The Weekly Reflektion Week 17 / 2020

John Paterson in his book ‘Behind the Mask, Regulating the Health and Safety in Britain’s Offshore Oil and Gas Industry makes the following statement regarding learning.
‘There is some recognition within the industry of this ability to learn from major events but an inability to learn from near misses.’
The learning from major events are often forced upon the industry by the public and political outrage from the fatalities/injuries and impact on the environment, and the financial consequences of the event. The near misses do not get this attention and the learning is consequently not forced upon the industry.

Do you extract maximum learning from near misses you experience in your own organisation? Do you actively share learning from near misses? Do you try to learn from the near misses of others?

The Elgin G4 well blowout on the 25th March 2012 was a near miss that could have escalated to a major accident if there had been an ignition source for the gas cloud. The resulting explosion could have led to multiple fatalities and the loss of the Elgin wellhead platform, the Rowan Viking drilling rig and potentially the Elgin platform. The resulting Major Accident would have led to an investigation and there would have been significant pressure to implement the recommendations from the investigation.

Reflekt organised a lunch and learn on the Elgin G4 blowout in September 2019. Reflekt obtained access to the Health and Safety Executive (HSE) report and based the presentation on this report. Reflekt also used an SPE paper from Total for some background on the well design and the emergency response. Reflekt invited Total to contribute to the presentation with any relevant information including information from any report from internal investigations that we are sure have been carried out. Reflekt appreciated that the HSE report may not contain all the relevant information for learning and that Total’s own investigation could be important. Total did not respond.

Elgin G4 did not have a significant effect on the regulations, standards and processes associated with the petroleum industry. The learning from Elgin G4 is limited since information on the incident is not readily available and there is no widely available presentation that covers the what, how and why of the blowout in sufficient detail including any recommendations to prevent recurrence. The significance of this will only come to light when a future incident occurs that has similar causes and circumstances but, this time, the gas finds an ignition source. Questions will then be asked as to why the industry did not learn from Elgin G4.

There is a lot of experience and a lot of evidence from research into incidents and accidents that the causes of failures in Major Accidents are often the same as the causes of failures in near misses. Learning from near misses should therefore be very relevant in Major Accident prevention.

There are two levels of learning that are important here. The first is the failure to learn from near misses like Elgin G4. The second is the failure to learn from the evidence and experience that we do not learn from near misses. That is, there are really no excuses here, we know we are not good enough. Let’s take a proactive approach and don’t put our industry in the position of having to defend why lessons were not learned at the hearings arranged for an investigation into a future Major Accident.

Reflekt AS