THE WEEKLY
REFLEKTION
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The Weekly Reflektion 20/2022
Building a culture needs actions that demonstrate that you are serious, stories to communicate these actions, and engagement to follow up that the actions have the desired effect. Do your systems and procedures apply to everyone and in every circumstance? Now that COVID is over, Mike and I would like to re-establish our Reflekt seminars to […]
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The Weekly Reflektion 19/2022
Repeated incidents show that we are often not effective at learning lessons and preventing recurrence. People can be seriously injured or die from this failure. Learning lessons demands organisational stamina to follow the process to the end. How is the stamina in your organisation? Several of our Reflektions recently have addressed the quality of investigations […]
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REFLEKT LISTEN AND REFLEKT
TEAMS MEETING WEDNESDAY 1st JUNE 2022, 1100, hrs Now that COVID is over, Mike and I would like to reestablish our Reflekt seminars to promote issues that we believe could lead to improvements in the petroleum industry in Norway. We have previously held breakfast seminars at the Auditorium at Ipark, Ullandhaug and we intend to continue with these following the summer. We have […]
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The Weekly Reflektion 18/2022
Some of the routines that are carried out on a process facility may seem banal and a waste of time. They are often established as the result of a serious incident or the potential for a serious incident. Sometimes the reason is lost in time and the routine then becomes the target for the latest efficiency drive. Interlock system […]
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The Weekly Reflektion 17/2022
Failure of leadership and supervision is often noted as a factor in incidents and accidents. Unfortunately, this is often an observation made by the investigation team and not a cause that has been identified through an assessment of why the leadership/supervision failed. Are your expectations to operational leaders/supervisors clear? One of the perceived advantages of the […]
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The Weekly Reflektion 16/2022
To be able to learn from poor performance, the causes have to be identified. To be able to learn from good performance, the same is true. Martin Linge platform (©Equinor) Is learning from repeated failures in field development projects in Norway all words and little action? Last week’s Reflektion addressed the Martin Linge development in Norway and […]
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The Weekly Reflektion 15/2022
Often the successful outcome of a project or activity has little to do with the care and attention you put into the planning and execution and more to do with luck. Are you lucky, and if so, why are you lucky? A quote that is often attributed to Napoleon Bonaparte is ‘I know he’s a good general […]
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The Weekly Reflektion 14/2022
Many companies promote values that they hope the employees, and the management, will aspire to. These values are sometimes open to interpretation. Do your values encourage the right behaviours in the right circumstances? Sometimes the management gets the idea for promoting ‘values’ within the company. This process often takes place when a major reorganisation or […]
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The Weekly Reflektion 13/2022
Human error plays a part in most accidents. Do your investigations stop there? Injury to boy’s neck after accident on the ski lift. Photo: Private Do you consider ‘inherently safer design’ in your investigations? In February this year, an 11-year-old boy was on downhill skis for the first time at a Norwegian ski resort, when […]
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The Weekly Reflektion 12/2022
The quality of a Quality Assurance system is only as good as the people responsible for it. When a company loses focus on the quality of processes in place and work carried out then an accident is just waiting to happen. Aircraft ZS-OEZ, type Boeing B737-200, with starboard engine missing How do you ensure your Quality Assurance […]
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The Weekly Reflektion 11/2022
‘I get it’ said Boris Johnson as he responded to the criticism over the Downing Street Parties in January 2022. ‘BP gets it’ said then Chief Executive following the BP Texas City Refinery disaster in March 2005. In April 2010 there was the blow out on the BP Macondo well. After the parties Boris said ‘I […]
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The Heimdal Incident
Failure to carry out a proper investigation of any incident, especially a serious incident, is a barrier to the learning from the incident. When reading some investigation reports and presentations, it is not surprising that learning from incidentsis a still a challenge. When you carry out investigations, do you really get to the bottom of what happened, how it happened, and why […]
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The Weekly Reflektion 10/2022
Introduction of foreign objects to a workplace may be acceptable, but this may cause unidentified hazards. RAF A330 Voyager Aircraft Do you have discipline around your work sites, and what is allowed? On 9th February 2014 an RAF Airbus A330 Voyager aircraft was flying over the Black Sea towards Afghanistan with 198 passengers and crew. The aircraft suddenly, without warning,pitched […]
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The Weekly Reflektion 09/2022
A good risk assessment requires a comprehensive overview of the actual and potential hazards and threats, and scenarios on how these will manifest themselves. This means using the imagination. The port engine of the Boeing 737 Southwest Airlines Flight 1380 Do you encourage the participants in risk assessment to use their imaginations? Risk assessments are an important tool for ensuring the safe […]
