The Weekly Reflektion 24/2022

We often hear people claiming that the only thing that doesn’t change in their organization is continuous change. The drive for better performance, whether improving safety, reducing the effect on the environment, increasing production, reducing costs, etc, inevitably leads to a change. However, we are not always so good at understanding why something is in place before we change it.

Do you find out why things are the way they are before you change them?

We would like to thank everyone that attended the ‘Listen and Reflekt’ 1st June 2022. The subject for was Learning from Incidents. . Also, thank you to everyone that participated in the discussion and contributed their own reflections. If ‘learning from incidents’ had been easy, then we would have fixed it a while ago. The offshore petroleum industry is a challenging recipe. The ingredients of fallible people with their personalities, strengths and weaknesses, complicated systems, dangerous materials andhazardous environments that combined shall not be a recipe for disaster. It’s challenging, however as Trevor Kletz once said, ‘we know how to prevent disasters, it’s just a case of applying the knowledge’. Gunnar Brekke from Equinor made us aware of ‘Chesterton’s Fence’ and we thought this was a good basis for a Reflektion.

Some people may enjoy watching the detective series ‘Father Brown’ where a catholic priest solves various criminal cases. A sort of religious Sherlock Holmes. The author of the ‘Father Brown’ books is C. K. Chesterton, and he had an interesting insight that is often referred to as ‘Chesterton’s Fence’. 

The principle that reforms should not be made until the reasoning behind the existing state is understood.

In our Listen and Reflekt we used rail crashes in the London area to highlight the human dimension and the fallibility of people. 

The crash at Southall 19th September 1997 was due to a driver of a High-Speed Train failing to respond to warning signals. The driver was alone and the Automatic Warning System (AWS) on the train was disabled, and no mitigation measures were in place to compensate. Prior to 1996 there was a requirement for two drivers, however this changed, presumably since the AWS was installed and proven. There was no requirement for two drivers as a compensating measure in the event the AWS was not working.

The crash at Ladbroke Grove, near Paddington station, on 5thOctober 1999 was also caused by a driver not responding to a warning signal. The rail system around Paddington is congested and complicated and the signals were known to be poorly placed. Prior to 1994 there was a requirement that drivers responsible for trains in the area had at least 2 years’ experience. Following privatization of the rail infrastructure this requirement was discontinued. The driver involved in the crash had two weeks experience.

Managing changes can be challenging and it is important that changes are subjected to a systematic process with involvement of people with the necessary competence and experience. One of the steps in the process should be a review of the existing system, procedure, equipment, etc that is planned to be changed to ensure its intention and the reason for why it is the way it is, is understood. A search of the company’s’ incident reports may reveal useful information.

Do you find out why it is, before you change it to something else?

Reflekt AS