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Telos Report




BP Texas City Site Report of Findings

Texas City's Protection Performance, Behaviors, Culture,

Management, and Leadership

21 January 2005


Introduction 1

I. Understanding Blame, Punishment, and a Just Culture 1

Getting Hurt on the Job

What is Recognized and Rewarded

II. Unsafe Acts and Violations

Unsafe Acts


Contractor Compliance

Ill. Workplace Factors

Conditions of the Kit and Catastrophe

Procedures at Unit/MAT Level

Pressure for Production

Leadership at Unit/MAT Level

IV. Organizational Factors: The Parents of the



"Problem Children" of Workplace Factors and Unsafe Acts 25

Organizational Factors: Commitment

Organizational Factors: Cognizance

Organizational Factors: Competence

Training, Development and Organizational Learning


In this introduction, we clarify what this document is, and what it is not. In the course of

doing so, we also clarify its intent. We provide the reasons this Assessment was done,

the selection basis for what is or is not in the Report, and how we used the data from the

Interviews and Surveys. We provide a summary of the interview and survey population,

and our approach to learning from the incidents at UU4, AU2 and the UU3. Finally, we

provide some guidance in the form of clarity about the structure of the report.

After the tragedy at the UU3 in September of last year, the Site Manager thought it would

be in the best interests of the site and the Leadership Team to initiate a practice of regular

assessments of 'safety behavior and culture'. Don also wanted to start as soon after the

tragedies as was possible. This first assessment would form a baseline against which site

leadership could regularly assess its progress toward being a petrochemical site free from

injuries and incidents that could cause harm.

From our perspective, the most important aspect of why this Assessment and Report were

commissioned is the authentic hunger for bad news that it is asked to address. Starting

with, but not limited to the Business Unit Leader, there has been a consistent call for the

'brutal facts', the way that it really is around here. "We need to know what it is really

like - nothing held back", we were told. There has been a genuine and consistent call for

the truth.

In our experience with many companies interested in adopting High Reliability principles

and/or being High Reliability Organizations, there is often a request for activities such as

these, but no real desire for the actual bad news. Like most audits in those companies, a

'good audit' is one that finds little wrong. In actual HROs a good audit would be one that

finds many things wrong; and each successive audit would continue to find more and

more wrong - but the problems being discovered would be at weaker and weaker levels

of signal strength. We are genuinely impressed with the strength of the desire to know

what is not working at Texas City.

Who did we talk to? Each Leadership Team Member suggested specific individuals from

their function or manufacturing area as candidates for interviewing. This produced a list

of names over one hundred and sixty in number. Nearly all interviews occurred in Texas

City between 8 and 30 November 2004; a small handful of interviews occurred by

telephone. Of the' List of One Sixty', one hundred and five were scheduled for an

interview with one of the three Telos partners. One hundred showed up for their

scheduled interview, and twelve individuals came to us requesting a 'blind interview',

that is, an interview with no name and almost no demographic information; this resulted

in one hundred twelve interviews. Other than these twelve 'volunteers', we made a strong

effort to achieve the agreed representation ratio of 14:30:28:28, that is fourteen

Leadership Team members, thirty Tier Two individuals, twenty-eight First Level Leaders, and twenty-eight Hourly employees. The actual ratio was 14:38:31 :29.



nine contractors we interviewed ranged from hourly workers to superintendents. In

addition to the interviews, we received over 1,100 surveys filled out by individuals at all

levels and from all areas of the site. We continue to receive them even as this Report

goes to the printer.

This Report makes no claims to represent the objective 'truth' about the Texas City Site's

protection I performance, behaviors, culture, management and leadership. This Report

does claim to be an honest and true representation of the way the people we interviewed

and surveyed see the Texas City Site's protection performance, behaviors, culture,

management and leadership. This Report intends to provide a sense and feel for what we

encountered in the confidential conversations, interviews and surveys of the members of

the Texas City Site working community. We attempt to do this, as much as possible, in

the very words they used, rather than in our own. We provide some introductory remarks

to each section. These are meant to illuminate how the report approaches protection, as

well as to narrow the scope of the report into specific frames through which we can

concentrate on specific factors. In addition, we occasionally make assertions regarding

what is being said - or what is not being said.

The Report, following this Introduction, is divided into the following sections:

Understanding Blame, Punishment, and a Just Culture; Unsafe Acts; Workplace Factors;

and Organizational Factors. Each section has an introductory paragraph that explains the

scope of the section, as well as a high-level view of the theory that organizes the data

within that section. This is often followed by a short paragraph that either further frames

the data or makes some assertions about what you are about to read.

