November 2, 2006 | Alex Paradies

Legal Woes and Root Cause Analysis – BP Texas City Explosion

When a major accident happens, the lawsuits can get nasty.

I ran across a document posted on the web that looks to be part of a lawsuit related to Sarbanes-Oxley compliance or the Sherman Anti-Trust laws in the US. I don’t know why individuals would be filing this suit, but lawyers might be able to explain it. The web site where the document is posted certainly does seem to focus on any negative information that can be found about BP. The document is posted at:

Why is a document posted at an “anti-BP” (my interpretation of the site) web site interesting?

1. When you read Attachment C you start to see the types of problems and expenses that can be generated by evan a simple request for documents that might occur because of a lawsuit after an accident. Here is just one item from the 20 item list:

“13. From 1998 to present, provide all emails warning of

problems on the Isomerization Unit from Petrospect

Inspection and Jacobs Engineering.”

Imagine how hard it would be to make sure that you had collected all (every) e-mail that anyone had written that warned of “problems” from a “Retrospect Inspection” and from a contractor – Jacobs Engineering. And remember, that’s just one of 20 information requests.

2. The document claims that “benchmarking” – and more specifically the Solomon Refinery Benchmarking Studies – is the root cause of the explosion at the BP Texas City Refinery.

The document points to the studies and management’s actions and then blames the explosion on senior BP managers wanting to increase their pay by improving their results in the benchmarking studies. Thus “benchmarking” is the root cause of the explosion. That’s the claim the letter at the web site makes.

WOW! And I thought my interpretation of the information released from the CSB was critical.

There is much that can be learned from the document – but let’s just look at a few of the less obvious points:

1. You never know when someone will subpoena your e-mails!

2. One item that you should consider is that you are probably underestimating the costs of an accident. When you estimate the costs, don’t forget the legal woes that can result from an accident.

3. Another unanticipated “cost” is the people who can loose their jobs over the residual blame that will, no doubt, ruin the reputations and careers of many. This started with those who were directly involved at the unit that exploded. But senior BP management is also finding out how far the blame can spread.

4. The PR nightmare after an accident is not a minor issue.

These less obvious costs of an accident aren’t the primary reasons to prevent accidents, but they are issues that are real and often overlooked when considering the benefits of maintaining excellent performance.

A Note for TapRooT® Users:

As you know, the TapRooT® System isn’t designed to place blame. Instead, it is designed to discover ways to improve performance. Therefore, the “root causes” hinted at (benchmarking and greed) in the document cited above aren’t a part of the TapRooT® System.

Instead, TapRooT® would look at the company’s standards, policies, and administrative controls related to specific causal factors that caused the accident. These “SPAC” should have been stringent enough to prevent the accident that occurred. If they weren’t – that’s a problem … a near-root-cause in the TapRooT® System.

Or, if the SPAC were adequate, then they must not have been used (followed). That too is a problem … another potential near-root-cause.

A more detailed analysis of BP’s standards, policies, and administrative controls and the compliance with those SPAC is no doubt one of the things that the CSB has undertaken as part of their investigation and root cause analysis of the explosion at the refinery.

Everyone concerned about improving refinery safety – and process safety management – will be waiting for the final CSB investigation to get a more thorough understanding of the facts related to the failures that lead to this tragic explosion and fire and any failures in BP’s implementation of the Process Safety Management regulation (a SPAC) that lead to the explosion. Until the complete report is released, we will be left wondering about the causes – the complete root cause analysis – of the explosion, fire, and resulting 15 deaths.

A Note for TapRooT® Summit Attendees:

Judge Andrew Napolitano will be one of the Keynote Speakers at the TapRooT® Summit. His talk is titled:

Accident Investigation Lessons from the Courtroom

This talk will provide you with even more ideas about the legal complications and liabilities possible when performing an investigation. If you know others who are interested in this topic, tell them about the Summit.

Root Cause Analysis
Show Comments

Leave a Reply

Your email address will not be published. Required fields are marked *