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  • Acci-Map: Societal, Corporate and Organizational Factors

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    Damien Naidu
    44 views1 page
    The document summarizes the societal, corporate, and organizational factors that contributed to an explosion at an industrial site that killed 15 people and injured 170. It identifies inadequate government oversight, cost cutting policies, lean staffing, outdated safety procedures, lack of communication and safety culture, and incomplete maintenance as key issues. The explosion occurred when equipment was overfilled during a startup after maintenance due to multiple failures to properly monitor the process and address safety issues.

    Original Description:

    AcciMap of BP Texas City Disaster

    Original Title

    organisational.pdf

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    The document summarizes the societal, corporate, and organizational factors that contributed to an explosion at an industrial site that killed 15 people and injured 170. It identifies inadequate government oversight, cost cutting policies, lean staffing, outdated safety procedures, lack of communication and safety culture, and incomplete maintenance as key issues. The explosion occurred when equipment was overfilled during a startup after maintenance due to multiple failures to properly monitor the process and address safety issues.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    44 views1 page

    Acci-Map: Societal, Corporate and Organizational Factors

    Uploaded by

    Damien Naidu
    The document summarizes the societal, corporate, and organizational factors that contributed to an explosion at an industrial site that killed 15 people and injured 170. It identifies inadequate government oversight, cost cutting policies, lean staffing, outdated safety procedures, lack of communication and safety culture, and incomplete maintenance as key issues. The explosion occurred when equipment was overfilled during a startup after maintenance due to multiple failures to properly monitor the process and address safety issues.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Societal

    Organizational / Management

    Corporate

    Government/
    Regulatory system

    Market forces

    Cost pressures

    Inadequate federal
    regulatory
    oversight

    EPA
    regulations

    Cost cutting
    (low ROI)

    BP
    maintenance
    policy and
    standards

    Lean staffing
    policy

    Decentralised
    management

    Pay incentives
    on personal
    safety

    Focus on
    LTIs
    Maintenance
    backlog

    Blow-down drum
    is replaced with a
    similar, smaller
    model

    Worker trailers
    sited near ISOM
    unit

    ISOM unit is
    started up after
    maintenance
    shutdown

    Outdated
    procedures

    No fatigue
    prevention
    policy

    Lack of
    appreciation of
    start-up risk

    BP site traffic
    safety policy

    No generative
    safety culture

    Local HSE
    manager has
    minimal
    resources and
    influence

    Lack of
    assessment of
    ignition sources

    No abnormal
    situation training

    Shift change
    during start-up

    Incomplete
    maintenance

    Pre-start check
    not done

    Lack of process
    safety
    leadership

    Poor or
    incomplete
    incident
    investigations

    Budget priorities
    (production)

    Policy violated

    Accident sequence

    OHSA or
    industry
    standards not
    met

    CSB understaffed and


    unable to undertake
    sufficient audits

    Attitude of
    casual
    compliance

    High level
    alarm is
    ignored

    Shift handover
    not conducted

    Management decision to
    not continue with startup not communicated to
    operators

    No monitoring
    of flow in/out
    of the tower
    Decision made
    not to install to
    flares

    Lack of open,
    clear
    communication

    Level control
    valve is shut
    off (no
    outflow)

    Acci-Map : Societal, Corporate and Organizational Factors

    Tower
    overfilled

    Truck left
    idling near
    the ISOM
    unit (ignition
    source)

    Rev

    Undersized
    equipment

    Heated raffinate
    escapes through the
    blow-down drum
    and is released to
    air

    Title:

    Explosion
    (15 dead and 170
    injured; site
    closed. Loss of
    production)

    Date:

    By:

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