The Weekly Reflektion Week 38 / 2019

This week’s Reflektion is inspired by my son and his response to my question on what was the most important factor for preventing accidents. ‘Do nothing’ he suggested.

When things are going well should we just leave things alone and assume they will continue to go well?

In the Reflektion in week 37 we were inspired by the HSE philosophy in a kindergarten my son attended. ‘No child should hurt themselves more than what is good for them’. I mentioned this to my son, who is now 10 years old. I then asked him, what he thought about safety and preventing accidents. ‘Do nothing’ he suggested ‘if you don’t do anything then no one will get hurt’. Interesting. It actually reminded me of some advice I received from a control room operator when I was working in the process department at the Sullom Voe oil terminal in Shetland. ‘The best thing you can do is keep your hands in your pockets and touch #¤%% all’. It was called the HIP TFA philosophy.

When things are going well, why should we do anything? Why should we change? Will they not continue to go well?

The first point to be considered is whether we really have a proper understanding of what ‘well’ is. At Reflekt’s breakfast seminar in March 2019 we asked the question ‘what does good look like?’ and reflected over whether our view of good was actually an appropriate basis for prevention of a Major Accident. The management in Occidental in the UK may have had a view that things were going well on Piper Alpha before 6th July 1988. Yet the Piper Alpha disaster happened, and the investigation revealed that things were perhaps not going as well as some may have liked to think. Perhaps the indicators the Occidental management were using did indicate that things were going well.

The second point is that we are encouraged to improve. In Norway the Norwegian Petroleum Safety Authority (PSA) requires the operators responsible for offshore oil and gas installation to strive to improve safety and reduce risk. Commercial and competition pressures require operators to find more efficient ways to operate. Innovation and application of technology are key focus areas for companies to improve performance. Improvement requires change and changes requires a process that ensures the change can be carried out without any adverse consequences. There are many Major Accidents that have a poorly managed change as a cause.. The Flixborough disaster in June 1974 being a case in point.

The third point is that sometimes changes are happening and we are not aware of them or their potential consequences. We think everything is going well and we think that we will continue this way. A HIP TFA philosophy perhaps. However, some changes may be gradually happening. Not significant enough that we notice the change on a day to day basis but over time the changes are creeping up on us and one day the changes result in a Major Accident. Creeping change and the potential consequences of creeping change will be the subject of our next breakfast seminar on the 25th September.

The fourth point is lady luck. Sometimes things are going well because the combination of circumstances that could cause a failure have not yet arisen. Since things seem to be going well we are not looking for problems and we are becoming complacent. The hand of lady luck is removed and the circumstances arise where the latent failures combine to produce a serious incident or even a Major Accident.

Even when things are perceived to be going well we need to be mindful. We need to continually search for weaknesses and ensure they are sorted out.        

Reflekt AS