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The Weekly Reflektion 08/2022
We are all influenced by feedback. Good feedback may give us a lift and perhaps encourage us to continue what we are doing and perhaps improve. Bad feedback may get us down but could give us that kick we need to improve. What about no feedback? Well, this may just indicate you don’t care. Albert Einstein in a reflektive mood What behaviours do you encourage by […]
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The Weekly Reflektion 07/2022
The drive for effective operations must be balanced with the drilling of robust wells. Welding on a pipeline What does ‘good’ look like to you in your operations, and is it the ‘good’ expected by others? We all strive to improve performance, to do better than we have done before, to set records both for professional pride and […]
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The Weekly Reflektion 06/2022
We may trust the systems and equipment that we use to ensure that the activities we carry out are safe but not everyone is in a position to be able to trust these systems. Welding on a pipeline Are you too easily satisfied that the safety systems on your facility are functioning satisfactorily? Peter Sandman, a […]
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The Weekly Reflektion 05/2022
Even the most advanced technology with sophisticated computer programs to control its use still has the human element. The burnt our wreck of a B2 stealth bomber How do you incorporate informal procedures into your management system? The B-2 stealth bomber ‘Spirit of Kansas’ crashed on take-off at the Andersen Air Force base on Guam […]
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The Weekly Reflektion 04/2022
Sometimes we need a reminder of the importance of our quest to prevent Major Accidents. What better example than how a Major Accident can significantly affect peoples’ lives. Fire on the Deepwater Horizon April 2010 Do you practice mindful leadership in your organisation? Thank you to Mike Smith in Lotos for bringing an article in […]
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The Weekly Reflektion 03/2022
Research and Development can lead to new understanding that can change the way safety systems are designed and operated. One example is the release of water deluge in the event of a gas leak. Do you systemically review the way you carry out tasks to ensure the hazards are controlled and the risks managed? On […]
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The Weekly Reflektion 02/2022
Agreeing with the majority in a group task is the easiest solution. The task in the Asch experiment How do you ensure conformity in a group does not lead to poor decisions? In 1951, Solomon Asch, a pioneer in social psychology, performed an experiment to investigate how the effect of social pressure from a majority […]
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The Weekly Reflektion 01/2022
Research and Development can lead to new understanding that can change the way safety systems are designed and operated. One example is the release of water deluge in the event of agas leak. Deluge Release on Process Facility How do you keep yourself updated with research and development related to the safety of your facilities? In the […]
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The Weekly Reflektion 52/2021
Do you understand the value of the coffee machine and the informal discussions that often arise there? Could a coffee machine prevent a blowout? Mike and I at Reflekt would like to wish all our readers a Happy New Year and no Major Accidents in 2022. A few years ago, I was working in the Operations Department supporting […]
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The Weekly Reflektion 51/2021
We at Reflekt wish all our subscribers, and other business connections a very happy holiday period, and keep yourselves safe in these trying times. We look forward to seeing you next year. Vajont Dam seen today from both above and below the dam We often establish a risk picture at the start of a project which we use to […]
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The Weekly Reflektion 50/2021
Our intuition is an important factor in making sense of the world around us in particular how we interpret information and make decisions. Sometimes however our intuition fails us. Do you sometimes take shortcuts to reach a view on problems you are facing? A football match is 22 people running around after a ball with a 23rd person trying to ensure the […]
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The Weekly Reflektion 49/2021
Sometimes doing the right thing takes a lot of effort and you have to overcome many obstacles along the way. When you are tyring to make things right you need to be in for the long haul. When you know something is right and you know it should be done, do you stay the course […]
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The Weekly Reflektion 48/2021
New technology often gives us an opportunity to make improvements to the way we do things and how much time it takes to get It done. Sometimes however new technology may have unexpected consequences that can lead to catastrophic results. When you introduce new technology or new ways of working, are you good at managing the changes? […]
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The Weekly Reflektion 47/2021
Having control of hazardous materials is an important first step in preventing many types of incidents. How do you ensure the training and behaviour of the people at the worksite meets your expectations? On the 22nd of May 2008, a fire in a storage area on the nuclear-powered aircraft carrier, the USS George Washingtontook 12 hours to extinguish, injured 37 fire fighters and caused US$70 million in damage. The investigation concluded that […]
