7/21/2019 organisational.pdf

http://slidepdf.com/reader/full/organisationalpdf 1/1

Acci-Map : Societal, Corporate and Organizational Factors

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   R   e   g   u    l   a   t   o   r   y

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   C   o   r   p   o   r   a   t   e

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   A   c   c   i    d   e   n   t   s   e   q   u   e   n   c   e

 Rev Title: Date: By:

Blow-down drum

is replaced with a

similar, smaller

model

Worker trailers

sited near ISOM

unit 

ISOM unit is

started up after

maintenance

shutdown

High level

alarm is

ignored

Management decision to

not continue with start-

up not communicated to

operators

Tower

overfilled

Level control

valve is shut

off (no

outflow)

Truck left

idling near

the ISOM

unit (ignition

source)

Explosion

(15 dead and 170

injured; site

closed. Loss of

production)

Heated raffinate

escapes through the

blow-down drum

and is released to

air

Lack of open,

clear

communication

Cost cutting

(low ROI)

Lean staffing

policy

Pay incentives

on personal

safety

Budget priorities

(production)

Incomplete

maintenance

Lack of process

safety

leadership

Attitude of

casual

compliance

Outdated

procedures

Decentralised

management 

Local HSE

manager has

minimal

resources and

influence

BP

maintenance

policy and

standards

No fatigue

prevention

policy BP site traffic

safety policy

No monitoring

of flow in/out

of the tower

Shift change

during start-up

Market forces

OHSA or

industrystandards not

met

CSB understaffed and

unable to undertakesufficient audits

Inadequate federal

regulatoryoversight

EPAregulations

Policy violated

No abnormal

situation training

Lack of

appreciation of

start-up risk Lack of

assessment of

ignition sources

Undersized

equipment 

No generative

safety culture

Decision madenot to install to

flaresPre-start check

not done

Cost pressures

Maintenance

backlog

Focus on

LTIs

Shift handover

not conducted

Poor or

incomplete

incident

investigations