It was typical of them to experience a fire every week, on average. A fire every week is a warning sign that something is critically wrong at the facility.

The question for any company is how good they are at managing through two inevitable barriers: the position paradox and the “check the box” mentality. Texas City is at high risk on these two counts. Position paradox: The people who have the most influence over the decisions that determine the safety and integrity management of a particular site are almost always the most distanced from those conditions. Unless managed, the result is blindness for the senior-most level of the site as well as those above the site. BP as a corporation has had this blindness and Texas City is no exception.

BP on Tuesday placed the lion’s share of the blame for the deadly blast at its Texas City refinery at the feet of low- and mid-level workers who it said were lax in following written company procedures during one of the most dangerous times in refinery operations. Had the six operators and one supervisor assigned to the start-up of the refinery’s so-called isomerization unit been doing their jobs, the explosion would not have happened … said Ross Pillari, president of BP Products North America.