFORM

ANCE ALIGNM

ENT

3 Some might argue that the change process begins with behavior and then results in commitment. Although this is a valid and rational argument, it has a fatal weakness in our view. It removes choice and responsiblity from people, and thus diminishes crucial aspects of that which makes us human.



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Let us consider an example of what an alignment or misalignment on the left-hand side would look like in the domain of values. To illustrate: A worker attends a Commitment Workshop where he takes a stand for the elimination of worker injury at the job site. Upon returning to work, he encounters deep collective resistance to his stand because of deeply held assumptions about safety—assumptions that make it a cultural norm to accept accidents as “inevitable.” It will be quite difficult for him to maintain his commitment without other kinds of support.

On the right-hand side of the Four Quadrants Model a relationship exists between individual behavior and collective systems. For example, a recognition and reward system will positively influence individual performance if and only if the system is designed properly. Otherwise, a negative relationship could be formed—one that drives individual behavior that is inconsistent with organizational safety goals.

Thus, alignment between the upper and lower quadrants is essential for people, processes and systems to be aligned, and for these alignments to have both interior as well as an exterior dimensions. There are countless ways to illustrate these connections and interrelationships between personal and collective safety.

Design and Engineering in an IIF ContextIn the Baker Panel report, process safety includes: “design and engineering of facilities, hazard assessments, management of change, inspection, testing, maintenance of equipment, effective alarms, effective process control, procedures, training of personnel, and human factors.” From the perspective of an integral approach, the net of process safety used by the Baker Panel has been stretched beyond its usefulness. We have demonstrated how the use of the integral approach reveals the complementary relationship between personal and process safety. Thus, from the perspective of the integral approach, it is better to separate these components into their appropriate quadrants. For example, human factors would be seen as an upper quadrant affair, and training for safety might have important aspects residing within each of the quadrants.

This is a step forward, but still more progress can be made by distinguishing “design and engineering” from the domain of process safety. Building upon and summarizing the work of James Reason4, three main approaches to safety management can be distinguished:

Personal Safety: Includes both behavior-based and commitment-based approaches, emphasizes individual unsafe acts and personal injury accidents, tends to view people as free agents who can choose to work safely, and more recently emphasizes the importance of personal responsibility.

Safety Engineering: Includes reliability engineering, ergonomics, risk assessment and management, and the view that human errors are not only the result of what happens inside a person’s head, but also are a function of the interface between the human entity (the upper quadrants) and engineering (the product of designers). This approach often focuses on people who work in high-risk jobs, such as controllers or key operators.

Organizational Safety: Includes the systems approach that views errors more as a consequence than as a cause. Errors reveal the latent condition within the system at large, which, if triggered, result in large system malfunction. This approach is akin to Total Quality Management and is similar to the engineering approach.

Although these approaches have been seen as competing or contradictory, they now can be viewed as partial, but true versions of the whole safety situation. Additionally, the safety engineering approach can be seen as a way to bridge the other two approaches. As an integrating function, engineering can be re-imagined to include the perspectives of all quadrants in service of an IIF workplace. This “engineering for integration” function can be drawn as follows:

PRO

CESS

SAF

ETY

PERS

ONA

L SA

FETY

4 Reason, James T., (1999) Managing the Risks of Organizational Accidents (Aldershot, Hants, England: Brookfield, Vt. USA: Ashgate)



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Safety CultureThus far, the personal and process aspects of safety have been discussed, as well as the potential role of safety engineering as an integrating function. However, the importance of the lower-left quadrant, labeled culture for short, has not yet been made clear.

It is worth noting here that while the Baker Panel Report emphasizes the need for a process safety culture, JMJ emphasizes the importance of culture within an integral safety approach. Reason5 writes that:

…the safety culture of an organization is the product of individual and group values, attitudes, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety programmes. Organizations with a positive safety culture are characterized by communications founded on mutual trust, shared perceptions of the importance of safety, and confidence in the efficacy of preventive measures.

Note in Reason’s quote the links among the quadrants; while culture is distinguished in the lower-left quadrant, it has deep connections with the other quadrants, as well.

We can see how culture is a powerful influence over individual beliefs and behavior, and at the same time is itself changed through the influences of strong leadership. Edgar Schein6, who has written extensively on culture and leadership, says:

…culture and leadership are two sides of the same coin in that leaders first create cultures when they create groups and organizations. Once cultures exist, they determine the criteria for leadership and thus determine who will or will not be a leader.”

From an integral perspective, JMJ strongly recommends that organizations or projects that wish to create and sustain a workplace from which people go home safe incorporate both personal and process safety into their approach and also do the work to link them together in a holistic and comprehensive system. Such an approach would necessarily include an analysis of the links between individual and collective values, culture and behavior, leadership and culture, design and engineering, the safety management system and individual safety performance, to name a few. We believe that the future of safety will require a more comprehensive perspective. Beginning on page 18, Appendix II illustrates a thorough comparison between a partial solution to safety and a holistic or integral solution.

