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A 21st Century Safety Solution Based on an Integral Approach
1. A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach Rick Strycker, Director of Development, JMJ Associates May 2007 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. www.jmj.com ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608
A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach Purpose Speciﬁcally, the panel asserted that the metrics, incentives and management systems at BP focused on measuring and The recent release of the Baker Panel Report creates an managing personal safety while ignoring process safety. In opportunity for expanding the practice of Incident and Injury- addition, BP had confused improving trends in occupational Free® (IIF®) safety worldwide. safety statistics for a general improvement in all types of safety. (See the Appendix to this paper for a summary of the Baker While the ﬁndings of the Baker Panel focused speciﬁcally on Panel’s ﬁndings and recommendations). 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 From the Baker Panel’s Report: The Panel has focused on process safety rather than personal misinterpretation of the Report may obscure other important safety. The Panel believes that its charter and the CSB’s dimensions of safety that are underemphasized by the report August 2005 urgent recommendation require this focus. writers. While acknowledging the signiﬁcant contribution made by the Baker Panel, we believe it is important to expand the In its request for an independent investigation, inquiry to include those underemphasized factors. Including the CSB was particularly concerned about: these factors will lead to a more integral approach to safety— an approach we feel is essential for creating and sustaining • The effectiveness of the safety management system an Incident and Injury-Free workplace. at BP Texas City reﬁnery, The purpose of this paper is to build on the work of the Baker • The effectiveness of BP North America’s corporate safety Report so that their work and the tragedy that spurred it can oversight of its reﬁning facilities, and accelerate the movement toward all workplaces creating being Incident and Injury-Free results. • A corporate safety culture that may have tolerated serious and long standing deviations from good safety practice. Context for the Baker Panel Report BP’s Texas City Reﬁnery in Texas City, Texas, is the second- As directed, the Baker Panel addressed each of these areas largest oil reﬁnery in the state and the third-largest in the of concern through the lens of process safety—in our view, United States. A major explosion occurred in an isomerization a much narrower lens than was required or desirable. In unit at the site on March 23, 2005, killing 15 people and addition, the panel addressed issues of leadership, culture injuring over 170 others. and safety management but did so exclusively from the perspective of process safety. Following two additional serious safety incidents during July and August of 2005, the U.S. Chemical Safety and Hazard Thus, the panel discusses process safety leadership, rather Investigation Board (CSB) recommended that BP Global than safety leadership in general, and process safety culture, commission an independent panel to investigate the safety rather than safety culture in general. Although this process situation within BP North America’s reﬁneries. The panel was safety focus is warranted in the Texas City context, it is our lead by former U.S. Secretary of State James Baker III. The opinion that it may inadvertently create an overly narrow lens Baker Panel Report, as it is now widely called, was released for safety in general. In the remainder of this paper, we offer on January 16, 2007. what we believe is a fuller, more comprehensive approach for those industries that have committed to Incident and Injury-Free performance. The Baker Panel’s Findings and Recommendations Working within the commissioning guidelines given by the Expanding the Focus CSB and BP, the panel conducted an extensive assessment The distinction between personal (occupational) safety of the conditions at BP’s Texas City reﬁnery, as well as other and process safety is important. However, the resulting major U.S. reﬁneries. The panel’s principal ﬁnding was that BP focus on process safety alone leads the Baker Panel to management had not distinguished between personal safety underemphasize both personal safety and the implicit (i.e., slips-trips-and-falls, driving safety, etc.) and process safety connections between personal and process safety. Later, (i.e., design for safety, hazard analysis, material veriﬁcation, we will point to other limitations, as well. The following quote equipment maintenance, process upset reporting, etc.). clariﬁes this distinction and the rationale behind the report. www.jmj.com ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608 Page 2 of 12
