The BP Group comprises many companies. Through these companies BP carry on business in many countries. The ultimate Group parent company is BP plc. BP plc has developed high level policies to ensure the health and safety of people and to protect the environment. Among the high level policies developed are those set out in the policy document Getting HSE Right (GHSER). Given the size of the BP Group, the range of activities carried on within the Group and the number of countries in which Group companies carry on business, the focus for ensuring that high standards of operation at the site level are achieved rests with those companies who are carrying on operations, rather than the Group parent company.
In February 2001 the HSE issued a "Summary of Findings and Recommendations report" to BP which contained the broad conclusions and recommendations resulting from the investigations carried out at the Complex. Because the incidents at BP Grangemouth had implications for other BP sites in the UK (Coryton, Bacton, and Hull etc) the "Summary of Findings and Recommendations report" therefore contained the following additional recommendations.
BP Group should ensure that relevant findings and conclusions which impact on Group level activities are addressed.
BP have reviewed the findings, recommendations and lessons from these incidents, and have implemented a number of improvements to Group level processes as outlined below.
BP should communicate findings and conclusions to the wider BP Group in the UK which will enable learning at other BP establishments.
BP have conducted a global and regional integrity management review following these incidents, paying particular attention to particular lessons arising from these incidents. Further work is underway to fully embed the wider organisational lessons from these incidents, for example in further improving the learning capability of the organisation. Shortly after the incidents, BP communicated initial findings to operating companies throughout the UK sites via the internal COMAH Liaison Group. The incidents and lessons are logged on the BP Reporting system accessible to all employees with a connection to the intranet. A workshop was held where the lessons learned from these specific incidents were disseminated across key contacts within the BP Group. This workshop also addressed the wider issue of improving lessons learned, systems and performance.
It was recommended that BP consider the period from the Hydro-Cracker Major Accident in 1987 in order to consider similarities between the accidents and establish if safety performance improved after this accident, when it deteriorated, and why the stated continuous improvement culture failed to fully materialise.
BP’s Task Force fully reviewed the incidents and why they happened, including review of past performance across the Complex. A significant number of actions were identified which have now been completed. The development of process safety Key Performance Indicators (KPIs) will help the site to monitor on-going process safety performance and prevent any future deterioration.
BP should review its Group safety assurance process as a key part of corporate governance. In particular BP should:
Develop performance measures for major accident hazards;
Review the targeting of audits to major hazards;
Review regulators letters and enforcement notices so that regulatory concerns and trends can be identified;
Introduce a review system for plant reliability so that the safety implications of unreliable plant can be identified at corporate level;
Analyse reports of process safety review findings at group level;
Review procedures for initiating "before the event" task force type audits where evidence exists of deteriorating performance which could lead to a major accident.
A wide variety of input and output measures are already employed to measure process safety performance. Plans are in place to report two new measures (one output and one input) at Group level for process safety/integrity management performance. BP have also implemented improvements to Group level audit protocols (to incorporate Process Safety more explicitly) in the annual assurance report process. Regulatory issues (including letters and enforcement notices) are a regular agenda item for COMAH Liaison Group Meetings. Linkages between plant reliability and safety are being addressed by a number of networks from operating companies. The Group’s Major Incidents Announcements (MIAs) have been analysed to identify common process safety themes. The Group also regularly shares information on incidents via the Quarterly Safety Bulletins (QSBs). BP operates a system of peer assists and peer reviews to proactively improve performance.
BP should review the corporate instructions to major hazard installation managers to identify when it is appropriate to consider shutting down or not restarting an installation. Consideration needs to be given to the COMAH Regulation 18 duty on the Competent Authority to prohibit use where serious deficiencies exist and this duty also needs to be brought to manager’s attention. Managers need to be aware of actions expected of them in the event of serious deficiencies occurring or being identified which have a major accident potential to people or the environment. The managerial and safety culture should enable and support managers in making this legally and financially difficult decision.
Since the incidents BP have developed a standard for Process Safety and Integrity Management. The annual Health, Safety and Environmental assurance process has been reviewed to provide additional assurance on satisfactory implementation of this standard in the business.
BP Group should consider the following Competent Authority findings in particular:
to achieve more widespread and consistent use of the existing root cause analysis system;
ROSOV fitment policy and ALARP "gross disproportion" test;
the role of safety reports;
resourcing of sufficient numbers of technically competent persons;
the role of Process Safety Management (PSM) Review;
strategy for reducing loss of containment incidents (including a pipework inspection and maintenance strategy) akin to the off-shore BP strategy for reducing hydrocarbon releases.
Root cause analysis is acknowledged as the correct approach to incident investigation within BP. BP has provided extensive and widespread training in these techniques over many years and continues to further develop its accident investigators with the introduction of new advanced "master classes". The new Process Safety/Integrity Management Standard requires that all facilities "shall eliminate/control/mitigate the hazards such that residual risks are as low as is reasonably practicable". The specific issue of fitment of ROSOVs is the subject of Draft Guidance from the HSE which BP is currently reviewing in conjunction with UK Trade Organisations. As part of restructuring processes BP companies formally examine the adequacy of manning levels. BP is also doing extensive work around Health, Safety and Environmental competencies and has also introduced a new Competency system. Companies in the Group have introduced a new Process Safety/Integrity Management Standard and new audit protocols have been developed. Guidelines for preparing safety reports were developed at Group level and best practice/shared experience is communicated via the COMAH Liaison Network. The new integrity management measures will provide a better focus for directing strategy towards reducing loss of containment incidents.