Commit to eliminating all worker injuryWe assert that there are more powerful commitments that could have been evoked by this inquiry. In our work with clients, we have discovered that the most powerful and satisfying commitment people can make in regard to safety is to the total elimination of workplace incidents and injuries. This is not an easy commitment for people, and sometimes it takes great courage to make it.

From this powerful commitment, one would look integrally to discover: what is missing, what will be our future goals, and what is the appropriate path to achieve them? In this case, we assert that from a stand for Incident and Injury-Free we naturally embrace both personal and process approaches to safety, including their interior and exterior aspects.

From an IIF context we take a holistic approach to keep one another safe as we are determined to use all means available, including how we speak to and interact with one another.

While it may seem like a minor point, from our many years of experience working with the personal aspects of safety and the Four Quadrants Model we know that there is a more powerful way to speak about safety that powerfully and explicitly includes the human dimension.

We constantly notice the propensity among our clients, other consulting companies, and even ourselves, to allow the seduction of language to shrink the human dimension from life and work. This objectification of life through language becomes ever more apparent when reviewing work from the integral perspective offered by applying the Four Quadrants Model.

In an apparent desire to be objective, the Baker Panel unwittingly constructs a world devoid of interiority. This style of writing tends to miss the point that human beings (with their intentions, values and commitments) are involved in every aspect of the process, from design through implementation and continuous improvement. The language of the Report not only separates the realm of the personal from the realm of process safety, it disconnects the role of people in keeping processes relevant and useful.

From our perspective, there is a danger when people begin to trust exclusively in an impersonal safety process to keep them safe. It is when people care deeply about themselves, their families, others at work, and their organizations, and act upon that care and concern, that they create and sustain a workplace that tends to be more safe than not. This is commitment in action.

5 Reason, James T., (1999) Managing the Risks of Organizational Accidents (Aldershot, Hants, England: Brookfield, Vt. USA: Ashgate)6 Schein, Edgar (1985): Organizational Culture and Leadership (San Francisco: Jossey-Bass)



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It is from care and authentic commitment that people choose to create and improve the processes and systems that are put in place to serve them. Processes and systems do notstand alone..

Adaptive situations vs. technical fixesFollowing the work of Ron Heifetz7, Professor of Leadership at the John F. Kennedy School of Government at Harvard University, we make the distinction between adaptive and technical situations as a key characteristic of our consulting approach and our point of view regarding leadership. Said simply, adaptive situations are those for which we do not yet have the solutions. Thus, they are in the domain of either what we don’t know or what we don’t know we don’t know. Inquiry is a primary tool for resolving adaptive situations.

This perspective is missing in the Baker Panel’s Report, and this creates the perception that the recommendations offered by the report could be followed as a kind of technical fix. An example of a technical problem is requiring people to wear personal protective equipment (PPE) on the work site. An example of an adaptive situation is when workers know they should wear their PPE but they do not and there is no apparent explanation for this fact.

It is JMJ’s strong opinion, based on many years of experience in this domain, that creating an Incident and Injury-Free workplace is always an adaptive situation, one that requires a great deal of learning, inquiry and bold acts of courageous leadership. Within this larger adaptive situation, there are also many sub-domains where learning is required. We also have discovered that there are many technical solutions involved in the safety journey. Note, however, that there is always a danger of misidentifying adaptive situations and over-relying upon technical fixes.

Within the Baker Panel’s recommendations, we see a mix of technical and adaptive situations, and it is the goal of good leadership to sort out which is which.

ConclusionThe March 2005 Texas City Refinery explosion resulted inThe Baker Panel Report, a document whose recommendations have been widely spread across industry and are servingto reinvigorate the inquiry into how to further improveworkplace safety. The process safety recommendationsmade therein are sound and to be commended. In addition,we have offered a perspective that expands upon these findings and recommendations.

This document outlines our views, based on nearly 20 years of experience working in the safety industry, and illuminates a more integral perspective on safety—one that distinguishes the separate elements of the safety situation and then integrates them into a more comprehensive approach. At the same time, the approach outlined here continues to emphasize the human dimensions of safety. Throughout our history, we have worked to emphasize and dignify care and regard for people as the heart of our safety commitment. In addition, we also have forged new ground in the direction of how to create integral approaches to safe workplaces.

In the last decade, industry has made tremendous progress in safety by taking on the personal, human work required to create an Incident and Injury-Free workplace. Our recommendation is to continue to build on and learn from all that has gone before with both the people and process orientations to safety.

Specifically, we recommend:

• Think integrally to promote more effective safety solutions. Design a safety program that addresses both the people and process aspects that together impact safety performance and apply safety engineering in a way that integrates all perspectives, as well.

