The Weekly Reflektion Week 10/2021

Thank you to everyone that attended the Reflekt Lunch and Learn on Resilience on 18th February.
One of the examples we used was the blowout on the Snorre A platform in 2004 where a subsurface hydrocarbon leak from a well compromised the suction anchors for the tension legs and threatened the platform with fire and explosion. This was a situation that was not predicted in the design nor considered in the operation.

When the decision seemed to be the right one, was it just luck or was it the result of a good process?

Outcome bias is where we judge the quality of any decision by the outcome achieved. When the outcome is desirable, we tend to assume that the decision-making process was satisfactory. This tendency leads to lack of review and little reflection over the process and hence no learning. Outcome bias also leads to little consideration on how much luck and factors that we had little or no control over, influenced that outcome. We are then surprised when we use the same decision process next time, and the results are different. We are unlucky. Outcome bias is often expressed in the aphorism ‘the end justifies the means’.

At the Lunch and Learn we described the way the offshore crew managed the recovery of the blow out on one of the wells on the Snorre A platform, successfully killing the well, and maintaining platform integrity. In our view their resilience was an important factor in their response. One of the participants in the Lunch and Learn asked a question. Would the conclusion wrt. resilience remain if the Snorre A situation had ended up differently?

This is an interesting question and one that we would like to address in this reflektion.

On reflection, our interpretation of the way the Snorre crew handled the incident has a certain element of outcome bias. A perception of the risks being acceptable since no one was injured, and the platform integrity was restored.

If the situation had developed differently then there are different perspectives to consider.

Any change that led to an assessment of a significant increase in risk may have led the crew to make different decisions. For example, an escalation in the blowout gas rate and/or the loss of tension in the tension legs may have led the OIM to abandon the platform before the risks became unacceptable. Therefore, we emphasized the common risk picture and situation awareness to ensure everyone understands what is happening, what changes have occurred and how to respond to these changes.

If the situation had developed negatively and the crew did not respond or responded too slowly then their assessment of the risks would have been questioned. If the situation had escalated to a fire/explosion or a platform collapse and there were people on board that could have been demobilized or evacuated earlier then this would of course influence any judgement on all their actions. Note that this is not necessarily a reflection on their resilience in tackling the incident.

How much did luck play in the management of the situation and its outcome? A rhetorical question for this Reflektion.

We would encourage you to use incidents like Snorre A to stimulate discussion and dialog in your organisation to help you manage a future serious incident and not to just to judge the actions of the people involved.

Reflekt AS