This website uses non-intrusive cookies to improve your user experience. You can visit our cookie privacy page for more information.

Appendix 3 - BP Initiative and investigations
Study into Root Causes of Accidents

Background

Prior to the series of incidents that occurred in May-June 2000 BP had in place a number of systems for recording information relating to health, safety and environmental incidents.

The Total Loss Control (TLC) database is used within the Complex as the primary means of first raising and then subsequently tracking and recording all incidents (both near misses and those resulting in some form of loss) that occur on the Complex. The system has only been in general use since August 1999 with much of the historical data having been compiled from data previously stored in a number of different database systems.

In addition incidents that have resulted in a serious or major loss/injury are normally subjected to a formal inquiry resulting in the publication of an Incident Report which is reviewed by a Local or Factory Committee of Enquiry.  Both the immediate and root causes of the incident are reviewed and appropriate recommendations prepared to avoid any future repetition of the incident. Near miss and minor incidents do not normally require formal investigation but the facility exists when entering the information onto the TLC database to assign immediate and root causes to the incident. A number of pre-determined immediate and root causes are available for selection.

An assessment of both the actual and the potential severity of the incident are required.

Analysis of the recorded incident information is carried out in order to determine the root causes of the incident. This is done in accordance with the BP Comprehensive List of Causes (CLC) approach methodology.

Overall the system should allow data to be recorded and trends to be identified so that lessons can be learned and action taken to ensure that a repetition of incidents is avoided. A consistent approach to the recording and analysis of the incidents is required in order for the system to be effective in fulfilling these requirements. The selection of the immediate and root causes criteria is particularly important if trends are to be identified.

Investigation

Following the series of incidents that took place initial investigations by BP and the Competent Authority identified similar incidents that had occurred previously and several questions therefore arose. Whether the existing system for recording information relating to health, safety and environmental incidents was appropriate? Whether data was being captured/recorded in a consistent format? Whether suitable analysis was being carried out, lessons learned and actions being taken based on the information gathered that should prevent incidents from recurring ?

In response BP appointed independent consultants as part of a project to back-track through the existing data to determine whether there were any connections and common causes between the incidents and to independently review the effectiveness of the current systems for recording and analysing incidents.

In response a series of independent reports were prepared which looked at a number of different areas:

As a result of the independent review it was concluded that overall BP Grangemouth has an excellent tool in the TLC database – but not one without faults. A number of issues were identified for the TLC system in relation to data capture, recording and analysis and consequently recommendations were made to BP for improvements.

As a result of the review of the significant incident reports and the FCCU incidents a number of issues were identified in relation to the use and application of risk tools and the management of health, safety and the environment in general at the Complex.

Consequently recommendations were made to BP for areas requiring improvement.

2010-03-23