John Bresland

Chairman

United States Chemical Safety 

The Chemical Safety Board

Safety Culture 

NRC Internal Safety Cu

Task Force 

Nuclear Regulatory Commission Hea

December 4, 2008
Disclaimer

The PowerPoint presentation given by JoChairman, the United States Chemical SaHazard Investigation Board to NRC InternCulture Task Force is for general informapurposes only. The presentation represeindividual views of the Chairman and all reconclusions or other statements regarding ongoing CSB investigations are preliminaand do not represent a formal adopted proBoard. Users of this presentation should that the contents were compiled solely for presentation. For specific and accurate incompleted investigations, please refer to tprinted version by going to the CSB webswww.csb.gov. and clicking on the specific 

under completed investigations
My agenda today• What is the Chemical Safe• Some CSB investigations• Culture in organizations• Safety culture at BP Texas • Developing a strong safet
What is the CSB?• The CSB is an independent U.S. fede

charged with investigating chemical 

• Authorized by United States Congres• Modeled after the National Transport

Board

• Five Board members nominated by t

confirmed by the Senate

• Professional investigation staff• Located in Washington, DC
In a typical year• Incidents screened by the 

to 900

• CSB Investigations – 8 to 
The CSB Investigation • We decide to investigate, the • Interviews, document request• Findings, conclusions, written • CBI review by company, com

recommendations

• Preparation of a video• Public meeting and Board app• Follow-up on recommendatio
• Some CSB Investiga
WEST PHARMACEUTICAL INVESTIGATI


Imperial Sugar Company Refinery, Port WFebruary 7, 2008

T2 Laboratories Jacksonville, Flor

December 19, 2007



Associated Press Photograph – Valero Refinery S
Culture in organization• Service culture – hotel indust• Customer focused culture – a• Financial results culture – Wa• Safety culture – airline indust

power

• Safety culture – chemicals ma

oil refining
BP Texas City refinery 

March 23, 2005

BP Texas City - 3/23/2005

The BP Texas City ExplosFire• March 23, 2005 – explosio

killed 15 workers

• July 28, 2005 – process re

hydrogen fire

• August 10, 2005 – gas oil 

hydrotreater incident
CSB recommendations in Texas City investigation

BP Board of Directors:

- urgent recommendation -- 

safety culture review panel
Issues in the CSB’s UrgenRecommendation to BP• Effectiveness of the BP Te

safety management syste

• Effectiveness of BP’s cor

safety oversight

• A corporate safety culture 

tolerated deviations from practice
The BP Independent SafetPanel – the Baker Panel • Led by former Secretary o

James Baker III

• Members from industry, a

government, trade unions

• Published its report in Jan
Baker panel findings on Bculture• BP had not provided effective p

leadership

• BP had not established an ope

relationship between managemworkplace

• Adequate resources were not a

process safety

• Managers not held responsible 

safety

• Lack of a unifying process safe
Other Baker Panel Find• Emphasis on personnel s

process safety

• BP had not defined the lev

process safety competencof executive management

• BP’s Board of Directors h

ensured that there was an process safety managemein place
Baker Panel Recomme• Senior management must pro

safety leadership

• Executive management shoul

appropriate level of process sknowledge

• Develop a positive, trusting a

process safety culture

• Clear expectations for proces

performance

• Develop leading and lagging 
Elements of a strong safe• Management commitment to s• Priority of safety over produc• Employee involvement and em• Regular communication betw

management and the work for

• Assignment of responsibility 
• Examples of organization

strong safety culture

• Examples of organization

weak safety culture
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