# data[].attributes.body
Right hand
consequence:
1. expolsion
2. enviromental pollution
3.worker injured and death

control on consequence:
1.explosion control
2.extinguishment fire and reduce secondary damage
3. Rescue of marine ecological animals
4.Deployment of containment devices
5.Personal and Family Compensation
6.Treat the injured and

pay medical expenses

# data[].attributes.body
Source of risk
1. Technical failure
2. Bad Management - inefficiency decision making
3. Safety instrumented system not working

Prevention Controls
1. Process safety metrics need to be developed
2. Update a shift communication policy or emphasis on communication
3.

Risk Event
Texas city explosion

Consequence
1. Property losses
2. Deaths or injuries onsite or offsite
3. Incidents with broad national significance

Recovery Controls
1.1 Positive Safety Culture
1.2 Safety instrumented system daily check
2 Process safety systems of high hazard industries need the same emphasis and focus as personal safety
3. Achieve a risk management office or risk management team to ensure the company have a proper risk register/risk strategy

# data[].attributes.body
Left hand: (Threat & Barrier)
Threat：
1. The review process has not been strictly enforced
2. The equipment has a serious problem and has not been repaired
3. Improper operation
4. Insufficient information transmission
Barrier：
1. Improper management
2. Technological issues
3. The employee is negligent at work and has not been trained

Right hand: (Consequence & Recovery Measure)
Consequence：
1. Facilities damage
2. Staff injuries and deaths
3. Environmental pollution
4. Government reputation will be suffered.
Recovery：
1. Regular inspection and maintenance of equipment
2. Purchase insurance
3. Properly arrange the injured, care for their families, and actively deal with and eliminate hidden dangers
4.Conduct strict safety inspection, avoid the second exposure

# data[].attributes.body
Left hand:
Threat:
1.The rig cant take much more pressure
2. BOP device failure
3. Old technology

Preventive controls:
1. Daily check for leaking sopt
2.oil-leaking warning device
3.hot-operation permission
4.Update equipment involving safety-related operation

# data[].attributes.body
3. After Texas City, what changes could have been introduced to stop Deepwater Horizon from occurring?

- Added remote shutdown function. Additional backup systems are needed to automatically shut down offshore Wells in an emergency.
- Reduce our use of fossil fuels.
- Add relief Wells. A relief well was required to be drilled at the same time as the first well. The cost would be much higher, but far less than the billions of dollars in compensation

# data[].attributes.body
1. ISOM unit alarm and maintenance, and the excess gas can be rerouted to blow down drum.
2. Put Don parus took over the refinary. Commission an employee Survey.
Controlled the degree of explosion and reduced secondary damage.

# data[].attributes.headline
1. What controls did BP use to manage risk at Texas City?

# data[].attributes.subject
1. What controls did BP use to manage risk at Texas City?

# data[].attributes.body
Establish a corporate safety culture.
Use device to monitor daily operations.
Establish a safety management system.

# data[].attributes.body
1. Equipment/Environment condition

a large part of the refinery infrastructure and process equipment were in poor condition
2. Poor risk management caused by culture and growth

As the BP became bigger, it's management system can't prevent and respond to the risks appropriately.
3. The safety system is not working properly
4. Staff's wrong Operation
the Day Board Operator fully opened the level control valve to the heavy raffinate storage tank and shut off the gas fueling the furnace.
Lack of Communication
5. Management

Site selection changes were not made in accordance with the management of change process (MOC)

# data[].attributes.body
1. Senior needs to focus on the risk management of the safety process in factory
2. Test and maintain the system regularly, and apply for system status in time
3. Regularlly check the factory environment and euipment to ensure the security.
4.Trainning for operators.

To improve operator's operating skills
5. Recularly improve and update operating specifications
6. In organizational level, establish Safety Management Agency.
7. Reconsidering and improving the current risk management process.

# data[].attributes.body
develop a Bow Tie diagram:

Develop Bow Tie diagram – First half of case – Left hand side (barriers)

Develop Bow Tie diagram – Second half of case – Right hand side (recovery measures)

Questions:

1. What controls did BP use to manage risk at Texas City?

2. How effective were the controls?

3. After Texas City, what changes could have been introduced to stop Deepwater Horizon from occurring?