This quote is from The Baker Panel Report (2007), one of the key reviews arising from the massive explosion and fires that killed 15 people and injured another 180 at the BP Texas City Refinery, Texas, on 23 March 2005.
As a Human Factors Specialist Inspector with the UK Health & Safety Executive (HSE) I produced several documents to communicate the key lessons to industry. I visited all of the UK refineries and many other facilities, to assess their progress against the main recommendations arising from the disaster. It led to a great deal of activity in the worldwide petrochemical industry in an attempt to learn lessons.
However, back to that quote: “People can forget to be afraid“.
Sure, at the time, everyone was talking about this disaster. But what about now? And what have other industries learnt from this? The lessons are certainly not unique to BP, and neither are they unique to the oil/gas/chemicals industries.
Regardless of the industry, people and organisations fail in similar ways.
The book by Andrew Hopkins discussing this event is called Failure to Learn. This title originates from the fact that there were so many warning signs from the industry, from BP’s other facilities and from within the Texas City refinery itself.
This ‘failure to learn’ was a reflection of BP.
But if other companies and other industries have not learnt from the disaster, this would be a bigger failure. In fact, it would be a tragedy.
This was quite different to many previous disasters, because so much of BP’s operations, systems, processes and structures were laid bare for the world to assess and discuss. The lessons are all there for you to consider.
The investigation by the US Chemical Safety & Hazard Investigation Board (CSB) resulted in a report that should be required reading for all senior leaders.
This CSB report is an excellent example of how to investigate the technical, human and wider organisational issues of a major incident. It also contains significant commentary throughout as to what constitutes good practice in these areas. For these reasons, I highly recommend the report to anyone wanting to learn about human and organisational factors generally, not just the specifics of this incident.
With so much information available, how do you start to consider the potential lessons for your company?
To help you reflect and learn, I have collated 12 quotes that illustrate some of the key human factors issues identified in the investigations.
This “reflection toolkit” can be downloaded as a pdf, containing links to three key investigation reports.
Article on humanfactors101.com that outlines the key human and organisational factors identified in the various investigations into this disaster.
The CSB report. Investigation report: refinery explosion and fire, U.S. Chemical Safety and Hazard Investigation Board (CSB), March 2007.
The Baker Panel Report. The report of the BP U.S. refineries independent safety review panel, 2007.