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The Weekly Reflektion 46/2021
Sometimes the measures we put in place to prevent a release of flammable or toxic fluids can lead to other problems that just make the situation worse. Do you consider how measures to prevent a leak could cause a leak? A few weeks after the start-up of production on a platform in the North Sea several gas alarms suddenly sounded in […]
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The Weekly Reflektion 45/2021
When hot work is carried out, how do you assess possible hazards? The assessment of hazards requires firstly identifying that the hazard is relevant and then describing how it can arise. Do you identify hazards and describe how these will arise? On February 8th, 2017, welding ignited a flammable atmosphere in a 100,000-gallon (380 m3) tank at the DeRidderpulp and paper mill facility in Louisiana, USA. The explosion killed […]
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The Weekly Reflektion 44/2021
The ‘rogue waves’ described by mariners for many years were thought to be a ‘tall story’ like the ‘fish that got away. Was it just imagination? Are you conscious of the residual risk in your operations? On the 12th of December 1978 the MV München cargo vessel was lost with all 28 hands in the North Atlantic during a storm. After an extensive search, a few life […]
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The Weekly Reflektion 43/2021
Sometimes the simplest of incidents can escalate to serious consequences by ways not quite anticipated in the wildest of imaginations. Do you understand how simple incidents can escalate to serious consequences? Sometimes the simplest of incidents can escalate to serious consequences by ways not quite anticipated in the wildest of imaginations. This incident is based on the ‘Bricklayers Song’ by the […]
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The Weekly Reflektion 42/2021
As the drive to reduce CO2 emissions receives more political attention and concerns from the public rise due to perception of more extreme weather, efforts to achieve emission targets will become more intensive. Our experience is that more focus in one area can lead to less focus in other areas. Will the focus on reduction in CO2 emissions have […]
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The Weekly Reflektion 41/2021
As systems become more complicated and control systems more sophisticated, Human-Machine Interface (HMI) is becoming increasingly important. Do you have good control of HMI in your operation? China Airlines flight 140, flying from Taiwan, was making its approach to Nagoya Airport in Japan on 26th April 1994. The first officer was flying the aircraft and he was experiencing problems pushing the nose down to […]
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The Weekly Reflektion 40/2021
The oil and gas industry is often criticised for its failure to identify risks. The removal of COVID-19 restrictions in Norway gave an interesting insight into the risk perception of the general public in Norway. Is it safe because other people say it’s safe? The oil and gas industry is often criticised for lack of effective risk identification processes […]
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The Weekly Reflektion 39/2021
We often talk about the importance of culture in influencing the behaviours of people in an organisation. But do we really understand how the culture has an affect and what aspects of the culture are actually influencing people? Do you understand how culture influences people in your organization? One of our Reflektions in April 2019 […]
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The Weekly Reflektion 38/2021
Sometimes you must have enough belief in what you are doing to overcome the obstacles that are put in your way. When your efforts are related to reducing risks and saving lives then you just have to stay the course. Do you stay the course when you believe you can reduce risk and save lives? Clair Cameron Patterson spent […]
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Reflektion – Equinor experience transfer final
We normally send out our Weekly Reflektion on Sunday morning and hopefully all our subscribers are happy with this routine. We decided to send out this extraordinary Reflektion today as it relates to one of the concerns we have on Major Accident Prevention in the Norwegian Petroleum Industry, complacency. The Reflektion is a reaction to […]
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The Weekly Reflektion 37/2021
Isolation of Energy is of fundamental importance to control of work and the safety of people involved in any activities. The processes for isolation and de-isolation need to be concise and systematic and proper verification is required to ensure the processes are followed. Do you have proper control of your isolations and de-isolations? Major plant […]
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The Weekly Reflektion 36/2021
Life extension, and conversion and re-use of some facilities is critical for effective use of resources, but we need to ensure this is done correctly. How do we ensure we have the correct priorities for conversions and change of use? The Stellar Daisy was transporting iron ore fines from Brazil to China when it capsized halfway […]
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The Weekly Reflektion 35/2021
Facilities are built to stand certain loads and loading conditions including loads from undesired events. The design accidental loads are used as the basis for the design the facilities. The dimensioning accidental loads are the loads the facility will most likely be subjected to. It goes without saying that the design accidental loads should as […]
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The Weekly Reflektion 34/2021
