One member of the assessment team went so far as to say the local refinery has the weakest oversight of the group - even worse than the BP refinery in Texas City, Texas, where a 2005 explosion killed 15 people and injured 170 others in what has been described as the nation's worst industrial accident in more than 20 years.
"The biggest problems were at Toledo, not at Texas City," said Nancy Leveson, a member of the BP U.S. Refineries Independent Safety Review Panel, which spent more than a year doing its review.
Former U.S. Secretary of State James Baker III created the panel in late 2005 by order of the U.S. Chemical Safety and Hazard Investigation Board in the wake of the Texas City explosion in March of that year.
Ms. Leveson, who does safety consulting for NASA's shuttle program, is a professor of aeronautics and astronautics as well as a professor of engineering systems at the Massachusetts Institute of Technology.
"The Toledo plant certainly has problems," agreed another panelist, L. Duane Wilson, a retired ConocoPhillips vice president.
Said Mr. Baker: "I don't think we're naive enough to think that problems like this existed only [at Texas City.]"
Mr. Baker's global law firm, Baker Botts LLP, which has represented BP in the past, was assigned to do an unprecedented safety-culture probe of the London-based oil company's U.S. refineries.
His panel included the nuclear industry's top executive, a former U.S. senator from Washington state, a heart specialist from the Mayo Clinic, executives from steel, chemical, oil, and other industries, and an economic development official.
Safety culture is an assessment of an industrial site's workplace atmosphere, to gauge the propensity for accidents based on the mindset, morale, training, attitude, and other often-intangible factors.
Anything from machinery inspection records to workloads are analyzed.
The Baker panel's report leaves no doubt that a lot of work remains at BP's Toledo-area refinery, which BP said has been in constant operation since 1919. It sits on 585 acres east of Toledo and south of Lake Erie's Maumee Bay, in the heart of Oregon's industrial zone along Cedar Point Road.
Survey results consistently showed workers at the Oregon refinery - especially operators, maintenance/craft technicians, and contractors - with lower morale and higher anxiety than those at other BP sites.
The report said local BP workers generally believe the corporation has put production ahead of safety. They have grown weary of frequent management changes, and - like workers at other BP refineries - are fatigued by excessive overtime.
"The Toledo refinery, which BP has owned far longer than the other four U.S. refineries, has a weak safety culture," the report said. It cited a history of poor communications, distrust, and management that is "generally more negative than management at the other refineries about issues concerning process safety culture."
At one point, the report describes the relationship between BP Toledo's unionized work force and its outside contractors as "hostility" that grew as the oil company started to bring in more outside workers in the 1990s.
The site has 500 BP employees and 350 full-time contractors, with an annual $42 million payroll, according to company literature.
"Toledo has a weak safety culture, largely because of chronic morale problems and a history of poor relations between refinery management and the unionized workforce," the report said.
Ron Unnerstall, BP Toledo's fifth plant manager in six years, said the panel's findings "are consistent with some of our internal reviews" and promised improvement.
Both Mr. Baker's panel and one that analyzed the Davis-Besse nuclear power plant's safety culture said that improving morale and other nontangibles can take five or more years.
"It'll happen faster," Mr. Unnerstall promised.
A document released by the company cited numerous improvements in Oregon since the Texas City explosion.
BP also issued a corporate-wide statement saying that it planned to embrace the Baker panel's recommendations throughout its domestic operations.
The panel's findings surprised Oregon Mayor Marge Brown and Ken Filipiak, Oregon city administrator. Both said BP has been a good neighbor.
But Ms. Brown acknowledged she has been dismayed by the turnover in plant managers. "In order to build trust, you have to be there more than a couple of years," she said.
Mr. Filipiak said Oregon has been assured by BP that it is "going to step up and do a better job."
"We're satisfied they're going in the right direction," he said.
The world's first safety-culture assessment came in response to its worst nuclear accident, the 1986 explosion at the Chernobyl nuclear plant near Kiev, Russia.
Such assessments continue to be rare.
Safety-culture assessments were done at NASA following the fatal shuttle disasters of 1986 and 2003.
Locally, FirstEnergy Corp. was ordered by Nuclear Regulatory Commission officials to do one at its Davis-Besse nuclear plant 30 miles east of Toledo, after the utility had neglected maintenance on that facility's old reactor head so much that the device nearly blew apart in 2002.
Mr. Baker's panel spent at least a week at each of BP's five U.S. refineries. It interviewed hundreds of employees, managers, and executives. It reviewed more than 7,500 completed surveys. It searched public and internal documents.
And it spent about six hours with Lord John Browne, chief executive of BP's global operations. That included about three hours with him in England and three on a conference call, Mr. Baker said.
The review team came up with numerous recommendations, mostly administrative ones for assessing risk, improving communications and training, enhancing self-auditing procedures, incorporating lessons from the Texas City explosion, and encouraging workers to be more forthcoming about safety issues they see on the job.
Carolyn W. Merritt, chairman and chief executive officer of the federal safety board that ordered the assessment, said Mr. Baker's panel "has given us an unprecedented insight into the safety culture of BP, one of the world's largest corporations."
"There is no doubt that the issues of safety culture and safety management identified in this report are serious and warrant immediate action by BP, its executives, and its board of directors," she said.
"This is an opportunity for review and reform on a worldwide scale."
The United Steelworkers union announced yesterday it has reached an agreement in principle with BP on a comprehensive joint safety initiative in conjunction with the Baker panel's report.
"The root causes [of the Texas City explosion] went much deeper, to the way process safety was managed throughout the corporation. And while the panel was not charged with looking beyond BP, we in the union know that similar problems exist throughout the oil industry," said Gary Beevers, vice president of United Steelworkers International.
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BP's Toledo refinery in Oregon has had "very deeply rooted" problems with safety oversight for years, according to a special review of the oil company's five U.S. refineries.