BP Texas City Site Report of Findings
Texas City's Protection Performance, Behaviors, Culture,
Management, and Leadership
21 January 2005
I. Understanding Blame, Punishment, and a Just Culture 1
Getting Hurt on the Job
What is Recognized and Rewarded
II. Unsafe Acts and Violations
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
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:
#1 Making Money
#5 Maior Incident
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
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
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
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
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
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.