Thứ Năm, 2 tháng 6, 2005

Where were the Senior Managers?


(Picture credit http://www.cokingcokers.com)
Excel-web sharing of spreadsheetsI read this a couple of weeks ago. It's an AP article regarding BP, which explains the reasons for a massive explosion at their Texas City plant. The blast killed 15 workers and injured more than 170. You can read the entire thing at your leisure, but here are some telling quotes.

..."Deeply disturbing" staff errors led to the oil refinery explosion and fire that killed 15 workers, and some employees could be dismissed as a result, plant operators said Tuesday...

..."The mistakes made during the startup of this unit were surprising and deeply disturbing"...

...Supervisors and hourly workers face discipline ranging from written reprimands to dismissal, Pillari said. He declined to say how many employees would be punished...

...The BP investigation determined that fluid level in a tower was 20 times higher than it should have been. Water or nitrogen in the tower when the unit was restarted may have caused a sudden increase in pressure that forced hydrocarbon liquid and vapor into the unit's stack.

But investigators still don't know what ignited the resulting vapor cloud. Earlier theories have suggested that sparks from a running truck engine could have been to blame.

Investigators found that supervisors seemed to be absent at times during the unit startup, and crews didn't know who was in charge.

Also, any of six supervisors had a six-minute window in which they could have sounded an alarm to evacuate the area, but that alarm was never sounded, Pillari said. The decision, he said, denied other workers "the opportunity to get out of harm's way." ...


I've highlighted what I consider the key phrase. During the startup of an immensely expensive and dangerous refinery, wouldn't senior management have plenty of feet on the ground?

Sidebar: Ironically, Texas City was also the site of the worst industrial accident in U.S. history. A fire aboard a ship at the city's docks triggered an explosion that killed more than 550 people.
Supervisors were absent? Where were the refinery managers?

Crews didn't know who was in charge? Wha...? Where were the refinery managers?

Pinning this on supervisory and hourly personnel appears, at face value, to be the ultimate cop-out.

Senior management needs to define strict processes for an operation this complex and then audit those processes to ensure they are followed. This is a failure of senior management, plain and simple.

AP: BP: Personnel Failures Led to Texas Blast
 

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