September 24, 2007 | Mark Paradies

Monday Accident & Lessons Learned: BP Texas City Explosion Puts Refinery Safety in the Spotlight

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OSHA came under considerable scrutiny after the BP Texas City explosion. The question most commonly asked was:

“Why didn’t OSHA spot the problems that led to the explosion and
stop it before the explosion and the loss of 15 people?”

Also asked was:

“Why didn’t the PSM rule keep this accident from happening?”

That focus on OSHA and the PSM Rule has led OSHA to focus more on refinery safety. Richard Fairfax, Director of OSHA’s Directorate of Enforcement Programs, told a US House of Representatives committee that, before the end of 2008, OSHA would conduct enforcement inspections at all 81 refineries under federal jurisdiction.

Thus refineries should be preparing for these inspections and improving their PSM implementation.

Areas where BP Texas City proved woefully inadequate were incident investigation and corrective action implementation. The accident at the Texas City Refinery was foretold by prior incidents. If these incidents had been addressed by implementing effective corrective actions to fix the incident’s root causes, there would have been no accident. Fifteen lives would have been saved!

If you are at a refinery, how are your programs in this area? Do you need to improve your incident investigation, root cause analysis, and corrective action implementation programs?

The TapRooT® System is used by many US and international refineries to enhance their investigation programs, improve safety, and improve process/ equipment reliability. If you are at a refinery that isn’t using TapRooT®, I’d recommend attending one of our courses to see what you have been missing.

What if you are at a refinery that is already using TapRooT®? You can still improve! One of the reasons that we sponsor the annual TapRooT® Summit is to give TapRooT® Users the chance to learn from the best practices of others and get the most from their use of TapRooT®.

But you can’t learn from the Summit if you don’t attend. What sessions should you attend? (There are so many good ones.) A single refinery probably needs several attendees … at least one for each of the following tracks:

1.  INVESTIGATION & ROOT CAUSE ANALYSIS BEST PRACTICES TRACK
• What’s New in Investigations and Corrective Action
• Investigation Lessons Learned from the Field
• Root Cause Analysis of the Accident at Three Mile Island (exercise)
• FACTS – Computerized Analysis of Fatigue as a Cause of an Incident
• TapRooT® User Best Practices
• Management and Performance Improvement
• TapRooT® User Success Stories from Healthcare & Industry
• Root Cause Analysis of Major Accidents (3 Investigation Presentations)
• Planning Your Improvements

2. CORRECTIVE ACTION PROGRAM BEST PRACTICES TRACK
• Innovative & Creative Solutions
• Evaluating the Effectiveness of Corrective Actions
• Using TapRooT® to Evaluate Common Causes & Extent of Condition
• Better Corrective Actions by Using Corrective Action Tools
• What Do Managers Need to Know About Performance Improvement & Root Cause Analysis
• How to Identify Culture Issues When Performing a Root Cause Analysis
• How to Get & Keep Management Support
• The Good, The Bad, & The Ugly: Rating Improvement Programs & Incident Investigations
• Root Cause Analysis of the Accident at Three Mile Island
• Planning Your Improvements

3. EQUIPMENT RELIABILITY & MAINTENANCE BEST PRACTICES TRACK
• How to Become Best of Class in Equipment Reliability by Maximizing Uptime – Heinz Bloch
• Best of Class in Equipment Reliability: Part II – Heinz Bloch
• Examples of Extreme Equipment Failure Investigations – Ken & Heinz Bloch
• Using TapRooT® to Solve Complex Equipment Problems – Ken Bloch
• Evaluating the Effectiveness of Corrective Actions – Brian Hennesey
• Engineering Methods to Improve Equipment Reliability
• Maintenance Best Practices
• Culture Shift Secrets – Changing Systems to Shift Cultures Towards High Performance
• Planning Your Improvements

4. SAFETY & RISK MANAGEMENT BEST PRACTICES TRACK
• Hazard Recognition: The First Step in Safety & Risk Management
• Dealing with Obstacles that Make Change Difficult
• Managing the Risks Associated with Change
• Root Cause Analysis of Major Accidents
• Advanced Behavioral Management: Developing a Modern Safety Culture
• Panel Discussion – Is There a Tradeoff Between Process Safety & Industrial Safety?
• TapRooT® User Success Stories from Healthcare & Industry
• The Good, The Bad, & The Ugly: Rating Improvement Programs & Incident Investigations
• Bringing Safety to the Corporate Board
• What the Corporate Board Needs to Know About Safety
• Planning Your Improvements

5. HUMAN ERROR REDUCTION & BEHAVIOR CHANGE BEST PRACTICES TRACK
• Exelon’s Error Free Performance Tool
• Human Performance Improvement Research
• Advanced Behavioral Management: Developing a Modern Safety Culture
• The Human Design Spec – Minimizing Human Error While Working in a 24/7 World
• Latest Human Performance Improvement Ideas from the Institute of Nuclear Power Operations
• Character Driven Success – Dr. Beverly Chiodo
• Changing Behavior by Praising the 49 Character Traits – Dr. Beverly Chiodo
• Innovative & Creative Solutions
• Planning Your Improvements

With all the knowledge you bring back to your refinery, you are sure to have one of the best incident investigation, root cause analysis, performance improvement, and corrective action programs in the industry.

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