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… from ‘Piper Alpha’ to ‘Deepwater Horizon’, do we really learn?

A couple of days ago I started to read the latest report of the Buncefield Disaster. The report highlights some root cause of the disaster in management failings;

“these pressures created a culture where keeping the process operating was the primary focus and process safety did not get the attention, resources or priority that it required.”

Sometimes it seems we never really learn from the past.

Is it that we do not recognize the recurring theme of organisational culture? Perhaps we do not understand how to address risks created by cultural problems?
Certainly the ‘lone gunman’ theory is more comfortable to accept, rather than consider an indictment of the wider system.

A History lesson

On the 6th of July 1988, in the North Sea, the oil platform “Piper Alpha” was destroyed as a result of an explosion and resultant fire. 167 dead and a significant impact on North Sea Oil production.

An enquiry was established (Cullen Inquiry, reported in late 1990) which was critical of the management of the operator. Cullen commented that senior management were too easily satisfied and relied on “the absence of any problems as indicating that all was well”. Like too many organisations still do, the operators tolerated “known problems” and management demonstrated only a “superficial response when issues of safety were raised by others”.

What changed? The introduction of more controls, audits and reviews. These included things like a Safety Case regime.

Fast forward 10 years …
On September 25th, 1998 in Victoria Australia the Longford Gas Plant suffered a major disaster (gas leak leading to explosion, fire). Fortunately this time only 2 people died, 4 million people had to get by without gas for 2 weeks.

The company blamed the operator on duty, but the official inquiry (a Royal Commission) blamed the company (Esso) for not ensuring its staff knew the risks they faced and the correct procedures for dealing with them.

As a result of ‘efficiency’ measures and cost cutting there was minimal staffing in the control room, this coupled with reductions in maintenance meant that it became ‘normal’ to have alerts go unattended for some time. Safety was a secondary concern to throughput, and profit.

Following the disaster Victoria (and other states) implemented some of the Safety Case regime that was developed after Piper Alpha – but still did not see the recurring cultural problem.

Another 7 years pass …
23 March, 2005 – Texas City Refinery, USA. Fire and explosion, 15 dead and 170 injured.

The operator (BP) had not maintained the plant well and had ignored prior incidents and reports about safety.

An inquiry led by former Secretary of State, James Baker, found that BP was more concerned with occupational safety than process safety. The management process (and incentives) encouraged a focus on measuring falls and driving accidents – while ignoring risks and hazards around the core processes and equipment of the refinery.
Despite the major fines and costs imposed in US courts, and the forced resignation of the Group CEO, it seems the company did not learn. This is the same BP that operated the Deepwater Horizon.

7 months later

December 2005, the Buncefield disaster. Again a formal inquiry finding that an operating company had its focus on efficiency and ‘token’, minimalist safety.

There is a common thread here we can learn from. Culture contributes to all these incidents.

The changes after the incidents are for more regulation and audit but not for changes to culture.

Efficiency is the enemy of reliability.

Reliability requires duplicating resources and having people able to deal with unpredictability. This would require training and development, encouraging independent thinking and retaining skilled and experienced people in process work.
Efficiency looks for standardisation and predictability. This will include removal of duplication, ‘risk managed’ maintenance and minimum wage for minimum thought staff.

The root cause of this risk is not just the organisation’s culture – but the market and the wider culture of investment and productivity. We need to promote a culture that supports reliability rather than just a focus on efficiency.

I have written about the principles of High Reliability Organising in other posts, but these aspects need to become part of the culture of an organisation that seeks to be resilient. Especially those who operate in these high risk areas such as oil and gas production.

Does your company truely have a safety culture? How is it manifested?
How have you tried to promote a culture of reliability in your organisation?

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