The Pryor Trust blowout in 2018 in Oklahoma, USA, killed 5 people. These deaths could and should have been prevented. What can we learn from this Major Accident? Why did the operator’s duty of care and the regulations not help prevent the blowout? On January 22nd, 2018, a blowout and rig fire at a Pryor […]
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The Weekly Reflektion 33/2021
The Pryor Trust blowout in 2018 in Oklahoma, USA, killed 5 people. These deaths could and should have been prevented. What can we learn from this Major Accident? Why did the operational team believe what they were doing was OK? On January 22nd, 2018, a blowout and rig fire at a Pryor Trust gas well […]
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The Weekly Reflektion 32/2021
The Pryor Trust blowout in 2018 in Oklahoma, USA, killed 5 people. These deaths could and should have been prevented. What can we learn from this Major Accident? Is your operational team performing as you expect them to? Are your expectations clear? On January 22nd, 2018, a blowout and fire at a Pryor Trust gas […]
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The Weekly Reflektion 31/2021
What is the worst Major Accident we have come across? What criteria should we use to judge the many Major Accidents that we have studied? The consequences in the terms of loss of life, impact on the environment or financial loss? In our view it is more appropriate to judge based on the failure of […]
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The Weekly Reflektion 30/2021
What is the worst Major Accident we have come across? What criteria should we use to judge the many Major Accidents that we have studied? The consequences in the terms of loss of life, impact on the environment or financial loss? In our view it is more appropriate to judge based on the failure of […]
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The Weekly Reflektion 29/2021
What is the worst Major Accident we have come across? What criteria should we use to judge the many Major Accidents that we have studied? The consequences in the terms of loss of life, impact on the environment or financial loss? In our view it is more appropriate to judge based on the failure of […]
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The Weekly Reflektion 28/2021
In the film Wizard of Oz, Dorothy wanted to find her way back home to Kansas and was told to follow the yellow brick road to find the Great Wizard of Oz who would help her get back home. The expression ‘follow the yellow brick road’ is often associated with a course of action that […]
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The Weekly Reflektion 27/2021
Following an incident, we often hear these words from the management “if only the operational team hadn’t done that” and “why didn’t they stop the job?”. What do these statements say about the management’s perception of risk management? Where should we focus our efforts on preventing incidents? Recently we have noticed that several companies […]
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The Weekly Reflektion 26/2021
Harald Norvik the former chairman of Statoil, now Equinor, once said. The most important quality in a leader is to inspire the people in their organization. While one can motivate with the carrot or the stick, inspiration really does require something special. How do you inspire your people to do a good job? The Ocean […]
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The Weekly Reflektion 25/2021
The saying ‘beware of Greeks bearing gifts’ is normally used to refer to an act of charity that masks a hidden destructive or hostile agenda. The saying comes from Greek mythology andthe Trojan War, in which the Greeks, led by Agamemnon, attempted to rescue Helen, who had been taken to Troy after falling in love […]
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The Weekly Reflektion 24/2021
Many experienced people in oil and gas now are out of work, and unable to find positions. The experience that these people have could be an important factor in safe operations in the future. Do employers consider the value of experience when recruiting new people? My LinkedIn timeline is full of experienced people looking for […]
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The Weekly Reflektion 23/2021
‘Disasters… happen when the decisions are made by people who cannot remember what happened last time. Daily Telegraph 17th May 1990’ leader on the Clapham Junction train disaster. Do you consider the job finished when the system is back in service and working? Equipment that has been subjected to degradation sometimes needs to be replaced […]
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The Weekly Reflektion 22/2021
Risk Assessments are often held using a meeting format and sometimes the basis for the assessment is the assessment carried out last time. During the meeting mitigation measures are identified and included in the action plan. Some of the measures identified may appear sensible in the moment, but do they actually reduce the risk? Do […]
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The Weekly Reflektion Week 21/2021
Once an organisation establishes a mindset it can be difficult to change and sometimes it takes a serious incident to realise the mindset was not good. Do you let your mindset blind you to the causes of your next disaster? I was just sitting down at my desk to write a Reflektion and as I […]
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The Weekly Reflektion 20/2021
In our operations, we are dependent on crews making quick and correct decisions to avoid serious incidents. How do we ensure our crews, when faced with a complex failure, have the training to respond correctly? Fifty-five years ago, on March 16th 1966, Gemini VIII made the world’s first space docking, followed by the first life-threatening, […]
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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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