• Commit to the elimination of all worker injury and then intentionally speak and interact in ways that elevate the human spirit in service of this commitment. Experience has shown that sustainable change begins when people take responsibility for what they want.

• Embrace the ongoing, adaptive nature of safety—it is a journey, not a destination.

Its adaptive nature requires that organizations continuously learn from their successes and mistakes. It requires vigilance and the willingness to continually think anew by recognizing that many safety situations do not have technical fixes.

Appendix I: Baker Panel’s Key Findings

Corporate Safety Culture

Process safety leadershipThe Panel believes that leadership from the very top of the company is essential. The Panel believes that BP has not provided effective process safety leadership and has not adequately established process safety as a core value. While BP has an aspiration of “no accidents, no harm to people,” BP has not provided effective leadership in making certain its management and workforce understand what is expected

7 Heifetz, Ronald (1994). Leadership Without Easy Answers (The Belknap Press of Harvard University Press: Cambridge, Mass)



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of them regarding process safety performance. BP has emphasized personal safety in recent years and has achieved significant improvement in personal safety performance, but did not emphasize process safety. BP mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance at its refineries. BP’s reliance on this data, combined with an inadequate process safety understanding, created a false sense of confidence that BP was properly addressing process safety risks. The Panel found that process safety leadership appeared to have suffered as a result of high turnover of refinery plant managers.

Employee empowerment • A good process safety culture requires a positive,

trusting, and open environment with effective lines of communication between management and the workforce, including employee representatives.

• At Texas City, Toledo, and Whiting, BP has not established a positive, trusting, and open environment with effective lines of communication between management and the workforce.

Resources and positioning of process safety capabilities

• BP has not always ensured that it identified and provided the resources required for strong process safety performance.

• BP does not have a designated, high-ranking leader for process safety dedicated to its refining business.

• The Panel believes that the company did not always ensure that adequate resources were effectively allocated to support or sustain a high level of process safety performance.

• BP’s corporate management mandated numerous initiatives that applied to the refineries and that, while well-intentioned, have overloaded personnel at BP’s refineries.

• Operations and maintenance personnel sometimes work high rates of overtime, and this could impact their ability to perform their jobs safely and increases process safety risk.

Incorporation of process safety intomanagement decision-making

• BP tended to have a short-term focus, and its decentralised management system and entrepreneurial culture have delegated substantial discretion to plant managers without clearly defining process safety expectations, responsibilities, or accountabilities.

• BP has not demonstrated that it has effectively held executive management, line managers and supervisors accountable for process safety performance.

• Process safety cultures at BP’s U.S. refineries.

• BP has not instilled a common, unifying process safety culture in its refineries. Significant process safety culture issues exist.

• The Panel found instances of a lack of operating discipline, toleration of serious deviations from safe operating practices, and apparent complacency toward serious process safety risks.

Process Safety Management Systems Process risk assessment and analysis

• While all of BP’s refineries have active programs to analyze process hazards, the system as a whole does not ensure adequate identification and rigorous analysis of those hazards.

• Examination indicates that the extent and recurring nature of this deficiency is not isolated, but systemic.

• Compliance with internal process safety standards.

• The consultants and Panel observed that BP does have internal standards/programs for managing process risks.

• Examination found that BP’s corporate safety management system does not ensure timely compliance with internal process safety standards and programs.

• Implementation of external good engineering practices.

• The Panel found that BP’s corporate safety management system does not ensure timely implementation of external good engineering practices that support and could improve process safety performance.

Process safety knowledge and competence• Many members of BP’s technical and process safety staff

have the capabilities and expertise needed to support a sophisticated process safety effort.

• The Panel believes that BP’s system for ensuring an appropriate level of process safety awareness, knowledge, and competence relating to its refineries has not been effective in a number of respects.



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• BP has not effectively defined the level of process safety knowledge or competency required of executive management, line management above the refinery level, and refinery managers.

• BP has not adequately ensured that its refinery personnel and contractors have sufficient process safety knowledge and competence.

• The Panel’s reviewed indicated that process safety education and training needs to be more rigorous, comprehensive, and integrated.

• The implementation of, and over-reliance on, BP’s computer based training contributes to inadequate process safety training of refinery employees.

Effectiveness of BP’s corporate process safety management system

• BP has an aspiration and expectation of “no accidents, no harm to people, and no damage to the environment,” and is developing programs and practices aimed at addressing process risks.

• BP’s corporate process safety management system does not effectively translate corporate expectations into measurable criteria for management of process risk or define the appropriate role of qualitative and quantitative risk management criteria.

• BP appears to have established a relatively effective personal safety management system by embedding personal safety aspirations and expectations within the refining workforce.

• BP has not effectively implemented its corporate-level aspirational guidelines and expectations relating to process risk. The Panel found that BP has not implemented an integrated, comprehensive, and effective process safety management system for its refineries.