What follows each section, comprising over eighty percent of this report, is titled 'Data

from the Interviews and Surveys'. Here you will encounter a series of quotes. These are

the voices of the people who work at the Texas City Site. The basis for selecting which

quotes made it into the Report, from the near-overwhelming mountain of text data we

received, was two things: criticality and typicality. All quotes represent the voice of

more than a few people. We have made minor changes to honor the confidentiality of the

conversations. However, for many of the stories included, there are two or three stories

that could not be told without, in some way, revealing the identity of its source to

members of this team.

We also limited repetition in the report, although in some cases, we have purposefully

included it. When included, this was done in order to provide you with an experience, as

we had at times, of the pervasive commonality of certain views at the site by being

exposed to the sheer quantity of those perceptions. Nevertheless, even in each section of

the report where we include this kind of repetition, we were forced to cut from one half to

one quarter of the quotes we had.

You will also encounter some quotes from the interviews and surveys repeated in more

than one section of this report. We have removed as much of this as we could, but we

I We use the tenn 'protection' to capture all of individual safety, process safety, integrity management, and

environmental safety. In this way we mean to cover most of the ways active failures and latent conditions at the site can intentionally left some in. We do this because a quotation or story changes as a function

of the context within which it is told. A certain statement about 'training', for example,

when viewed through the lens of a specific' organizational factor', will mean something

very different than when it is viewed through the lens of a specific 'workplace factor'.

In addition to our work with the interviews, we did review all the data from the surveys.

After that review, we chose not to concentrate much attention on the multiple-choice data

from the surveys because the text data was so surprisingly rich. We received so much

information, in terms of both quantity and quality, from the BP Texas City Site survey.

Some people attached two or three handwritten or typed pages to their completed survey.

We did test the answers we received from questions in our interviews against the data

from the surveys in order to confirm consistency. In many cases, we also tested both the

interview database and the survey database for any substantial internal site differences in

perspective. Between manufacturing areas, for example, we found only one substantive

difference. Protection performance itself, and the way people spoke about their area's

protection performance and culture, was significantly better in the A&A manufacturing

area than it was in any of the Refinery MATs. In addition, when asked about morale, the

majority in each salaried category said it "was staying the same", whereas in both hourly

categories (operations and maintenance), the majority in each said that it was declining.

But even in these cases, as with nearly all the multiple-choice questions, the difference in

numbers tended to be less than one, to only a few percentage points. One exception is the

table below. In this question, we asked people to force-rank what they perceive to be the

priorities at the Texas City Site from the options we gave them, also appearing in the list

below. Their answers were:

Ranking Priority

#1 Making Money

#2 CostlBudget

#3 Production

#4 Environmental

#5 Maior Incident

#6 Quality

#7 Security


#9 People

We have studied the survey data in only a preliminary way in terms of race and gender,

and we have not studied the data at all in terms of organizational heritage, years at Texas

City, or functional area. We are happy to review survey data more specifically with you

in the future, but we chose neither to overwhelm nor distract you with numbers,

percentages, and negligible internal differences in this report.

We originally intended to include within this report - or as a part of the off site - an

exploration into the human, workplace, and organizational factors perhaps not fully


People are generally seen as free agents (having 'free will'), and able to choose between

correct and erroneous actions. This builds the case for the notion that most errors, then,

must be deliberate. When errors do occur, they are often understood as deliberate

actions, and are viewed as blameworthy. These errors are then dealt with by warnings,

sanctions, and demands 'to be more careful in the future'.

These measures are ine1Iective since they never get to the underlying latent conditions

that had to be there in nearly all cases for the human error to cause an injury or an

incident. The view that the AU2 incident was just a matter of "a choice someone made

not to tie off' is a good example.

Therefore errors continue, and the operator continues to be primarily implicated in further

bad events. The cycle worsens because these new errors are seen as even more egregious

because, obviously, the warnings and sanctions are being ignored. And around we go.

This cycle, when tied to 'what gets rewarded around here' form the background of what

is good and bad in the culture of protection at Texas City.

For almost all individual injuries, and for all process safety or integrity management

incidents, viewing the person at the human/machine (or human/process) interface as the

most significant cause is not very fruitful because the underlying conditions never get

addressed. While incident investigations include 'system errors', the incidents live as a

conversation at the site as one of blame for the individuals. Of course there is always a

fair amount of blame for management from some at the human/machine interface (for not

having bleeders between every pump and block valve, for example).

It is more fruitful, in terms of fighting 'the safety war' with a sustainable safety and

integrity management 'fitness program', to view human error as a consequence rather

than the cause. Even in the quotes below, where individuals acknowledge mistakes they

made (our best people can make some of our worst mistakes), the authentic search for

workplace and organizational factors is necessary.