A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach Not all reﬁning hazards are caused by the same factors or is a list of areas of focus that are either missing from the involve the same degree of potential damage. Personal or Baker Panel Report or that need more emphasis: occupational safety hazards give rise to incidents—such as slips, falls, and vehicle accidents—that primarily affect • The exclusive focus on process safety as the context of one individual worker for each occurrence. Process the report misses a potentially more powerful context—the safety hazards can give rise to major accidents involving elimination of worker injury for both personal and process the release of potentially dangerous materials, the safety approaches. release of energy (such as ﬁres and explosions), or both. • The Report’s exclusive process safety focus Process safety incidents can have catastrophic effects underemphasizes the role of personal responsibility, and can result in multiple injuries and fatalities, as well commitment and behavioral change in creating a safe as substantial economic, property, and environmental workplace damage. Process safety reﬁnery incidents can affect workers inside the reﬁnery and members of the public • The report addresses safety culture but only in the context who reside nearby. Process safety in a reﬁnery involves of process safety and therefore underestimates the the prevention of leaks, spills, equipment malfunctions, importance of a strong safety culture that supports both over-pressures, excessive temperatures, corrosion, metal personal and process safety. fatigue, and other similar conditions. Process safety programs focus on the design and engineering of facilities, • The Report collapses elements of safety into the hazard assessments, management of change, inspection, process safety domain (i.e., human factors, design and testing, and maintenance of equipment, effective engineering) that are best kept separate and held as alarms, effective process control, procedures, training of components of the whole safety situation. personnel, and human factors. The Texas City tragedy in March 2005 was a process safety accident. A JMJ Response It is our experience that safety, and in particular the creation The Panel has focused on process safety rather than of a sustainable Incident and Injury-Free workplace, is a personal safety. The Panel believes that its charter and the complex adaptive problem that cannot be addressed with CSB’s August 2005 urgent recommendation require this technical solutions. The overemphasis on process safety in focus. the report, and the manner in which the issues are addressed In its report, the Baker Panel concludes that BP has: there, does not sufﬁciently address the complexity of the whole safety situation. …emphasized personal safety in recent years and has achieved signiﬁcant improvement in personal safety Following are a few critical aspects—perspectives on performance, but BP did not emphasize process safety. safety performance—that we believe must be considered BP mistakenly interpreted improving personal injury rates to complement the ﬁndings of the Baker Panel Report and as an indication of acceptable process safety performance ensure positive, sustainable safety outcomes. at its U.S. reﬁneries. BP’s reliance on this data, combined with an inadequate process safety understanding, • Think integrally to promote more effective solutions. created a false sense of conﬁdence that BP was properly addressing process safety risks. • Commit to the elimination of all worker injury and speak and interact in ways that elevate the human spirit in service of this By placing attention on process safety, we commend the commitment. panel for its useful recommendations, which should be taken seriously and acted upon. From the perspective of • Distinguish adaptive situations from technical ﬁxes to open JMJ’s consulting experience, however, these ﬁndings while new opportunities for learning. 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 www.jmj.com ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608 Page 3 of 12
A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach Think integrally to promote holistic solutions Gadamer’s philosophical hermeneutics interprets the collective consciousness of a society, which makes it an Based on JMJ’s experience in safety consulting, we have interior collective, or lower-left quadrant, perspective. Finally, found that the Four Quadrants Model 2 is the most useful Marxist economic theory examines the external behavior of tool for promoting integral thinking as it provides a way of a society, which is a lower-right quadrant view. Together, all explaining the complexity of life in a very simple and elegant four pursuits—psychoanalysis, behaviorism, philosophical framework. This model, which at ﬁrst seems quite abstract, hermeneutics and Marxism—can offer complementary, rather becomes quite practical when used to determine if we are than contradictory, perspectives. It is possible for each of these thinking about all aspects of a problem, issue or challenge. to be partially correct and necessary for a complete account of human experience. Each of these schools, taken separately, First, the abstract explanation. Each unit of reality can be however, provides only a partial view of social science. described as being both a whole system in itself, and a part of a larger whole system, with interior and exterior aspects. Each When the unit of reality we are discussing is a human system, unit also has individual and collective aspects. Observing or a human being, we can begin to ﬁll in the quadrants with reality from the outside constitutes an exterior perspective. contents that correspond with the appropriate X and Y axes Observing it from the inside is the interior perspective, and so for that speciﬁc unit of reality. When we’re looking at people, forth. If you map these four perspectives into quadrants, you for example, the upper-left quadrant includes feelings, have the four dimensions of any unit of reality as seen in this personal values, commitments, attitudes, and so on. Many Four Quadrants Model: 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 To give an example of how this works, consider four schools other things that also are important to us. To balance the of social science. Freudian psychoanalysis, which interprets overemphasis on the right-hand aspects of safety, we often people’s interior experiences, is an account of the interior hold conversations about left-hand, interior aspects, which individual, or the upper-left quadrant of the Four Quadrants typically provide insights into values-based solutions to safety Model. Meanwhile, B. F. Skinner’s behaviorism, which limits issues, like the value of human life, treating people with itself to the observation of the behavior of organisms, dignity and respect, and the desire to stay safe because of is an exterior individual, or upper-right quadrant, matter. the love and care one has for family. www.jmj.com 2 Adapted from Wilber, Ken (2001). A Theory of Everything. (Shambala: Boston) ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608 Page 4 of 12
