The document discusses organizational failures that led to a fatal explosion at a BP Texas City facility in 2005. It identifies five key issues: 1) Lack of ownership and encouragement of safety issue reporting at all levels, 2) A siloed culture that lacked meaningful communication between units, 3) Overreliance on personal safety metrics and underemphasis of process safety, 4) A "check the box" mentality of superficial compliance, and 5) Failure to complete recommendations from past audits and investigations, leading to casual compliance. The recommendations are to address these issues to improve safety culture, communications, process safety focus, compliance practices, and accountability.

1. 1
Texas City 10 Years On Organisational Failures
“I urge everyone involved in operations and safety programs to take time to visit the CSB’s BP investigation
web page, review the key findings in the report, and ask
“Is any of this happening at my facility?”
(CSB Chairman John Bresland on 5th Anniversary of Fatal BP Texas City 2005 Explosion)
Systemic Failure Reference Recommendation
Lack of Ownership "We have never seen a site where the notion 'I could die today'
was so real.“ (Telos Report – January 2005)
Encourage reporting of safety issues throughout all
levels in the organisation (both personal and
process safety)
Lack of
Communication
“A silo-based culture exists, where Units and Workgroups
function as separate entities rather than in a collaborative
manner.“ (Stanley Report – June 2005)
Ensure that there is meaningful communications
with personnel on lessons learned and common
issues and experiences between Assets.
Personal Vs.
Process Safety
“Reliance on the low personal injury rate at Texas City as a
safety indicator failed to provide a true picture of process safety
performance and the health of the safety culture.”
(CSB Report – March 2007)
Ensure management promote and react to process
safety KPI information
Compliance “A ‘check the box’ mentality was prevalent at Texas City, where
personnel completed paperwork and checked off on safety
policy and procedural requirements even when those
requirements had not been met.” (CBS Report – March 2007)
Ensure standards and procedures are followed
adequately and within compliance throughout all
levels of the organisation
Casual
Compliance
“Repeated failure to complete recommended actions from
audits, peer reviews and past incident investigations.”
(Stanley Report – June 2005)
Ensure all employees are accountable and
responsible for facilitating the identification of
hazards and the risks associated with those hazards