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Former U.S. Secretary of State James Baker headed a panel to investigate BP after a refinery explosion in March of 2005 killed 15 people and injured 170. It was the worst industrial accident in the United States in 10 years.

The panel recommended that BP change their safety procedures at all of their refineries.

The investigation found significant safety culture issues existed throughout BP’s U.S. refining network as the company emphasized personal safety but neglected process safety risks that could result in major accidents.

“Instances of a lack of operating disciplines, toleration of serious deviations from safe operating practices, and apparent complacency towards serious process safety risks existed at each of the U.S. refineries,” the panel said in a release.

BP, one of the world’s biggest oil companies, needs to strengthen accountability at all levels of management and create a new system to identify and manage safety risks, the report found.

The CEO of BP John Browne said that the company’s leadership team would be meeting with the panel to discuss implementing the changes.

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