A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach Integrating Personal and Process Safety hand. The subjective and objective aspects of work, for example, We also gain insights into safety by examining the two are often occurring in the same time and space. In safety, we upper quadrants of the Four Quadrants Model, those about would be looking for values expressed in action, or attitudes the individual, as compared to the collective aspects found reﬂected in behavior. In the lower quadrants, we look for the links within the lower two quadrants. For example, if we accept the between shared values and systems, or culture and processes. distinctions of the Baker Panel, we could say that personal safety encompasses the upper, or individual, quadrants (both INDIVIDUAL ALIGNMENT 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 the GROUP ALIGNMENT distinction as follows: PERSONAL SAFETY The Function of Alignment If 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 PROCESS SAFETY 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 Thus, taken together, personal and process safety form of alignment having to do mostly with values; on the right- a more complete safety picture. Let us now consider the hand side is an exterior type of alignment having to do with left- and right-side integration, the subjective (interior) and observable behavior or performance. objective (exterior) aspects of safety, as well. The Subjective and Objective Aspects of Safety SAFETY PERFORMANCE ALIGNMENT In our safety practice, when we speak about personal safety, SAFETY VALUES ALIGNMENT 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 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 www.jmj.com view. It removes choice and responsiblity from people, and thus diminishes crucial aspects of that which makes us human. ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608 Page 5 of 12
A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach Let us consider an example of what an alignment or Personal Safety: Includes both behavior-based misalignment on the left-hand side would look like in and commitment-based approaches, emphasizes the domain of values. To illustrate: A worker attends a individual unsafe acts and personal injury accidents, Commitment Workshop where he takes a stand for the tends to view people as free agents who can choose elimination of worker injury at the job site. Upon returning to work safely, and more recently emphasizes the to work, he encounters deep collective resistance to his importance of personal responsibility. stand because of deeply held assumptions about safety— assumptions that make it a cultural norm to accept accidents Safety Engineering: Includes reliability engineering, as “inevitable.” It will be quite difﬁcult for him to maintain his ergonomics, risk assessment and management, and commitment without other kinds of support. the view that human errors are not only the result of what happens inside a person’s head, but also On the right-hand side of the Four Quadrants Model a are a function of the interface between the human relationship exists between individual behavior and collective entity (the upper quadrants) and engineering (the systems. For example, a recognition and reward system product of designers). This approach often focuses will positively inﬂuence individual performance if and only on people who work in high-risk jobs, such as if the system is designed properly. Otherwise, a negative controllers or key operators. relationship could be formed—one that drives individual behavior that is inconsistent with organizational safety goals. Organizational Safety: Includes the systems approach that views errors more as a consequence Thus, alignment between the upper and lower quadrants is than as a cause. Errors reveal the latent condition essential for people, processes and systems to be aligned, within the system at large, which, if triggered, result and for these alignments to have both interior as well as an in large system malfunction. This approach is akin exterior dimensions. There are countless ways to illustrate to Total Quality Management and is similar to the these connections and interrelationships between personal engineering approach. and collective safety. Although these approaches have been seen as competing Design and Engineering in an IIF Context or contradictory, they now can be viewed as partial, but true In the Baker Panel report, process safety includes: “design and versions of the whole safety situation. Additionally, the safety engineering of facilities, hazard assessments, management engineering approach can be seen as a way to bridge the of change, inspection, testing, maintenance of equipment, other two approaches. As an integrating function, engineering effective alarms, effective process control, procedures, training can be re-imagined to include the perspectives of all of personnel, and human factors.” From the perspective of an quadrants in service of an IIF workplace. This “engineering for integral approach, the net of process safety used by the Baker integration” function can be drawn as follows: 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 PERSONAL SAFETY 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 PROCESS SAFETY 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: 4 Reason, James T., (1999) Managing the Risks of Organizational Accidents (Aldershot, Hants, England: Brookﬁeld, Vt. USA: Ashgate) www.jmj.com ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608 Page 6 of 12
