The CSB commends the BP Refineries Independent Safety Review Panel for its diligence in producing this comprehensive report on BP's safety management and culture, which was released today.
The panel, which BP formed in response to the CSB's urgent recommendation of August 2005, has completed its task in a thorough, independent, and credible manner, as it was chartered to do. We thank Secretary Baker for his leadership as well as the other ten distinguished panelists and the panel staff. We acknowledge BP for funding the panel and for its cooperation.
The Baker panel has given us an unprecedented insight into the safety culture of BP, one of the world's largest corporations, which experienced a catastrophic accident in Texas City in March 2005.
The report demonstrates that the "serious concerns" the CSB voiced in August 2005 about BP's safety practices - in the early phases of our accident investigation - were indeed justified.
There is no doubt that the issues of safety culture and safety management identified in this report are serious and warrant immediate action by BP, its executives, and its board of directors.
The panel's findings present a landmark opportunity for the boards of directors and executives of oil and chemical companies throughout the world to re-examine their own safety cultures and ask whether they are sufficiently investing in the people, procedures, and equipment that will make their workplaces safe from catastrophic accidents. This is an opportunity for review and reform on a worldwide scale.
Corporate leadership at the highest level is accountable for the safe operation of facilities that use hazardous chemicals. Safety culture is created at the top, and when it fails there, it fails workers far down the line. That is what happened at BP.
After we have had the opportunity to review the panel's report in detail over the next few weeks, we anticipate the Chemical Safety Board will vote on closing the August 2005 urgent recommendation to BP. When that occurs, we will make a further public announcement.
The CSB's final report on the root causes of the March 2005 explosion is in the final drafting stages and is currently planned to be released on March 20, 2007, at a public meeting in Texas City. It will propose recommendations at the national level to prevent similar tragedies in the future.
Background Information
The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in safety regulations, standards, and management systems. The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Please visit our website, www.CSB.gov.
For more information, contact Daniel Horowitz at (202) 441-6074 cell (Houston) or Sandy Gilmour at (202) 251-5496 cell (Houston). To arrange an interview with Chairman Merritt or CSB lead investigator Don Holmstrom, please contact Jennifer Jones in Washington, DC, at (202) 261-3603 or (202) 577-8448 cell.
A Chronology of the CSB's Investigation of the 2005 Texas City Accicdent
March 23, 2005 - An explosion during restarting of the ISOM unit at the BP Texas City refinery kills 15 workers in and around trailers and injures about 180 others
March 24, 2005 - CSB investigators arrive at the BP Texas City refinery
March 26, 2005 - The CSB team points out the hazard of placing trailers so close to operating refinery units
April 1, 2005 - CSB investigators make initial entry into the damaged ISOM unit and identify the atmospheric blowdown drum as the likely source of the release
April 28, 2005 - CSB investigators say diminished outflow from an ISOM unit distillation tower resulted in overpressurization and flooding and led to the flammable release during startup
June 28, 2005 - CSB lead investigator Don Holmstrom announces that a review of computer records shows that two alarms and a level transmitter, which could have warned operators of the flooded condition of ISOM unit equipment, failed to operate properly in the hours leading to the explosion
July 28, 2005 - The Texas City refinery experiences a serious hydrogen fire in the Resid Hydrotreater Unit that causes $30 million in property damage and forces residents to take shelter
August 10, 2005 - Another incident related to mechanical integrity in the refinery's Gas Oil Hydrotreater forces another community shelter-in-place alert
August 17, 2005 - The Chemical Safety Board issues its first-ever urgent safety recommendation, calling on BP to convene an independent panel to assess safety culture and oversight at all five of its North American refineries
October 24, 2005 - BP announces formation of the 11-member panel of experts, chaired by former U.S. Secretary of State James A. Baker III
October 25, 2005 - The Chemical Safety Board issues new urgent safety recommendations calling on the American Petroleum Institute to develop new safety guidance for the placement of trailers away from hazardous process areas
October 27, 2005 - In preliminary findings released at a public meeting in Texas City, CSB investigators describe a history of abnormal startups in the ISOM unit, previous vapor releases, and mechanical failures; they refer to the unit's blowdown system as "outdated and unsafe"
November 10, 2005 - CSB Chairman Merritt testifies before the newly established Baker panel, notes the role of worker fatigue and operator downsizing in the accident
December 22, 2005 - The CSB releases a narrated computer animation of the events leading the accident; the video is viewed in refineries and chemical plants worldwide
June 30, 2006 - The CSB releases blast damage information for 44 trailers located near the ISOM unit; notes serious damage to a distance of almost 600 feet from the center of the explosions
October 15, 2006 - The CSB issues a safety bulletin based on the July 28, 2005, hydrogen fire, calling for expanded use of positive material verification to prevent accidental releases
October 30, 2006 - The CSB releases new preliminary findings pointing to the role of corporate cost cutting in setting the stage for the Texas City accident, and noting that BP executives were aware of safety problems in Texas City prior to the explosion
October 31, 2006 - The CSB recommends that the American Petroleum Institute develop new practices urging the elimination of atmospheric blowdown drums similar to those in Texas City at all U.S. refineries; the Board also calls on OSHA to establish a refinery special emphasis enforcement program
The CSB investigation of the accident at BP Texas City is the largest, costliest, and most complex in the nine-year history of the agency. To date, more than $2 million has been spent conducting this independent federal investigation.