On March 17, 2005, the business unit leader in charge of BP’s Texas City refinery sent a summary to all of the site’s supervisors. It passed on the findings of a safety-culture survey by outside consultants. Seeing the “brutal facts” so clearly defined was hard to digest, the email said, including the concern about “the conflict between production and safety.”
The same summary carried good news. The site had got off to a good start in 2005, with safety performance that “may be the best ever.” Texas City had also had “the best profitability ever in its history last year,” more than $1 billion in profit.
The safety performance in question was the kind BP measured most closely: how often its workers got hurt. In 2004, according to the U.S. Chemical Safety Board, Texas City had the lowest OSHA recordable injury rate in its history, nearly a third of the average for oil refineries. Yet three people had died at the refinery that year, in three major accidents.
The injury rate mattered for more than pride. In the BP bonus plan used at the refinery, safety counted for 10 percent of the total and cost leadership for 50, and for 2003 and 2004 the injury rate was the only safety measure in it.
Six days after the email, on March 23, operators restarted a unit that made components for gasoline. At its heart was a tower 170 feet tall. As they filled it, the level indicator showed the liquid level falling. It was rising. At 1:04 p.m., the control system showed operators 7.9 feet of liquid in the tower. The real level was 158 feet. The tower’s backup high-level alarm did not go off. Operators had reported before the restart that the level transmitter gave inaccurate readings, and the repair had been put off until after startup. The day before, technicians checking the critical alarms had been told there was no time for more checks.
At about 1:14 p.m. relief valves on the overfilled tower opened, and flammable liquid geysered out of a vent stack. At 1:20 it ignited. The explosions and fire killed 15 people, all of them in or near office trailers close by, and injured 180.
The Chemical Safety Board’s report, issued in 2007, listed among the causes BP’s “reliance on the low personal injury rate at Texas City as a safety indicator,” which “failed to provide a true picture of process safety performance.” A separate panel, chaired by former Secretary of State James Baker, reached the same view across BP’s US refineries: BP had “mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance.”
The board’s recommendations asked the oil industry and the steelworkers’ union to write a standard for process safety indicators, “leading and lagging,” and asked BP’s board to make sure its senior executives used both.