2.5.16 Fatalities and Injuries.....

2.5.16 Fatalities and Injuries........................................................................................................68
2.5.17 Equipment and Facility Damage.......................................................................................68
2.5.18 Offsite Damage .................................................................................................................70
2.5.19 Post-Incident Emergency Response..................................................................................70
3.0 SAFETY SYSTEM DEFICIENCIES IN UNIT STARTUP .........................................................71
3.1 Work Environment Encouraged Procedural Deviations.............................................................72
3.1.1 Procedures Did Not Reflect Actual Practice.....................................................................73
3.1.2 Procedural Changes Without Management of Change (MOC) ........................................76
3.1.3 Startup Procedure Lacked Sufficient Instructions ............................................................77
3.1.4 Summary...........................................................................................................................78
3.2 Ineffective and Insufficient Communication Among Operations Personnel..............................79
3.3 Malfunctioning Instrumentation .................................................................................................81
3.4 Poor Computerized Control Board Display................................................................................83
3.5 Ineffective Supervisory Oversight and Technical Assistance During Unit Startup....................85
3.6 Insufficient Staffing During Start Up .........................................................................................86
3.6.1 Refining and Corporate Management Decisions Affected Staffing .................................88
3.7 Operator Fatigue .........................................................................................................................89
3.7.1 Fatigue Factors..................................................................................................................90
3.7.2 Operator Performance Impaired by Fatigue......................................................................91
3.7.3 Lack of a BP Fatigue Prevention Policy ...........................................................................93
3.8 Inadequate Operator Training.....................................................................................................94
3.8.1 Training for Abnormal Situation Management.................................................................94
3.8.2 Verifying Operator Knowledge and Qualifications..........................................................96
3.8.3 Simulators Not Used to Train for Hazardous Scenarios...................................................96
3.8.4 Refinery and Corporate Management Decisions Affected Training.................................98
3.9 Failure to Establish Effective Safe Operating Limits...............................................................100
3.10 Distraction Not a Factor ...........................................................................................................101
3.11 Summary...................................................................................................................................102