In 2005, an explosion at BP’s Texas City refinery killed 15 people, injured more than 170 others, and resulted in billions of dollars in losses, including asset damage, production disruption, regulatory penalties, and legal settlements. Investigations found that the incident was not caused by a single failure, but by breakdowns across procedures, training, and operational controls. All these areas fall within the scope of OSHA’s Process Safety Management (PSM) standard.

Most organizations today have PSM programs in place, yet serious incidents continue to occur, including a recent refinery explosion in Port Arthur, Texas in March 2026. In many cases, the PSM elements are in place, but they are not functioning together or are not aligned with how the facility operates. Over time, this disconnect affects how risks are identified and controlled.

PSM is structured around 14 elements, but it does not function as 14 independent activities. Its effectiveness depends on how well those elements are applied, connected, and maintained over time.

Where breakdowns begin

One of the most common failure points is how PSM is managed day to day. Many organizations treat it as a set of requirements to satisfy rather than a system to operate. Hazard analyses, procedures, training, and maintenance programs may all exist and appear complete, but when they are not connected or consistently maintained, gaps begin to form. Because these activities do not directly contribute to production, they may be deprioritized in favor of short-term operational demands. Over time, the program becomes an exercise in documentation rather than a reflection of how the work is performed and maintained in the field.

That disconnect becomes more visible when programs are not kept current. Procedures may no longer reflect current operations, documentation can lag behind equipment or process changes, and required activities such as audits or reviews may be delayed. These gaps may not appear significant on their own, and the program can still look complete on paper. In reality, it no longer reflects current conditions and disconnects develop between documented practices and how the facility operates.

Incident investigation is another area where this breakdown appears. In many cases, the level of investigation is based on the outcome of the event. Near misses or minor incidents may receive limited attention, while more serious incidents trigger deeper analysis. The underlying causes, however, could be the same. Evaluating incidents based on potential consequences and likelihood of recurrence provides a more accurate view of risk exposure. What happens after the investigation is just as important. If findings are not incorporated into procedures, training, or system updates, the same conditions remain in place and incidents could be repeated.

Breakdowns extend beyond internal programs

Contractor management introduces a different type of risk. Contractors may arrive on site with established safety programs that meet their own requirements, but those programs do not always align with the expectations of a PSM-covered facility. Differences between contractor practices and facility requirements can create inconsistencies that are not immediately visible and may not be identified early enough in the process. Pre-bid meetings, bid clarification discussions, and pre-mobilization planning are where expectations should first be aligned, including environmental, health, and safety (EHS) requirements. Without that alignment, differences in how work is planned and executed can introduce additional risk.

In many cases, there is limited visibility into how well the PSM program is performing. Programs may appear complete, but gaps between documented practices and actual operations are not always visible without a structured review. Compliance audits (required at least every three years) and gap assessments provide a baseline for identifying those issues and prioritizing corrective actions. Without a structured understanding of program performance, improvements tend to be reactive rather than proactive.

Across each of these areas, the pattern is consistent: PSM breakdowns do not typically result from a single failure or a missing element. They develop over time as programs fall out of alignment with current operations and those gaps are not addressed. As they accumulate, the system safeguards become less effective.

Maintaining an effective PSM program requires a clear understanding of how the system is performing, where gaps exist, and how they are prioritized and addressed. Without that level of visibility and follow-through, even well-developed programs can drift out of alignment with actual operations and the risks those operations present. When those risks are not fully understood or managed, small gaps can escalate into major incidents.