Getting Hurt on the Job

When responding to queries about injuries and incidents on the job and the perception of

a just culture and appropriate organizational responses to those incidents and injuries,

many acknowledge being injured and have the perception that the organization did not

respond appropriately. A few say that personal injury leads to punishment and

harassment and this impacts reporting of routine injuries. Some say the injury response

by the company is all about managing the numbers versus caring about the employee and

managing the injury. An overwhelming number of interviewees say employees are to

blame for the incidents. Very few say there are any collective individual or

and some say the

company response is appropriate.

The following responses are mostly from the question, "Have you ever been hurt on the


After an incident we add more detail to the procedure and fire the victim.

In the past management did not show proper care. Now they seem to care more, but

always after someone has been hurt. A superintendent once told me he judged if it was

unsafe by how many people had been hurt by it. He is still here today.

Once a safety incident occurs, Texas City reacts and manages it pretty well; what we do

not manage is the circumstance leading up to the event; mostly we do not recognize it.

For the most part investigations are negative as you must be politically correct when they

come to interview you; on one hand you can get in trouble with the union leadership and

on the other hand you can get in trouble with the refinery leadership. The result is an

investigation report stripped of the real issues by Legal. And what you get is not really

helpful, at least at my level.

Actions and investigations for root causes are always after some gets hurt.

Finding a way to validate that the incident was the result of human failure or poor

decision-making seems to be the objectives of our investigations and after After Action


I see very little of the result of BP incidents as a contractor unless that incident was

caused by a contractor or the injured party was a contract employee.

Investigations all lead to the conclusion that human error caused the mishap; I find that a

little disturbing from the perspective that it provides little insight about a meaningful


Auto accident en route to sister site - unavoidable - but we were treated as if we caused

the accident even though the other driver was cited. Forced to come to work via taxi

when unable to drive and under pain medication, which causes drowsiness - bad

headache - unable to perform a job; management was trying to avoid a lost time from

work. Personal concern was felt, but more concern was given to avoid lost time from


Had an eye injury - foreign object to eye - from a wind blower. I was given a shift change

to avoid a lost workday with no or little communication from the supervisor making these

changes, or their basis of these changes. Not once did I get to attend the meeting or

engage in the treatment path, work obligation, or even if I needed time off to heal. I was

told to show up and sit in the office with no production work assignment. Things have

changed some since this occurred.

Hit in the head. Management was all over it and really cared!

Hurt leg. Yes, management did fix a short ladder. (We had to step high to get to the first

big step to get off); they extended the ladder.

I have had 4 recordables! Alii got each time was negative response to my actions! Only

one had any action taken!

I have not been hurt significantly; I did slip and fall on an oil spill once, but did not report



No, I have not had any major injuries, but I have been in a near miss incident. Yes, my

supervisor showed proper care and took appropriate action to solve the root cause.

No, I run like hell and have ducked and dodged every hazard in this dump.

No, not sure if it is luck or skill.

No. An employee in my group was injured. Management took the time to follow up on

employee and insisted on closing the loop to resolution.

No. But, I know someone who was injured in my unit. After the investigation we never

heard about the outcome or what we learned from the accident

They said it could not have happened on job, so suddenly it didn't.

Yes - told to get something done; didn't have time or people to get what was needed to

do it very safely - my risk was perceived as limited - today it is somewhat better.

Yes - dangerous asphalting sampling methods at TC-RDU; yes - we eliminated asp

sampling and shut down asp station. .

Yes - due to an inept engineer's oversight. And I was blamed for it.

Yes - more than once. But I usually don't report it because we don't want to ruin BP's

safety record and if you do report it, you will hear about it at safety meetings for the next

3 yrs.

Yes, they took real good care of my family and me.

Yes - unit was in a rush to start up and scaffold was not removed prior to startup. No, we

still start up without proper removal of scaffold.

Yes - working short handed. No concern was shown.

Yes, a switchgear flashover. Unreliable equipment still in service. Management blamed

us for incident, but did give more training on equipment and policies.

Yes, and they just wanted to find someone to blame.

Yes. I burnt a finger getting lunch out of oven. It would have taken away our days worked

without an accident. Now when we get hurt, you drag yourself out the gate, if you're able,

and say it happened at home.

Yes, I have been hurt and had management punish me and make a fool of me. Need I

say more?

Yes, I have been injured. Management showed concern at the time, but over the years,

the same habits are beginning to show up that caused the injury in the first place.

Yes, I have. I committed an unsafe act, and yes, they resolved the cause. My own fault -

got in a hurry and took some short cuts.

Yes, I was injured because management chose to hire a contractor that felt our safety

rules were too stringent for him. He stated so in court. Management did not remove or

discipline the contractor.

Yes, I was: mine was a lack of knowledge of possible engulfment in an area where there

was a leak. An investigation was done and recommendations made. A lot was done to

help insure the possibility of an accident like mine may somehow be avoided. But over

time they are slowly being less and less adhered to.

Yes, if you do a lot of physical work you're going to get hurt eventually.

