Last week (November 9, 2006), BP reached a settlement with Eva Rowe, 22, just before jury selection was to begin in her civil lawsuit against the company for the death of Rose's parents in last year's deadly Texas City refinery explosion. It was the last of the lawsuits involving fatalities that had not been resolved out of court.

Also, six workers who were fired from their jobs at the Texas City refinery after the accident settled their libel suits with BP, according to the Associated Press. They each claimed that BP defamed them by blaming them for the accident. The six were involved in restarting, after a month-long outage, the unit that exploded on March 23, 2005, killing 15 workers and injuring 180.

Making amends

BP, one of the world's three largest oil companies, with profits of $19 billion in 2005, according to an October telecast on CBS's "60 Minutes," is trying to bring closure to the worst U.S. industrial disaster since 1989:

  • BP claims it has committed more than $1 billion over the next five years to upgrade and maintain the Texas City facility and has made safety improvements, including introducing better training programs and removing more than 200 temporary structures.

  • A ten-person "Fatality Investigation Team" was set up, composed of technical and safety experts from across BP as well as hourly and supervisory personnel from the Texas City refinery, to determine critical factors and system causes and report findings and recommendations.

  • BP entered a settlement with OSHA relating to the explosion and paid a fine of $21.3 million to resolve more than 300 separate alleged violations of OSHA regulations.

  • BP accepted an U.S. Chemical Safety Board recommendation and set up an independent panel led by former U.S. Secretary of State James A. Baker to assess the health of its safety management systems and safety culture across its U.S. refining network. The panel's final report is expected late this month.

  • A sum of $700 million was set aside to compensate victims of the explosion without the need to litigate. By April of this year, settlements had been reached with more than 230 people who had been injured. Eva Rowe was the last family member of a worker who died to reach an agreement with BP.

  • BP has also embraced transparency — to disclose what the company learned through its investigations with the local Texas City community, other companies, regulators, the media, and industry as a whole. In April, John Mogford, BP's London-based senior group vice president, safety & operations, detailed lessons learned to the Second Global Congress on Process Safety in Orlando, Fla.

Lessons in safety1 — Plant leadership teams must have the time to focuson day-to-day operations and cannot be distracted by too many competing demands. "Managers need to know what’s happening in their control rooms and on the plant," said Mogford.

Background: "There were three key pieces of instrumentation (related to the unit restart that triggered the explosion) that were actually supposed to be repaired that were not repaired. And the management knew this," said Carolyn Merritt, chairwoman of the U.S. Chemical Safety Board (CSB) at time. She has since retired..

2 — Capture the right metricsthat indicate safety trends. "Do not get seduced by personal accident measures, they have their place but do not warn of incidents" such as the Texas City catastrophe, advised Mogford.

Background: In the five years prior to the explosion, BP had reduced its OSHA recordable injury rate by almost 70 percent and its fatality rate by 75 percent. In 2004, BP Texas City had the lowest injury rate in its history, nearly one-third the oil refinery sector average, according to the CSB.

3 — Procedures are ineffective if they are not up-to-date and routinely followed. Background: BP’s own rules require office trailers to be parked at a safe distance from dangerous operations, but BP had placed trailers full of workers in an open area, right next to the unit being filled with gasoline, according to the CSB. BP also failed to tell the workers in those trailers about the dangerous operation about to take place close by, according to the CSB.

4 — Two-way communication is absolutely crucial. "If people believe leaders aren’t listening or don’t appear to be taking team members’ concerns seriously, then soon they stop raising them. This is about staying in touch, being aware, being responsible and listening," explained Mogford.

Background: There is evidence that Texas City’s plant manager, Don Parus, was alarmed by unsafe conditions at the refinery and tried to get the attention of his bosses in London, according to the "60 Minutes" report. He showed them a culture perception survey revealing that most workers at the refinery felt the plant was unsafe. One worker wrote, “The equipment is in dangerous condition and this is not taken seriously.” Another wrote, “This place is set up for a catastrophic failure.”

In the survey, most employees agreed that "production and budget compliance gets recognized and rewarded before anything else at Texas City," according to the CSB's investigation.

5 — Document all incidents thoroughly — including near misses. It's important to investigate all process incidents and loss of containment incidents the same way serious injuries are investigated, said Mogford.

Background: In the ten years leading up to the disaster, there had been eight major gasoline vapor releases on the unit the triggered the explosion — any one of which could have been catastrophic, according to the CSB's investigation.

6 — An effective feedback loop is essentialto capture and incorporate into operating procedures and training programs lessons learned from earlier incidents and process upsets, said Mogford.

7 — Safety cultures don't fall apart overnight. "The factors which contributed to the explosion at Texas City were years in the making," said Mogford. Without the right safety metrics, and without listening to workers' concerns, management is in the dark, and easily slips into denial.

8 — Acknowledge mistakes publicly. "It’s a painful process," said Mogford, but a necessary one to rebuild trust among the workforce and refinery neighbors. "There’s nothing proprietary about an awful incident of this kind," said Mogford.

BP's Mogford did not address two issues that the CSB's investigation team believes to be linked to the explosion. They also serve as lessons to be considered:

9 — Beware of budget cuts. When BP acquired the Texas City refinery from Amoco eight years ago, the plant already was in a state of disrepair, according to the "60 Minutes" report. Instead of spending money to revitalize the plant, BP executives in London told their refinery managers world-wide to cut their budgets.

"Twenty-five percent of their (worldwide refinery) fixed costs were cut. And when you cut that much out of a budget in a facility, you lose people, you lose equipment, you lose maintenance, you lose trainers," Merritt told "60 Minutes." "Our investigation has shown that this was a drastic mistake.

10 — Safety training can't mask system deficiencies. Several years of audits and reports by BP had identified serious cracks in safety systems, said the CSB. But most BP safety initiatives focused on improving personnel safety, such as slips, trips and falls, rather than management systems, equipment design, and preventive maintenance programs, according to the CSB.

There's one more lesson to ponder, uncovered in the "60 Minutes" investigation:

11 — What's the point of a safety meeting? The morning of the blast, one BP worker told "60 Minutes" a safety meeting was held for 300 to 400 workers. "There was not a thing said about that unit starting up," said the worker, Pat Nickerson. "The plant was about to start up the unit, which is an especially dangerous procedure, but none of the workers were told about this at the safety meeting?" reporter Ed Bradley asked.

"Nothing was said," Nickerson replied.

"Placing a trailer during a startup operation that’s going to be full of people without any warning is the telltale sign that you’ve lost that understanding and realization of the very risk of what you do," CSB Chairwoman Merritt told Bradley.