The Weekly Reflektion 13/2025
Welcome to Reflekt’s Breakfast Seminar, first coming Wednesday 26th March 2025 0800 to 1000 hrs at the Quality Pond Hotel in Forus.
The main theme for Havtil in 2025 is Artificial Intelligence is also a risk factor. This theme and the depiction of the ‘black box’ in the Havtil film is the inspiration for our next breakfast seminar.
‘The black box’, can it be trusted?
Contact graeme.dick@reflekt.as, mike.pollard@reflekt.as, or post@reflekt.as if you would like to attend.
More details on our website www.reflekt.as
Breakfast will be served at 0730.
The behaviour of the management sets the tone for the culture in the company. Looking for signs of weakness and talking about the traps that human nature may lead us into are ways of developing a culture of challenge.
Do you accept the easiest explanation when there is an indication of a serious problem?
Reflekt have always been interested in behavioural biases and how they affect the way we make decisions and how these can lead to unsafe situations, or possible major accidents. Several of these biases were seen in the major accident addressed in this Reflektion.
On January 31, 2013, a massive explosion occurred at the headquarters of Pemex (Petróleos Mexicanos), the state-owned oil company in Mexico City. The blast killed 37 people and injured more than 120 others. The explosion was later determined to have been caused by a gas leak in the building’s basement.
In the weeks before the explosion, workers reported the smell of gas in the building’s basement, but employees and maintenance teams dismissed the reports, assuming it was related to a minor issue with the sewage system, a frequent problem in the area. Since previous gas leaks had not led to explosions, they relied on past experienceinstead of properly investigating the new risk. This heuristic effectis related to people relying on mental shortcuts rather than a thorough analysis when making decisions.
The minor gas leaks in the Pemex facility had become a regular occurrence and over time these became part of normal operation. The risk associated with the leaks was regarded as acceptable, again since these leaks had never led to a major incident. Employees and decision-makers became desensitised to this risk and this is a typical consequence of normalisation of deviance.
During the investigation it was noted that Pemex officials and maintenance teams also assumed the building’s safety systems, such as ventilation were sufficient to handle any gas leak, so no evacuation orders were issued, even after multiple gas odour reports. The belief that the safety systems had always worked led to delayed action and ultimately a fatal explosion.
The gas leak that accumulated in the basement of the Pemex building, created a highly flammable environment which ignited, possibly due to an electrical switch. The massive explosion led to a collapsing of parts of the building.
Do you treat repeated “minor” issues as potential major risks? Do you encourage challenging past assumptions? Just because it has gone well before does not mean that this will continue.