Yes, styrene loading arm (docks) broke. Management showed concern only after it was

shown that it was not my error.

Yes! Safety and law department grossly falsified accident report. Would not make

corrections. Claimed it did not matter and nobody would ever read. False report is still in

my file.

Yes! I had a lengthy lost-time accident. Nobody did a thing to repair the problem. I was

harassed and made to feel I should not have gotten hurt. The problem was repaired 12

years later because a manager had the same accident! Go figure!

Yes, a burned hand. Did not report it, due to new hire probation.

Yes, because the sewers didn't work - backed up with water and trash. Show proper

care to who? They still are working on the sewers after 6 years.

Yes, burned on temporary piping was told to be careful; nothing was done to prevent it

from happening again.

Yes, drum was improperly placed on pallet, hurt my back trying to fix problem. Reported

to supervisor, but never sent to medical.

Yes, I have been hurt but never reported it due to the enormous amount of B.S. that goes

with it. Supervisors and superintendents are punished in performance review because

someone that works for them gets injured. Hourly workers are punished by loss of bonus

money from VPP.

Yes, I reported it and they made me feel like a fool, and they will not make me feel that

way again.

Yes, I tried to lift too much weight by myself. No, we are still working jobs short handed.

Yes, I tripped on newly installed walkway that was improperly made. No notice of new

change was communicated by supervision. Management made corrections immediately

at investigation response.

Yes, I was hurt while working on the job at docks. The personnel at the docks told

management the loading hoses were unsafe to work with but they did nothing about until

someone had an incident They took action to solve problem by trying to blame me in

being unsafe but others on committee didn't see it that way. The management on the

docks were the ones to put the blame on me.

Yes, I was put in a taxi and sent to mainland ER for stitches.

Yes, I was reprimanded for not reporting injury right when it happened. As far as solving

the root cause, no common sense was used. This incident had no fix needed, but people

tried to think of ways to fix a problem that didn't need a fix.

Yes, improper maintenance, always my fault, that's what management said.

Yes, keep it to myself. This is common practice.

Yes, lack of attention to task. Management handled the incident with due concern but, the

solution was useless. An action item was created just to satisfy a report requirement.

Yes, lack of attention, rookie mistake, and no root cause to solve.

Yes, lack of training and my lack of experience. I did what 2 other senior operators were

doing and got hurt The equipment failure causing the accident was addressed 5 years


Yes, lost part of a thumb. Yes, they fixed problem machine and bought new and safer


Yes, mechanical failure; I was blamed in the end. I was not the root cause.

Yes, minor steam burn resulting in FA visit; management encouraged self treatment to

avoid OSHA recordable injury.

Yes, it was automatic find fault with the person that got hurt. They are out to take a free

ride. I really think BP spends more money getting out of paying on-the-job injuries, than

they would if they were just taking care of their employees. The problem with what

caused the injury: some fixed, some not. No one wants to get hurt out here and, don't get

me wrong, I now work for a superintendent that does honestly care and tries to fix the

problem, but in the past when I got hurt, the superintendent could care less - it was just a

mark by his name. Let's face it. Some people are only concerned with their advancement

and budget.

Yes, and all they did was harass me and fight workmen's compo

Yes, one time something got in my eye. Management sent me to medical to make sure it

was scratched even though I flushed it out.

Yes, only after a trip to the ER, did a change come to have contractors do the risky job


Yes, pulled muscle in neck. In fact, they drug me through the process with workman's

compensation for years. I will not notify them again.

Yes, received burn to leg. All management cared about was procedures, OSHA, etc.

Yes, sprained lower back, yes, management did show appropriate action.

Yes, they made fun of me.

Yes, they want you back to work as soon as possible regardless of your condition.

Yes, they wanted to give me disciplinary action to me, when it was not my fault.

Yes, told to get the job done, period, no ifs, ands, or buts.

Yes. Acid 90% sprayed on arm, due to thin pipe. The line was replaced, but never

checked before that, and never checked after.

Yes, because I took a short cut, which was not the fault of the supervisor -- just so we

could keep the job moving and on schedule. Now I pay for my decision every day of my

life, and will keep paying until the day I die. For those five minutes back, so that I could

think out what I did wrong, I would pay a lot. Again,! took the short cut and not the


Yes. Burned with hot H~ at WTP #1 late 70's, took several years to correct problem.

Yes. Due to decision makers in supervision not really knowing their jobs. Too many

people making decisions based on who they know and not on what they know!!!

Yes. I was unaware of a hazard. Yes, care was good. Concern was weak. Response to

fix the problem was ok.

Yes, lack of review of risk of job prior to beginning work. After the fact, we did resolve the

root cause and correct the situation.

Yes, it was my own personal failure to follow proper PPE. The root cause was addressed.

However, I personally felt that management was more concerned with safety stats rather

than my personal welfare.

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