Process-safety oversights highlighted in Deepwater and Texas City

A lack of focus on process safety was a common factor of both the BP Texas City refinery explosion in 2005 and the Deepwater Horizon oil-rig disaster two years ago, US investigators have found.

Releasing the preliminary findings of an inquiry of process safety in the US offshore drilling and production industry, the US Chemical Safety Board (CSB) said Transocean and BP, trade associations and US regulators put too much emphasis on personal injury and fatality data to measure health and safety.

This approach overshadowed the use of leading indicators that are more appropriate for managing the potential for major incidents. Moreover, the industry and the regulator had not effectively learned the lessons of Texas City and other serious process incidents at the time of the Macondo well blowout in April 2010.

Noting the lack of sustained focus on process safety, CSB investigator Cheryl MacKenzie described an “eerie resemblance” between the two incidents – particularly in the fact that the two explosions coincided with similar events at both sites that were taking place to celebrate workers’ personal-injury accident records.

Investigator MacKenzie said: “The emphasis on personal injury and lost work-time data obscures the bigger picture: that companies need to develop indicators that give them realistic information about their potential for catastrophic accidents. How safety is measured and managed is at the very core of accident prevention.

“If companies are not measuring safety performance effectively and using those data to continuously improve, they will likely be left in the dark about their safety risks.”

Further preliminary findings of management system deficiencies underlying the Macondo blowout include:

• BP and Transocean hazard-assessment systems were inadequate, with safety documents overly focused on personal safety issues, such as working at height, and inadequately addressing the potential for major accidents;
• Hazard assessments of major-accident risks on Deepwater relied heavily on prompt, correct manual intervention by the rig crew to prevent a major accident – a policy that is not considered a reliable safety layer;
• Systems for managing the safety of process changes were inadequate;
• Systems for investigating incidents and implementing and disseminating the findings were inadequate; and
• Findings relating to a ‘well kick’ – an unanticipated, hazardous influx of hydrocarbons into the well bore that can precede a blowout – which occurred a short while prior to the explosion, were not acted on.

A robust system of process-safety indicators might have revealed many of these deficiencies before the explosion, CSB investigators concluded.

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