The Health and Safety Executive has highlighted a series of management failures as being responsible for life-threatening accidents at BP's Grangemouth complex.
BP's Grangemouth plant had three major incidents in a month
The report found standards had been allowed to slip, managers had not detected "deteriorating performance" and had failed to abide by the law.
BP said it has invested £80m in improvements since the fire, power failure and pipeline rupture between May 2000 and June 2000.
Falkirk East MP, Michael Connarty, said BP's plans to cut up to 1,000 jobs at the plant will jeopardise safety.
During the period between 29 May and 10 June 2000 three incidents occurred at the complex.
A power distribution failure was followed by a medium pressure steam main
rupture and a fire in the Fluidised Catalytic Cracker Unit (FCCU).
Each had the potential to cause fatal injury and environmental impact, said the report.
BP was prosecuted for the failures and fined more than £1m in January 2002.
The petrochemical giant pleaded guilty to two charges relating to the FCCU fire and the steam main rupture incidents.
The HSE report, published on Monday, is the result of a joint investigation (led by HSE) with the Scottish Environment Protection Agency (Sepa).
The key lessons from the
report for the chemical and refinery industries are:
Alistair McNab, HM Principal Inspector of Health and Safety, who led the investigations, said: "This was a thorough and wide-ranging investigation which extended beyond the plant and installation to examine human factors, management of health and safety and the safety culture.
- the ability to properly measure major hazard performance is crucial in
allowing companies to detect deteriorating standards and enable managerial
intervention before a major incident occurs.
- making sure process safety is properly managed by specific focus on major
hazard control as distinct from "conventional" health and safety management.
- do not underestimate the dangers from the more mundane systems on a chemical
site such as disruption to utility supply systems (steam, electricity etc).
"The investigation started immediately after the first incident in May 2000 and at its peak involved up to 20 inspectors."
He said that BP had cooperated fully throughout the investigation.
"Since these incidents there has been a sustained improvement of safety performance across the Grangemouth complex," he said.
In a statement BP Grangemouth, said: "BP identified those areas where we had fallen short of our high expectations for our management of safety and environmental performance.
"We implemented immediate actions to address the issues.
"Since 2000, BP Grangemouth safety performance has improved dramatically.
"In addition to a fundamental review of safety procedure, the site spent about £80m on task force actions in 2001.
"The lessons learned from the Grangemouth experience has been shared with other BP sites around the world."