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• Safety management at the BP Grangemouth Complex - findings

Health, safety and environmental management at the BP Grangemouth Complex

Safety management at the BP Grangemouth Complex - Finding

The key findings of the Competent Authority in relation to health, safety and environmental management at Grangemouth resulting from the incident specific investigations and the site wide safety culture and human factors investigation are given below.

BP group policies

BP group policies set high expectations but these were not consistently achieved because of organisational and cultural reasons at the Complex:

• BP group policies (Getting HSE Right (GHSER); Getting Maintenance and Reliability Right and the Major Accident Prevention Policy) set high standards and follow the principles of the HSE POPMAR model for successful health and safety management, and are capable of delivering compliance with the law and the company stated aims of “no accidents, no harm to people and no damage to the environment”;
• The management structure based on separate business streams acting in a loose federation remained substantially in place until April 2000, despite the changes implemented by the new Complex Director from November 1999.  The historical structure did not enable consistent leadership and a strong site safety strategy to be set and consistently achieve high standards across the Complex;
• The three incidents would not have occurred if BP’s high standards and policies and procedures been followed consistently across the Complex. 

BP Group & Complex Management

BP Group & Complex Management did not detect and intervene early enough on deteriorating performance:

• Prior to the appointment of the new Complex Director and Health, Safety and Environmental Manager in October 1999 significant weaknesses existed in recognition of and acceptance of the safety and reliability performance with major accident hazard implications. A series of major initiatives had been instigated by BP in November 1999 to address this. However these did not have sufficient time to fully effect a significant improvement in culture and performance in the 6 months leading up to the series of incidents;
• Inadequate performance measurement and audit systems, poor root cause analysis of incidents, and incorrect assumptions about performance based on lost time accident frequencies (DAFWCF – days away from work case frequencies) and a lack of key performance indicators for loss of containment incidents meant that the company did not adequately measure the major accident hazard potential. Since the incidents BP have worked in conjunction with the wider chemical industry and with the HSE to develop new Key Performance Indicators for process safety.

COMAH and Pressure Systems process safety regime

BP failed to achieve the operational control and maintenance of process and systems required by law:

• Insufficient management attention and resources was given to maintaining and improving technical standards for process operations and enforcing adherence to standards, codes of practice, good engineering practice, company procedures and the HSE guidance;
• Maintenance of containment and integrity of high hazard plant was inadequate at the FCCU and in the MP steam main incidents;
• Process safety review used elsewhere in BP for major accident hazard installations review (to analyse installation condition and ensure prevention of major incidents) was not used and no effective equivalent procedure was in place;
• Learnings from major chemical industry accident reports (Texaco and Associated Octel) were not adequately actioned.  On-site loss of containment incidents of relevance to the FCCU incident were not properly analysed and actioned. The BP approach to ROSOV fitment in the FCCU did not appear to be based on a robust ALARP case;
• The safety report for the Fluidised Catalytic Cracker Unit (FCCU) installation claimed a higher level of reliability and safety performance than was actually present and therefore claims and conclusions made in the safety report that “ hardware and software controls in place in the FCCU are adequate to prevent the occurrence of a major accident which could affect the general public, personnel working on-site or the environment” was unjustified (and probably partly unjustified even in 1997 when the statement was made). The safety report was not proactively used as a management standard for continued safe operation, nor used as an audit tool to verify the claims made for safe operation. It is acknowledged however that BP was actively trying to improve safety reports under the COMAH regime;
• Public speculation in the aftermath of the three incidents was that demanning may have been a cause. No evidence was found of this. Senior management asserted that maintenance spending and manning was well above par for the BP Group. However, demands on maintenance resource were high, largely due to the unreliability of the plant. Outsourcing of maintenance had increased lead times;
• BP did not apply the required degree of expertise to some key technical tasks and had no overall plan as to what resources of technically competent people were required to manage the major accident hazards effectively;
• Management of change, required in the COMAH Major Accident Prevention policy, was less than adequate in all three incidents. The BP Task Force audit identified initiative overload which caused a prioritisation problem for managers.

BP Task Force

The BP Task Force findings and recommendations properly addressed the way forward to ensure safe and reliable operations at BP Grangemouth, but will require sustained visible leadership and enhanced employee involvement over a period of years to continue to improve safety culture:

• The BP Task Force audit, set up after the incident, was thorough with independent oversight. The findings, if successfully implemented, should lead to the BP aim of a safe site with upper quartile performance in the petrochemicals industry and achieve full compliance with the law;
• The Competent Authority are tracking BP’s implementation of the action plan arising from the findings of the BP Task Force by means of a 5 year inspection plan as required by the COMAH Regulations.