The panel, in a statement summarizing its 370-plus page report on BP's operations, said the company had made strides in personal accident prevention but came up short on the bigger picture.
"The panel maintains a central theme that prior to the Texas City tragedy BP emphasized personal safety and had achieved significant improvements in personal injury rates, but the company did not emphasize process safety," the statement said. "BP mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance at its U.S. refineries."
The 11-member panel made 10 recommendations, including that an independent monitor report to the company's board of directors for a period of five years. The full report was to be released later Tuesday.
Baker has led the panel investigating corporate management at Houston-based BP Products North America following the March 2005 blast that killed 15 people and injured more than 170 others.
The U.S. Chemical Safety and Hazard Investigation Board, known as the CSB, urged BP in August 2005 to hire outside experts to look at the company's oversight of safety management systems and make its findings public — similar to an investigation at NASA following the space shuttle Columbia tragedy.
Read the Baker panel's report (374 pages)
The panel, announced in October 2005, has traveled to BP's five U.S. refineries and interviewed hundreds of employees.
"BP tended to have a short-term focus in its U.S. refining operations, and its decentralized management system and entrepreneurial culture delegated substantial discretion to U.S. refinery plant managers without clearly defining process safety expectations, responsibilities or accountabilities," the panel said in the report.
The report explains that the panel focused on "process" safety rather than personal safety.
"Process safety in a refinery involves the prevention of leaks, spills, equipment malfunctions, over-pressures, excessive temperatures, corrosion, metal fatigue, and other similar conditions," the report says.
"Process safety programs focus on the design and engineering of facilities, hazard assessments, management of change, inspection, testing, and maintenance of equipment, effective alarms, effective process control, procedures, training of personnel, and human factors. The Texas City tragedy in March 2005 was a process safety accident."
The release of the BP report was twice delayed because of his work with the Iraq Study Group, which made its recommendations to President Bush last month on how to revamp U.S. policy in Iraq.
The release of the report comes less than a week after London-based BP said Chief Executive John Browne would step down by the end of July, more than a year ahead of schedule.
BP said Friday that Browne, 58, will be succeeded by Tony Hayward, the head of exploration and production, who will assume the task of trying to repair the company's reputation with the public and investors. Problems stem from a series of well-publicized mishaps that include the Texas explosion and last year's giant oil spill in Alaska.
The 2005 explosion has so far cost the company around $2 billion in compensation payouts, repairs and lost profits. BP has settled hundreds of lawsuits related to the accident, putting aside $1.6 billion just to resolve legal disputes.
Based on its investigation, the CSB has criticized BP for its safety systems at Texas City, about 40 miles southeast of Houston, finding the company fostered bad management at the plant and failed to fix problems.
In September 2005, the U.S. Occupational Safety and Health Administration found BP committed more than 300 willful violations of its rules and fined the company $21.3 million.
BP's own December 2005 report blamed failures by management at the refinery, saying it didn't make safety a priority, tolerated risks and failed to communicate. But BP added it "found no evidence of anyone consciously or intentionally taking actions or decisions that put others at risk."
The CSB has credited BP for cooperating with its investigation, making sweeping changes in how it recognizes potential hazards and hiring the Baker panel.
BP has said it will invest about $1 billion over five years to improve and maintain the Texas City site. BP also operates refineries in California, Indiana, Washington and Ohio.