The Weekly Reflektion Week 35 / 2020

While working on an assignment connected to Major Accident prevention, I needed to refer to the report from the Cullen Inquiry into Piper Alpha. The particular issue was related to the authority an investigation leader has to extend the investigation mandate in order to cover issues that may not have been considered in the original terms of reference. The scope of the Piper Alpha investigation was intended to be wide-ranging and gave Lord Cullen a reasonable justification to look at almost any issue that may be related to the disaster. Lord Cullen did however state ‘my remit did not entitle me to embark on a roving excursion into every aspect of safety at work in the North Sea or into every grievance, however sincere or well-founded, that was entertained.’ Any investigation will need to be limited since there is neither unlimited resources nor unlimited time.

How do you set your expectations to any investigation? What scope do you give the investigation team? How do you balance between the relevance to the incident, the potential learning and improvements and the time allocated to the investigation?

The investigation into a major accident should have four main objectives:

1. Find out what happened, how it happened and why it happened and recommend measures that should be implemented to prevent any recurrence. In this process one has to recognize that each major accident is unique so the focus in identifying measures is to address the causes of the Major Accident. 

2. Identify other processes and conditions that are important for prevention of Major Accidents that may not be directly related to the causes, however, are found to be in need ofimprovement through the investigation work.  

3. Identify any actions or conditions that could be considered as criminal and that should be followed up in the criminal courts. This is essentially a task for the police and their investigation. 

4. Reestablish trust in the companies, the authorities and the politicians involved in the industry. People working in the industry and the public need continual assurance that any industry, in particular industries with a risk of major hazards, can be run safely and with an acceptable risk for people andthe environment. A Major Accident will seriously erode that trust and if the industry is to regain public confidence then itmust demonstrate that it will learn and that a Major Accident will not happen again.

An investigation into a Major Accident should address all these objectives. In fact, an investigation into any incident and accident should address these objectives. While the consequences may be less the principles are the same.

The investigation needs to be carried out by personnel with the appropriate technical, operational, and organizational competence and include people that have investigation experience. The investigation must be thorough and be perceived as thorough. The investigators should be recognized as impartial and objective and be perceived to have no vested interest in any potential outcome. The media will inevitably have a focus on any Major Accident and its investigation. The media will have their own agenda and their own focus areas that may not correspond with the focus areas for the investigation team. If the investigation is not seen as thorough and objective, then the Major Accident may live on far beyond the implementation of any lessons learned.