A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach Safety Culture Commit to eliminating all worker injury Thus far, the personal and process aspects of safety have We assert that there are more powerful commitments that been discussed, as well as the potential role of safety could have been evoked by this inquiry. In our work with engineering as an integrating function. However, the clients, we have discovered that the most powerful and importance of the lower-left quadrant, labeled culture for satisfying commitment people can make in regard to safety short, has not yet been made clear. is to the total elimination of workplace incidents and injuries. This is not an easy commitment for people, and sometimes it It is worth noting here that while the Baker Panel Report takes great courage to make it. emphasizes the need for a process safety culture, JMJ emphasizes the importance of culture within an integral safety From this powerful commitment, one would look integrally to approach. Reason5 writes that: discover: what is missing, what will be our future goals, and what is the appropriate path to achieve them? In this case, …the safety culture of an organization is the product of we assert that from a stand for Incident and Injury-Free we individual and group values, attitudes, competencies, naturally embrace both personal and process approaches to and patterns of behavior that determine the commitment safety, including their interior and exterior aspects. to, and the style and proﬁciency of, an organization’s health and safety programmes. Organizations From an IIF context we take a holistic approach to keep one with a positive safety culture are characterized by another safe as we are determined to use all means available, communications founded on mutual trust, shared including how we speak to and interact with one another. perceptions of the importance of safety, and conﬁdence in the efﬁcacy of preventive measures. While it may seem like a minor point, from our many years of experience working with the personal aspects of safety Note in Reason’s quote the links among the quadrants; while and the Four Quadrants Model we know that there is a more culture is distinguished in the lower-left quadrant, it has deep powerful way to speak about safety that powerfully and connections with the other quadrants, as well. explicitly includes the human dimension. We can see how culture is a powerful inﬂuence over individual We constantly notice the propensity among our clients, other beliefs and behavior, and at the same time is itself changed consulting companies, and even ourselves, to allow the through the inﬂuences of strong leadership. Edgar Schein6, seduction of language to shrink the human dimension from life who has written extensively on culture and leadership, says: and work. This objectiﬁcation of life through language becomes ever more apparent when reviewing work from the integral …culture and leadership are two sides of the same coin in perspective offered by applying the Four Quadrants Model. that leaders ﬁrst create cultures when they create groups and organizations. Once cultures exist, they determine the In an apparent desire to be objective, the Baker Panel criteria for leadership and thus determine who will or will not unwittingly constructs a world devoid of interiority. This style be a leader.” of writing tends to miss the point that human beings (with their From an integral perspective, JMJ strongly recommends that intentions, values and commitments) are involved in every organizations or projects that wish to create and sustain a aspect of the process, from design through implementation workplace from which people go home safe incorporate both and continuous improvement. The language of the Report personal and process safety into their approach and also do not only separates the realm of the personal from the realm the work to link them together in a holistic and comprehensive of process safety, it disconnects the role of people in keeping system. Such an approach would necessarily include an analysis processes relevant and useful. of the links between individual and collective values, culture and behavior, leadership and culture, design and engineering, the From our perspective, there is a danger when people begin safety management system and individual safety performance, to trust exclusively in an impersonal safety process to keep to name a few. We believe that the future of safety will require them safe. It is when people care deeply about themselves, a more comprehensive perspective. Beginning on page 18, their families, others at work, and their organizations, and Appendix II illustrates a thorough comparison between a partial act upon that care and concern, that they create and sustain solution to safety and a holistic or integral solution. 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) www.jmj.com 6 Schein, Edgar (1985): Organizational Culture and Leadership (San Francisco: Jossey-Bass) ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608 Page 7 of 12
