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BP U.S. Refineries independent safety review panel (The Baker Report)

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    Panel Statement
    Process safety accidents can be prevented.
    On March 23, 2005, the BP Texas City refinery experienced a catastrophic process accident.  It was one of the most serious U.S. workplace disasters of the past two decades, resulting  in 15 deaths and more than 170 injuries.
    In the aftermath of the accident, BP followed the recommendation of the U. S. Chemical  Safety and Hazard Investigation Board and formed this independent panel to conduct a  thorough review of the company’s corporate safety culture, safety management systems,  and corporate safety oversight at its U.S. refineries. We issue our findings and make specific  and extensive recommendations. If implemented and sustained, these recommendations  can significantly improve BP’s process safety performance.
    Throughout our review, we focused on being thorough and then letting the chips fall where  they may. As our charter contemplates, we allowed BP to comment on our report to ensure  its factual accuracy. However, we are solely responsible for our report’s final content.  Although we necessarily direct our report to BP, we intend it for a broader audience. We are  under no illusion that deficiencies in process safety culture, management, or corporate  oversight are limited to BP. Other companies and their stakeholders can benefit from our  work. We urge these companies to regularly and thoroughly evaluate their safety culture,  the performance of their process safety management systems, and their corporate safety  oversight for possible improvements. We also urge the same companies to review carefully  our findings and recommendations for application to their situations.
    Preventing process accidents requires vigilance. The passing of time without a process  accident is not necessarily an indication that all is well and may contribute to a dangerous  and growing sense of complacency. When people lose an appreciation of how their safety  systems were intended to work, safety systems and controls can deteriorate, lessons can be  forgotten, and hazards and deviations from safe operating procedures can be accepted.  Workers and supervisors can increasingly rely on how things were done before, rather than  rely on sound engineering principles and other controls. People can forget to be afraid.  When systems and controls deteriorate, everything can come together in the worst possible  way. Equipment malfunctions and controls fail. An explosion and fire occur. People lose their  lives or suffer horrible injuries. Families and communities are devastated.
    The burden of these catastrophes is uniquely and unfairly borne by the victims, their  families, and their friends. This was the case for the Texas City victims—men and women  who were providing a livelihood for themselves and their families. These victims were fathers  and mothers, husbands and wives, sons and daughters, and friends. We dedicate our report to the survivors of this tragedy and the memory of those who lost their lives. 

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