On March 23, 2005, a massive explosion at BP’s Texas City refinery killed 15 people and caused more than 170 injuries in one of the worst U.S. workplace accidents in decades.
The direct cause of the tragedy was the release of highly flammable material from a process unit that had malfunctioned in the past.
But investigators pin the larger cause on a defective safety culture that included apathy over signs of trouble, a focus on production speed and costs over safety and widespread complacency over the built-in hazards of the refining process itself.
In short, in a setting in which human error can have catastrophic results, BP forgot to be afraid.
Lessons from Texas City
In the aftermath of the explosion, an independent panel headed by former Secretary of State James A. Baker III launched an investigation into what went wrong at Texas City. In early 2007, the panel released its findings in a report that blasted BP’s safety culture and urged the company to make safety the top priority at its refineries. But the Baker Report also made clear that BP was far from alone in failing to embrace safety culture. It called for companies to use the lessons of Texas City to renew their focus on safety culture as the best defense against the perils of industrial processes that are, by their nature, dangerous.
“We are under no illusion that deficiencies in process safety culture … are limited to BP,” the investigators concluded.
Call for renewal
The Baker panel’s call for a renewed focus on safety culture jibes with growing interest in the concept in a range of complex, high-risk industries, including the chemical industry. Over the past year, the Nuclear Regulatory Commission has stepped up the focus on safety culture as part of its plant-inspection process. Hospitals across the nation are looking for ways to combat human error in medical care, which kills as many as 100,000 hospital patients each year, according to the Institute of Medicine. The U.S. Chemical Safety & Hazard Investigation Board has called for more attention to safety culture, with a special focus on the role of contract workers in optimal process safety.
“We’re looking at a safety-culture revolution,” says Mike Phelps, vice president of safety and health at Baton Rouge-based Turner Industries Group, which launched a new company-wide safety-culture initiative in 2006. “Certainly the major, progressive contractors are looking closely at safety culture.”
Roots in nukes
Yet formidable obstacles to effective safety culture remain, starting with widespread misunderstanding of what it means. Indeed, the renewed focus on safety culture comes more than two decades after the event that spawned the term: the 1986 Chernobyl nuclear disaster that blew a 1,000-ton cap off a reactor and spewed radioactive material into the skies above Europe.
The atmosphere of secrecy and intimidation that preceded the disaster at Chernobyl gave rise to safety culture’s core components: a focus on safety as an organization’s top priority and a workplace environment where employees at all levels are encouraged—and rewarded—for raising safety concerns, even when that means slowing schedules or missing deadlines. It also means looking closely at whether established rules and procedures make sense. At Texas City, for instance, trailers were placed as close as 121 feet to the isomerization unit where the explosion took place, a situation that was dangerous but did not violate plant rules.
Even well meaning managers often confuse the personal safety of individual workers with the safety of process hazards.
“You mention ‘safety culture’ and a lot of people will say, ‘You mean hardhats?’” says Carey Foy, a safety-culture expert with Wilkinson, Foy LLC in Baton Rouge. “They think it means sticking to the rules, when really it means stepping back and asking if the rules themselves represent the safest way of doing things.”
More than trust and talk
An open and trusting workplace is not the only component in a healthy safety culture, notes Lisamarie Jarriel, who oversees a whistleblower program for the Nuclear Regulatory Commission. The NRC cites 13 components to a healthy safety culture, including adequate training, routine self-assessments and a decision-making process that puts safety first.
“People won’t report concerns if they don’t have sufficient training to know when something doesn’t look right,” Jarriel says. “It’s got to be the whole picture.”
Moreover, without constant vigilance, apathy and complacency can undermine the safety culture of any organization. Both can be deadly. Apathy was a factor in the 2002 near-disaster at the Davis-Besse nuclear plant in Ohio, where the reactor head nearly burst because of undetected corrosion. Leaks and stains on reactor walls suggested something was amiss, but plant operators never vigorously investigated their source.
NASA, which popularized the concept of safety culture in the U.S., has its own record of the perils of complacency. In 1986, NASA engineers shrugged off concerns about the cold weather launch of the doomed Shuttle Challenger, which burst apart shortly after take-off. In 2003, NASA officials had grown complacent about another deviation from proper procedure, this time the shedding of foam from shuttle fuel tanks. Again, complacency proved fatal when the Shuttle Columbia disintegrated upon re-entry.
While those tragedies are high-profile examples, a “creeping incrementalism” that jeopardizes safety can occur at any organization, Foy says. Safety-culture experts call it normalization of deviation: the idea that when a system doesn’t operate as it should but nothing bad happens, that deviation must not really matter.
“Your standards start to slip, and each time there’s a justification as to why that must be okay,” Foy says. “Over time, you develop a culture where less-than-optimal safety is acceptable.”
A leadership issue
Starting in the 80s, safety culture transformed the way pilots fly commercial aircraft. Co-pilots, once silent partners in the cockpit, became true partners under new cockpit resource management rules. In a little more than a decade, air carrier accidents linked to human error declined from 90 in 1990 to 55 in 2002, according to federal data.
Yet direct cost-benefit analysis rarely applies to safety culture investments in aviation or any other industry, says Foy, a former commercial pilot.
“You can’t quantify what catastrophe you’ve prevented,” Foy says.
As a result, leadership is often the crucial issue in an organization’s approach to safety, especially when it requires time and money that eat into profits, he says.
“Profit is a very legitimate goal, so it’s difficult sometimes to boards of directors and managers to want to invest in this,” he says. “They want to make prudent decisions where they can see a direct payoff.”
Phelps, of Turner Industries, views investment in safety culture as part of sound operations. He notes that Turner is taking its employees’ feedback seriously, and has changed several safety processes in light of their feedback.
“There’s tremendous competition out there, and this is about being both safe and smart,” he says. “We’ve asked our employees not to pull any punches with us on safety, and we mean that.”
For Foy, the final question comes down to values.
“Ultimately, this is a leadership issue that speaks to whether you are willing to do all you can to keep people safe,” he says. “That has to take place at every level, but it has got to start at the top.”
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