A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach It is from care and authentic commitment that people choose This document outlines our views, based on nearly 20 years to create and improve the processes and systems that are put of experience working in the safety industry, and illuminates in place to serve them. Processes and systems do not a more integral perspective on safety—one that distinguishes stand alone.. the separate elements of the safety situation and then integrates them into a more comprehensive approach. At Adaptive situations vs. technical ﬁxes the same time, the approach outlined here continues to emphasize the human dimensions of safety. Throughout our Following the work of Ron Heifetz7, Professor of Leadership history, we have worked to emphasize and dignify care and at the John F. Kennedy School of Government at Harvard regard for people as the heart of our safety commitment. In University, we make the distinction between adaptive and addition, we also have forged new ground in the direction of technical situations as a key characteristic of our consulting how to create integral approaches to safe workplaces. approach and our point of view regarding leadership. Said simply, adaptive situations are those for which we do not yet In the last decade, industry has made tremendous progress in have the solutions. Thus, they are in the domain of either safety by taking on the personal, human work required to create what we don’t know or what we don’t know we don’t know. an Incident and Injury-Free workplace. Our recommendation is Inquiry is a primary tool for resolving adaptive situations. to continue to build on and learn from all that has gone before with both the people and process orientations to safety. This perspective is missing in the Baker Panel’s Report, and this creates the perception that the recommendations Speciﬁcally, we recommend: offered by the report could be followed as a kind of technical ﬁx. An example of a technical problem is requiring people to • Think integrally to promote more effective safety solutions. wear personal protective equipment (PPE) on the work site. Design a safety program that addresses both the people and An example of an adaptive situation is when workers know process aspects that together impact safety performance they should wear their PPE but they do not and there is no and apply safety engineering in a way that integrates all apparent explanation for this fact. perspectives, as well. • Commit to the elimination of all worker injury and then It is JMJ’s strong opinion, based on many years of experience in intentionally speak and interact in ways that elevate the this domain, that creating an Incident and Injury-Free workplace human spirit in service of this commitment. Experience is always an adaptive situation, one that requires a great deal of has shown that sustainable change begins when people learning, inquiry and bold acts of courageous leadership. Within take responsibility for what they want. this larger adaptive situation, there are also many sub-domains where learning is required. We also have discovered that there • Embrace the ongoing, adaptive nature of safety—it is a are many technical solutions involved in the safety journey. Note, journey, not a destination. however, that there is always a danger of misidentifying adaptive Its adaptive nature requires that organizations continuously situations and over-relying upon technical ﬁxes. learn from their successes and mistakes. It requires vigilance and the willingness to continually think anew by recognizing Within the Baker Panel’s recommendations, we see a mix of that many safety situations do not have technical ﬁxes. technical and adaptive situations, and it is the goal of good leadership to sort out which is which. Appendix I: Baker Panel’s Key Findings Conclusion The March 2005 Texas City Reﬁnery explosion resulted in Corporate Safety Culture The Baker Panel Report, a document whose recommendations Process safety leadership have been widely spread across industry and are serving The Panel believes that leadership from the very top of the to reinvigorate the inquiry into how to further improve company is essential. The Panel believes that BP has not workplace safety. The process safety recommendations provided effective process safety leadership and has not made therein are sound and to be commended. In addition, adequately established process safety as a core value. While we have offered a perspective that expands upon these BP has an aspiration of “no accidents, no harm to people,” ﬁndings and recommendations. BP has not provided effective leadership in making certain its management and workforce understand what is expected www.jmj.com 7 Heifetz, Ronald (1994). Leadership Without Easy Answers (The Belknap Press of Harvard University Press: Cambridge, Mass) ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608 Page 8 of 12
A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach of them regarding process safety performance. BP has • BP has not demonstrated that it has emphasized personal safety in recent years and has achieved effectively held executive management, line signiﬁcant improvement in personal safety performance, but managers and supervisors accountable for did not emphasize process safety. BP mistakenly interpreted process safety performance. improving personal injury rates as an indication of acceptable • Process safety cultures at BP’s U.S. reﬁneries. process safety performance at its reﬁneries. BP’s reliance on this data, combined with an inadequate process safety • BP has not instilled a common, unifying understanding, created a false sense of conﬁdence that BP process safety culture in its reﬁneries. was properly addressing process safety risks. The Panel found Signiﬁcant process safety culture issues exist. that