The Weekly Reflektion 50/2022

The investigations into major accidents often note the signals before the accident that indicated some things were not right. The disregard for safety precautions, the breaches of the control of work procedure, recurring incidents, concerns from the staff. Sometimes the signals are strong, for example a dropped object from 20 meters. Sometimes the information may be ambiguous or no more than a gut feeling that things are not right, weak signals. These signals are of course perfectly clear in the light of hindsight after the incident has occurred.

What signals are you watching for to ensure you don’t have a Major Accident?

Road traffic fatalities in Norway had been steadily declining since 2016. The statistics for the first six months of 2022 however show a twofold increase from the same period in 2021. The main increases are motorbikes and private cars. The fatalities for the first 6 months in the period 2016 to 2022 are as follows; 62, 42, 43, 48, 45, 30, 63. Norway has relatively low speed limits and the number of fatalities per head of population in 2021 was the lowest in Europe. The correlation between speed and fatalities is well documented in traffic studies. A report on traffic accidents in the period 2017 – 2020 concluded that drivers on Norwegian roads in general respected the speed limits. The main reason given by the Norwegian Public Road Administration (Statens vegvesen) for the increase in fatalities in in car accidents in 2022 is distractions. The latest cars, in particular electric cars, have large VDUs that often capture the driver’s attention while driving. Update of software, navigation systems, finding the way around the many radio channels, answering the mobile that is linked to the car computer system are all fighting for attention. Using mobile phones while driving is also a major factor by diverting the driver’s attention from the road and other traffic. The Norwegian Public Road Administration does not exclude speed as a factor in the fatality increase and an increase in speed just before an accident may also be due to distraction. The increase in road accident fatalities is a signal that should be followed up by drivers, police and the road authorities and ignoring this signal is likely to lead to a higher fatality rate.

We have used the BP Texas City refinery explosion 23rd March 2005 in several Reflektions and will continue to do so in the future. At Texas City prior to the explosion that killed 15 people and injured 200 there were many signals that some things were not right. Here are some examples:

2003 Working environment study at the refinery – serious concerns about the potential for a major accident

2003 BP audit – the current condition of the infrastructure and assets is poor at Texas City

2004 BP audit – Widespread tolerance of non-compliance with basic HSE rules

2004 BP Getting HSE right process – Texas City refinery in complete decline

2004 Refinery safety report – 3 major process accidents with 3 fatalities

2004 Employee survey – Production and budget compliance gets recognised and rewarded above anything else.

2004 – lowest ever recordable injury rate (not all bad, but not really a beacon of hope for Major Accidents)

February 2005 statement by Refinery Safety manager – I truly believe we are on the verge of something bigger happening at Texas City Refinery

The changeout of refinery manager six times in seven years and a corporate focus on 25% cost reduction may explain why the signals were not acted on. 

Reflekt AS