THE WEEKLY
REFLEKTION
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The Weekly Reflektion 19/2021
Sometimes when things fail, we just get lucky. While it is a relief when the situation is saved by lady luck, it’s not something we want to rely on. Do your automatic systems behave as your people expect them to behave? Loganair flight BE-6780, a SAAB 2000 turboprop, was preparing to land at Sumburgh Airport in the […]
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The Weekly Reflektion 18/2021
In a remote operating environment, where conditions can change quickly, effective decision-making demands good and up to date information. How do you ensure your operations have enough information to make good decisions? At the beginning of November 1989, Typhoon Gay was forming in the Gulf of Thailand, the first typhoon in the past forty years […]
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The Weekly Reflektion 17/2021
As time goes on the ‘risk picture’ usually changes, sometimes for the better but sometimes for the worse. Reflekt have seen these changes being missed in recent incident investigations. What signals do you look for to indicate that circumstances have changed, and previous assumptions are no longer valid? An activity or an operation that has […]
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The Weekly Reflektion Week 16/2021
A passenger ferry ran aground and sank. In a high technology society, how did this happen? Does your crew know what to do in the event of an emergency? How do you know? On 26th November 1999, the passenger ferry Sleipner was travelling from Stavanger to Bergen in Norway, having just left Haugesund at 1850 hrs. Sixteen […]
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The Weekly Reflektion 15/2021
Sometimes in your career you will hear about incidents that you will never forget. It may be a major accident that gets a lot of publicity. It may be an incident related to your discipline and that you have a good understanding of the details. It may be an incident that gives you that OMG […]
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The Weekly Reflektion Week 14/2021
Do you remember where you were when the Twin Towers collapsed? Are you certain? Flashbulb memory is a highly detailed, vivid snapshot of a moment and circumstances, but is it reliable? Thanks to Tiril Pollard for this Reflektion and for keeping me on the straight and narrow! If you ask anyone where they were when […]
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The Weekly Reflektion Week 13/2021
Do you notice an area for improvement, make a note to do something about it, but then forget? Don’t put off taking action. This week’s Reflektion concerns an incident in the Gulf of Mexico where a hazard was recognised, but immediate mitigating actions proved insufficient. A hardhat, a clipboard, and an open grating On a […]
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The Weekly Reflektion Week 12/2021
With extreme weather seemingly becoming more regular, how robust our operations to the changing conditions. Is your inspection and maintenance program achieving the aim of a safe and effective operation? Do you err on the side of caution? A lightning strike on the crude distillation unit at the Milford Haven refinery in South Wales caused […]
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The Weekly Reflektion 11/2021
In well established organisations with people that have worked together for many years and know each well and irritate each other in a predictable manner, you may need some outsides eyes, and ears, to stimulate improvements. Do you considered how your behaviours and actions are perceived by others? Robert Burns wrote the poem “To A […]
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The Weekly Reflektion Week 10/2021
Thank you to everyone that attended the Reflekt Lunch and Learn on Resilience on 18th February.One of the examples we used was the blowout on the Snorre A platform in 2004 where a subsurface hydrocarbon leak from a well compromised the suction anchors for the tension legs and threatened the platform with fire and explosion. […]
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The Weekly Reflektion 09/2021
The standards we use do originate somewhere. Do not dismiss them without knowing where they come from and what they were intended to do. Could an accident with 21 fatalities caused by a lack of competence and failure to recognize signals happen in your operation? On January 15th, 1919, a tank 15m tall, 27m in […]
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The Weekly Reflektion Week 08/2021
The Swiss cheese model of accident causation was developed by Dante Orlandella and James Reason at the University of Manchester. The model describes a series of barriers that prevent hazards becoming Major Accidents. The barriers are likened to slices of swiss cheese since they have holes that can let the hazards through. Do you understand […]
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The Weekly Reflektion 07/2021
Learning from Major Accidents is the main focus for Reflekt, and we have used the Piper Alpha disaster 6th July 1988 in several Reflektions. This time we have the perspective of one of the survivors. If you had survived a major accident what would you recommend to prevent it happening again? Steve Rae is the […]
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The Weekly Reflektion Week 06/2021
Do you accept shortcuts and allow people to override safety systems to be able to take these shortcuts?
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The Weekly Reflektion Week 05 / 2021
The potential for fire and explosion from leaking hydrocarbons is well understood and systems are in place to prevent and mitigate these. The narcotic effect of hydrocarbons is perhaps less well understood. Do you understand the narcotic effect of hydrocarbons and how people may respond to these effects? The Brent Bravo platform is a concrete […]
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The Weekly Reflektion Week 04 / 2021
The inspiration for this reflection is the great feedback we received after the reflections on the Ibrox and Bradford City disasters. The Hillsborough disaster was preceded by warning signs and escalated due to poor emergency response planning and execution. Do you use experiences from earlier incidents in your planning, and have you covered the relevant […]
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The Weekly Reflektion Week 03 / 2021
When things go wrong it is important that the problem(s) is (are) communicated to others concisely. Sometimes protocols need to be established to ensure communication is effective. How would people in your organisation communicate in the event of an unexpected situation that could turn into an emergency? On 8th January 2016, a Canadair CRJ200 aircraft, West Air Sweden Flight […]
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The Weekly Reflektion Week 02 / 2021
The antiquated wooden stand at the Bradford City football stadium, Valley Parade caught fire in May 1985. 56 people were killed, and 265 injured while watching a football match. Not doing anything is inexcusable when signals are clear. How receptive are you to such signals? On 11 May 1985, Bradford City had just won the […]
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The Weekly Reflektion Week 01 / 2021
The 50th anniversary of the Ibrox disaster is on January 2nd,2021. 66 people were killed leaving a football match. Let’s hope there will be no disasters in 2021 that we will be remembering in 2071. Signals that things are not as they should be are often present, but are we looking for these signals? On […]
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The Weekly Reflektion Week 53 / 2020
The anniversary of the loss of the Rowan Gorilla 1 has just passed. Thankfully, there were no casualties. Past incidents are a valuable source of learning, and the lessons are available if you look for them. Do you utilize these hard-earned learnings? On the 22nd October 1980, the jack-up rig Dan Prince sank approximately 600 miles south of […]
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The Weekly Reflektion Week 52 / 2020
We read many reports on investigations into major accidents and one statement that occurs pretty often is ‘Investigators believe a safety inspection might have prevented a disaster’. This statement appeared in the investigation into a fire that killed 25 workers. Do you carry out regular inspections to ensure the people on your facilities will survive […]
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The Weekly Reflektion Week 51 / 2020
The streetlight effect is a type of observational bias that leads people to search for something where it is easy or convenient to look. As well as being less of an effort it can give the feeling of doing something productive. It is however no excuse the day a Major Accident happens on your site. […]
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The Weekly Reflektion Week 50 / 2020
Good communication is often vital in an operational environment. As George Bernard Shaw once said, “The single biggest problem in communication is the illusion that it has taken place.” Do you make sure your communication is clear and concise? The Crimean War (1853 – 1856) was fought between an alliance of the United Kingdom, the […]
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The Weekly Reflektion Week 49 / 2020
When there just doesn’t seem to be enough time in the day to do everything you need to get done, then you won’t have time to do everything and/or you don’t have time to do everything properly. Time pressures may lead to shortcuts, unfinished conversations with incorrect conclusions and hastily made decisions. Time pressure may […]
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