process safety leadership appeared to have suffered as a result of high turnover of reﬁnery plant managers. • The Panel found instances of a lack of operating discipline, toleration of serious Employee empowerment deviations from safe operating practices, and apparent complacency toward serious • A good process safety culture requires a positive, process safety risks. trusting, and open environment with effective lines of communication between management and the workforce, Process Safety Management Systems including employee representatives. Process risk assessment and analysis • At Texas City, Toledo, and Whiting, BP has not established a positive, trusting, and open environment with effective • While all of BP’s reﬁneries have active programs to lines of communication between management and the analyze process hazards, the system as a whole does not workforce. ensure adequate identiﬁcation and rigorous analysis of those hazards. Resources and positioning of • Examination indicates that the extent and recurring nature process safety capabilities of this deﬁciency is not isolated, but systemic. • BP has not always ensured that it identiﬁed and provided • Compliance with internal process the resources required for strong process safety safety standards. performance. • The consultants and Panel observed that BP does have • BP does not have a designated, high-ranking leader for internal standards/programs for managing process risks. process safety dedicated to its reﬁning business. • Examination found that BP’s corporate safety • The Panel believes that the company did not always ensure management system does not ensure timely compliance that adequate resources were effectively allocated to support with internal process safety standards and programs. or sustain a high level of process safety performance. • Implementation of external good engineering practices. • BP’s corporate management mandated numerous initiatives that applied to the reﬁneries and that, while well-intentioned, • The Panel found that BP’s corporate safety management have overloaded personnel at BP’s reﬁneries. system does not ensure timely implementation of external good engineering practices that support and could • Operations and maintenance personnel sometimes work improve process safety performance. high rates of overtime, and this could impact their ability to perform their jobs safely and increases process safety risk. Process safety knowledge and competence • Many members of BP’s technical and process safety staff Incorporation of process safety into have the capabilities and expertise needed to support a management decision-making sophisticated process safety effort. • BP tended to have a short-term focus, and its decentralised management system and entrepreneurial • The Panel believes that BP’s system for ensuring culture have delegated substantial discretion to plant an appropriate level of process safety awareness, managers without clearly deﬁning process safety knowledge, and competence relating to its reﬁneries has expectations, responsibilities, or accountabilities. not been effective in a number of respects. www.jmj.com ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608 Page 9 of 12
A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach • BP has not effectively deﬁned the level of process Panel observations relating to process safety safety knowledge or competency required of executive management practices management, line management above the reﬁnery level, The Panel observed several positive notable practices or, and reﬁnery managers. in the case of BP’s process safety minimum expectation • BP has not adequately ensured that its reﬁnery personnel program, an excellent process safety management practice. and contractors have sufﬁcient process safety knowledge and The notable practices relate to creation of an engineering competence. authority at each reﬁnery and several other reﬁnery-speciﬁc. • The Panel’s reviewed indicated that process safety education and training needs to be more rigorous, comprehensive, and Performance Evaluation, Corrective Action, integrated. and Corporate Oversight • The implementation of, and over-reliance on, BP’s • Signiﬁcant deﬁciencies existed in BP’s site and corporate computer based training contributes to inadequate systems for measuring process safety performance, process safety training of reﬁnery employees. investigating incidents and near misses, auditing system performance, addressing previously identiﬁed process safety-related action items, and ensuring sufﬁcient Effectiveness of BP’s corporate process management and board oversight. safety management system • Many of the process safety deﬁciencies are not new but were • BP has an aspiration and expectation of “no accidents, no identiﬁable to BP based upon lessons from previous process harm to people, and no damage to the environment,” and safety incidents, including process incidents that occurred at is developing programs and practices aimed at addressing BP’s facility in Grangemouth, Scotland in 2000. process risks. Measuring process safety performance • BP’s corporate process safety management system • BP primarily used injury rates to measure process safety does not effectively translate corporate expectations into performance at its reﬁneries. BP’s reliance on injury rates measurable criteria for management of process risk or signiﬁcantly hindered its perception of process risk. deﬁne the appropriate role of qualitative and quantitative risk management criteria. • BP tracked some metrics relevant to process safety at its reﬁneries; however, BP did not understand or accept what • BP appears to have established a relatively effective this data indicated about the risk of a major accident or personal safety management system by embedding the overall performance of its process safety management personal safety aspirations and expectations within the systems. As a result, BP’s corporate safety management reﬁning workforce. system for its reﬁneries does not effectively measure and • BP has not effectively implemented its corporate-level monitor process safety performance. aspirational guidelines and expectations relating to process risk. The Panel found that BP has not implemented an integrated, Incident and near miss investigations comprehensive, and effective process safety management • BP acknowledges the importance of incident and near system for its reﬁneries. miss investigations. www.jmj.com ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608 Page 10 of 12