Panel observations relating to process safety management practicesThe Panel observed several positive notable practices or, in the case of BP’s process safety minimum expectation program, an excellent process safety management practice. The notable practices relate to creation of an engineering authority at each refinery and several other refinery-specific.

Performance Evaluation, Corrective Action, and Corporate Oversight

• Significant deficiencies existed in BP’s site and corporate systems for measuring process safety performance, investigating incidents and near misses, auditing system performance, addressing previously identified process safety-related action items, and ensuring sufficient management and board oversight.

• Many of the process safety deficiencies are not new but were identifiable to BP based upon lessons from previous process safety incidents, including process incidents that occurred at BP’s facility in Grangemouth, Scotland in 2000.

Measuring process safety performance• BP primarily used injury rates to measure process safety performance at its refineries. BP’s reliance on injury rates significantly hindered its perception of process risk.

• BP tracked some metrics relevant to process safety at its refineries; however, BP did not understand or accept what this data indicated about the risk of a major accident or the overall performance of its process safety management systems. As a result, BP’s corporate safety management system for its refineries does not effectively measure and monitor process safety performance.

Incident and near miss investigations• BP acknowledges the importance of incident and near miss investigations.



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• BP has not instituted effective root cause analysis procedures to identify systemic causal factors that may contribute to future accidents.

• BP has an incomplete picture of process safety because BP’s process safety management system likely results in under reporting of incidents and near misses.

Process safety audits.• BP has not implemented an effective process safety audit system for its refineries

• The Panel was concerned that the principal focus of audits was on compliance and verifying that required management systems were in place to satisfy legal requirements.

Timely correction of identified process safety deficiencies.

• BP expends significant efforts to identify deficiencies and to correct many identified deficiencies, which BP often does promptly.

• BP has sometimes failed to address promptly and track to completion process safety deficiencies identified during hazard assessments, audits, inspections, and incident investigations.

• The review found repeat audit findings suggesting that true root causes were not being identified & corrected.

• BP does not take full advantage of opportunities to improve process operations and systems.

• BP does not effectively use the results of its operating experiences, process hazard analyses, audits, near misses, or accident investigations to improve process operations and systems.

Corporate oversight• BP acknowledges the importance of ensuring that the company-wide safety management system functions as intended.

• The company’s system for assuring process safety performance uses a bottom-up reporting system that originates with each business unit. As information is reported up, data is aggregated. By the time information is formally reported at the Refining and Marketing segment level refinery-specific performance data is no longer presented separately.

• The Panel found that neither BP’s executive management nor its refining line management has ensured the implementation of an integrated, comprehensive, and effective process safety management system.

• BP’s Board of Directors has been monitoring process safety performance of operations based on information that corporate management presented to it.

• A substantial gulf appears to have existed between the actual performance of BP’s process safety management systems and the company’s perception of that performance.



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The Baker Panel’s Recommendations

1. Process Safety Leadership The Board of Directors, executive and corporate management must provide effective leadership on and establish appropriate goals for process safety.

They must demonstrate their commitment to process safety by articulating a clear message on the importance of process safety and matching that message both with the policies they adopt and the actions they take.

2. Integrated and Comprehensive Process Safety Management System

BP should establish and implement an integrated and comprehensive process safety management system that systematically and continuously identifies, reduces, and manages process safety risks at its refineries.

3. Process Safety Knowledge and Expertise BP should develop and implement a system to ensure that its executive management, its line management, all refining personnel, and contractors, possess an appropriate level of process safety knowledge and expertise.

4. Process Safety Culture BP should involve the relevant stakeholders to develop a positive, trusting, and open process safety culture.

5. Clearly Defined Expectations and Accountability for Process Safety BP should clearly define expectations and strengthen accountability for process safety performance at all levels in executive management and in the managerial and

supervisory reporting line.

6. Support for Line Management BP should provide more effective and better coordinated process safety support for the line organization.

7. Leading and Lagging Performance Indicators for Process Safety BP should develop, implement, maintain, and periodically update an integrated set of leading and lagging performance indicators for more effectively monitoring the process safety performance.

BP should work with a wide range of organizations to develop a consensus set of indicators for process safety performance for use in the refining and chemical processing industries.

8. Process Safety Auditing BP should establish and implement an effective system to audit process safety performance at its refineries.

9. Board Monitoring BP’s Board should monitor the implementation of the recommendations of the Panel and the ongoing process safety performance of BP’s refineries.

The Board should, for a period of at least 5 years, engage an independent monitor to report on BP’s progress, and should also report publicly on the progress and on BP’s ongoing process safety performance.

10. Industry Leader BP should use the lessons learned to transform the company into a recognized industry leader in process safety management.

a 21st century safety solution based on an integral approach

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