The Weekly Reflektion Week 04 / 2020

Reflekt was started in October 2017 and since then we have produced 115 Reflektions that we hope have been interesting reading and perhaps provided useful learning. Reflekt has also organised five seminars on learning from Major Accidents. Our belief that the unique insights from the investigations into Major Accidents can be used both to prevent Major Accidents and improve performance has been strengthened. Our own knowledge and understanding of Major Accidents has developed through the Reflektions, the seminars and the projects we have worked on since we started. The Petroleum Safety Authority (PSA) focus for 2020 is ‘Never another Major Accident’ a sentiment we support wholeheartedly and we are available to help in how to achieve this.   

The Major Accident occurs, the Major Accident is investigated and mitigation measures are identified. Actions are taken to implement these measures, but will the actions last? And how do you know?

The Deepwater Horizon disaster in the Gulf of Mexico was a well blowout that led to an explosion and fire that killed 11 people, seriously injured 17 and led to the destruction of the Deepwater Horizon drilling rig. 780 000 m3 of oil were spilled into the Gulf of Mexico and it took 87 days to contain the leak until a plug was set on the 15th July, although the well was not sealed until the 19th September 2019. The disaster and the subsequent public outcry almost led to the demise of BP, a supermajor oil company, due to costs for the clean-up and litigation. The reputations of the involved parties, BP, Transocean and Halliburton were severely damaged. The reputation of the oil industry was badly affected by the disaster and the public and politicians rightly questioned how the industry could let such an incident occur. The disaster led to an extensive investigation and the consequences of the disaster are still influencing the oil industry today. EU Directive 2013/30 Safety of Offshore Oil and Gas Operations was issued as a consequence of the disaster and this led to an update of the Offshore Safety Case Regulations in the UK in 2015. The PSA in Norway established a cross-disciplinary internal project team in May 2010 to follow up the incident and look at possible changes to Norwegian regulations in the wake of the disaster. The following statement is made on the PSA website. Four years after Deepwater Horizon (DwH), the PSA sees visible improvements in Norway on the key lessons from this incident. But the acid test is whether these effects are lasting.

What is the acid test for whether the key lessons from Deepwater Horizon or any other Major Accident have been learned and retained? The acid test cannot be based on negative results, i.e. the fact that a major accident has not happened does not necessarily indicate that the lessons have been learned.

How do you know that a Major Accident is not just around the corner? How do you know whether you have been operating on the limits and that perhaps only luck has prevented the Major Accident?

The PSA main issue for 2020 is ‘Never another Major Accident’ and as noted above we agree with and support the sentiments. However, words and sentiments are not enough and actions are required. Our first contribution is related to investigations and audits. Welcome the investigations and embrace the audits. Create a culture where these are encouraged by the management and accepted ways of doing business. If the organisation sees the management encouraging investigations and audits, this will remove any stigma attached to the activities, and they may then be accepted as positive.

If the organisation feels that they are not performing in any area, calling for an ‘outside eyes’ audit may help identify improvement possibilities. The goal should be to improve, not to avoid others noticing we are not performing. Mindful leaders should always be on the lookout for these opportunities. The investigations and audits can be used as ‘acid tests’ for whether lessons from Major Accidents have been learned if they are organised and executed to this end.

Reflekt AS