A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach • BP has not instituted effective root cause analysis procedures Corporate oversight to identify systemic causal factors that may contribute to future • BP acknowledges the importance of ensuring that the accidents. company-wide safety management system functions as • BP has an incomplete picture of process safety because intended. BP’s process safety management system likely results in • The company’s system for assuring process safety under reporting of incidents and near misses. performance uses a bottom-up reporting system that Process safety audits. originates with each business unit. As information is reported up, data is aggregated. By the time information • BP has not implemented an effective process safety audit is formally reported at the Reﬁning and Marketing system for its reﬁneries segment level reﬁnery-speciﬁc performance data is no • The Panel was concerned that the principal focus of longer presented separately. audits was on compliance and verifying that required • The Panel found that neither BP’s executive management management systems were in place to satisfy legal nor its reﬁning line management has ensured the requirements. implementation of an integrated, comprehensive, and Timely correction of identiﬁed effective process safety management system. process safety deﬁciencies. • BP’s Board of Directors has been monitoring process • BP expends signiﬁcant efforts to identify deﬁciencies and safety performance of operations based on information to correct many identiﬁed deﬁciencies, which BP often that corporate management presented to it. does promptly. • A substantial gulf appears to have existed between the actual • BP has sometimes failed to address promptly and track performance of BP’s process safety management systems to completion process safety deﬁciencies identiﬁed during and the company’s perception of that performance. 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. www.jmj.com ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608 Page 11 of 12
A JMJ Response to the Baker Panel Report A 21st Century Safety Solution Based on an Integral Approach The Baker Panel’s Recommendations 6. Support for Line Management BP should provide more effective and better coordinated 1. Process Safety Leadership process safety support for the line organization. The Board of Directors, executive and corporate management must provide effective leadership on and 7. Leading and Lagging Performance Indicators establish appropriate goals for process safety. for Process Safety They must demonstrate their commitment to process BP should develop, implement, maintain, and safety by articulating a clear message on the importance periodically update an integrated set of leading and of process safety and matching that message both with lagging performance indicators for more effectively the policies they adopt and the actions they take. monitoring the process safety performance. BP should work with a wide range of organizations 2. Integrated and Comprehensive Process Safety to develop a consensus set of indicators for process Management System safety performance for use in the reﬁning and chemical BP should establish and implement an integrated and processing industries. comprehensive process safety management system that systematically and continuously identiﬁes, reduces, and 8. Process Safety Auditing manages process safety risks at its reﬁneries. BP should establish and implement an effective system to audit process safety performance at its reﬁneries. 3. Process Safety Knowledge and Expertise 9. Board Monitoring BP should develop and implement a system to ensure BP’s Board should monitor the implementation of the that its executive management, its line management, recommendations of the Panel and the ongoing process all reﬁning personnel, and contractors, possess an safety performance of BP’s reﬁneries. appropriate level of process safety knowledge and expertise. The Board should, for a period of at least 5 years, engage an independent monitor to report on BP’s 4. Process Safety Culture progress, and should also report publicly on the BP should involve the relevant stakeholders to develop progress and on BP’s ongoing process safety a positive, trusting, and open process safety culture. performance. 5. Clearly Deﬁned Expectations and 10. Industry Leader Accountability for Process Safety BP should use the lessons learned to transform the BP should clearly deﬁne expectations and strengthen company into a recognized industry leader in process safety accountability for process safety performance at all levels management. in executive management and in the managerial and supervisory reporting line. www.jmj.com ® ™ Mark of JMJ Associates, LLP. © 2008 JMJ Associates, LLP. All rights reserved. v.CRDOCT0608 Page 12 of 12
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