The Weekly Reflektion 37/2022
Acronyms are abbreviations formed from the initial letters of the words in the expression being abbreviated. Some acronyms become so well established that they replace the original name or expression, e.g., NASA, IOU, SNAFU. Often the acronym becomes memorable and conveys a distinct understanding. The acronyms we are using today are WYLFIWYF and WYFIWYF.
Are you aware that the mandate for an investigation and the composition of the investigation team can determine the outcome?
Professor Erik Hollnagel is someone who has given many insights into humans, their behaviours and how to understand human behaviour in the context of accident prevention. His views on ‘Safety-1and Safety-2’ will be a subject for a future Reflektion. Hollnagel with Jonas Lundberg and Carl Rollenhagen published an article in Safety Science 47 (2009) 1297-1311. The article was titled ‘What-You-Look-For-Is-What-You-Find – The consequences of underlying accidents models in eight accident investigation manuals’.
The title is the basis for our first acronym WYLFIWYF. When an incident or accident occurs and we have decided to investigate, we tend to make assumptions on the causes even with only initial and superficial information. These assumptions are often reflected in the mandate for the investigation and for considering who and which disciplinesshould be part of the investigation team. Soon the investigation is in full swing with site visits, interviews, documentation and process reviews, etc, etc. Timelines and chain of events are developed, direct and underlying causes identified, findings, recommendations and actions proposed and agreed.
Our second acronym is WYFIWYF, What-You-Find-Is-What-You-Fix. This seems pretty obvious and why would any organisation not want to fix the problems that are identified in an investigation? Of course, these problems should be fixed, however are there perhaps other problems that are not uncovered and therefore no efforts are made to fix these. Our concern is related to a third acronym WYLFIWYF, What-You-Look-For-Is-What-You-Fix.
The following incident is taken from a report commissioned by the Petroleum Safety Authority (PSA) ‘Læring frahendelser’ by Proactima. The report seems only to be available in Norwegian, however well worth a translation to English.
In October 2015 a leak of about 6-7 m3 from the loading hose occurred while transferring crude oil to a shuttle tanker. The cause of the leak was corrosion, and this was suspected at the outset of the investigation. The investigation team included corrosion experts and metallurgists and corrosion mechanism was soon identified. The following is from the summary of one of the investigation reports.
The steel corroded as a result of repeated admission of seawater to the hose. Changes in the internal hose environment between anaerobic hydrogen sulphide (H2S) in the oil and oxygen saturated seawater have laid the basis for three possible corrosion mechanisms:
· seawater corrosion accelerated by local breakdown of the steel’s oxide layer (Fe3O4 – magnetite)
· seawater corrosion accelerated by the presence of iron sulphate
· elementary sulphur corrosion. Admission of seawater will basically give rise to the corrosion mechanisms assumed to have operated in the hose segments. The corrosion picture in the segments is regarded as complex.
The hose used was not rated for seawater and admission of seawater was not unexpected for this application. The hoseshould not have been used for the loading operation and the investigation did not focus on why this was the case. Maybe not as interesting as the corrosion mechanism.