THE WEEKLY
REFLEKTION
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The Weekly Reflektion Week 48 / 2020
When things go wrong, we often end up criticizing the people involved and sometimes this criticism is justified. However, does telling someone that they did something wrong give them an indication of how to do it right? Maybe. Telling someone that they have done something right on the other hand gives a clear indication of […]
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The Weekly Reflektion Week 47 / 2020
When people are exposed to hazards the situation may require them to react instinctively, that is without ‘thinking’. There are several factors that could influence their reaction. If we understood these factors perhaps, we could influence them to ensure the reactions prevented any harm or accident. What do people think about when they react instinctively? […]
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The Weekly Reflektion Week 46 / 2020
When a decision is made there may be some information that is missing, uncertain or unreliable. To progress the decision-making, assumptions may have to be made. Experience shows us that it is not always clear what is actually being assumed. When you make assumptions what do you actually assume? During the installation of a steel jacket for […]
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The Weekly Reflektion Week 45 / 2020
Your work is the thing you do to create value, but there is a difference between being busy and being productive. Are you so busy that you do not have time to do your job? I investigated a dropped object on a production platform where the area technician signed off on a work permit without checking that […]
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The Weekly Reflektion Week 44 / 2020
One dilemma that is faced by companies with activities in different countries is how to resolve a situation where a risk may be acceptable in one country and not in another. This is particularly challenging with technical risk where the company may aspire to common standards in all countries. Are you susceptible to ‘what the […]
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The Weekly Reflektion Week 43 / 2020
The importance of working together in a team can be summed up in the equation 1 +1 = 3. This was one of the mottos at my son’s kindergarten. It applied to everyone, including the management and of course the children. Do you promote teams and teamwork (perhaps One Team) toachieve success, and if you […]
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The Weekly Reflektion Week 42 / 2020
Does creating a scapegoat bring the team together? This week’s Reflektion concerns the clash between a blame culture, and a learning culture. Does getting rid of the people who make mistakes improve overall team performance? A few years ago, I was responsible for drilling operations on an offshore production platform. During a well operation the drilling supervisor proposed […]
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The Weekly Reflektion Week 41 / 2020
Major Accidents often lead to a revision of relevant standards to help prevent a recurrence. There have often been signals that improvements have been needed, but perhaps these have not been heeded. This month is the 99-year anniversary of the Mount Mulligan mine disaster in Australia, and we will revisit the accident in this Reflektion. […]
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The Weekly Reflektion Week 40 / 2020
Thanks to several of our readers who pointed out an error in last week’s Reflektion on tunnel safety. The Ryfylke tunnel is not the longest undersea tunnel, but the longest undersea road tunnel. There are several undersea rail tunnels that are longer, notably the Channel Tunnel. Good to see an engaged set of readers! The […]
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The Weekly Reflektion Week 39 / 2020
Thanks to Steven Viddal for his input to this Reflektion and drawing our attention to a newspaper article by Ove Njaa a professor in societal safety at the University of Stavanger. We really appreciate any suggestions for themes or specific incidents that would be worthy of a Reflektion. The distinction between personal safety and process […]
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The Weekly Reflektion Week 38 / 2020
High workload for the operating staff can be a major issue that can lead to incidents and accidents. People are often determined to do a good job and satisfy the customers; however, if they feel they are under pressure, they may start to improvise and find ways of doing the work quicker. Shortcuts became common […]
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The Weekly Reflektion Week 37 / 2020
We have recently had a lot of new subscribers to the Weekly Reflektion and it is good to hear that there is a growing interest in what we are trying to do. Richard Heyerdahl from Proactima is one of these and he sent us some experience from an investigation he was once asked to carry […]
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The Weekly Reflektion Week 36 / 2020
In last week’s Reflektion we discussed the scope of the investigation into an incident and the flexibility of an investigation team should have to broaden the terms if required. This week we will discuss the learning potential from incidents and what you should consider on how to prevent the incident happening again, anywhere. What criteria […]
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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 […]
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The Weekly Reflektion Week 34 / 2020
The Iroquois Theatre in Chicago was opened on the 23rdNovember 1903. The theatre was described as the most beautiful in Chicago and critics claimed there were few theatres in the USA that could rival its architectural perfections. The location of the theatre was deliberately chosen to attract women on day trips from outside Chicago since […]
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The Weekly Reflektion Week 33 / 2020
We have facilitated several workshops over the past few years with a focus on building a ‘One Team’ culture, where the operator, the rig contractor, the service providers and the partners consciously cooperate to ‘make each other good’ with a goal of achieving a superior final product. Haven’t we always cooperated? Do the different players […]
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The Weekly Reflektion Week 32 / 2020
Trevor Kletz was an industrial safety advisor in Imperial Chemical Industries (ICI). He published a monthly newsletter describing incidents that had occurred in the company and actions needed to prevent them. Soon he was sending out 2000 copies a month to both internal and external recipients. After he retired be published many of these in […]
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The Weekly Reflektion Week 31 / 2020
167 people died on the 6th July 1988 due to explosions and fires on the Piper Alpha platform in the UK sector of the North Sea. The Public Inquiry into the Piper Alpha Disaster was led by Lord Cullen and failure in the operation of the permit to work system was identified as one of […]
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The Weekly Reflektion Week 30 / 2020
I studied at Strathclyde University and every day, during the term, from 1977 to 1981, I walked from Central Station across George Square towards the University. I passed by sandstone buildings blackened by the soot of the industrial city unaware of the Georgian and Victorian architecture. I walked past the City Chambers without realizing that […]
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The Weekly Reflektion Week 29 / 2020
Four box girder bridges collapsed between November 1969 and November 1971, all due to deficiencies in the industry standards and practices in use at the time. Our experience indicates that it is difficult to undertake comprehensive investigations, recognize common issues and disseminate lessons throughout the industry quickly. Difficult, but imperative that we manage to learn […]
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The Weekly Reflektion Week 28 / 2020
Albert Einstein proposed his special theory of relativity in September 1905. The theory predicts the equivalence of mass and energy and leads to the iconic equation of E = mc2. Einstein and other physicists recognized the implications of the equivalence and the potential to create weapon of mass destruction. Einstein fled to the USA before the second world […]
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The Weekly Reflektion Week 27 / 2020
The ‘elephant in the room’ is often used to describe an issue that everyone knows is the most important issue for the people in an organization, however it is not the issue that is being discussed. Peter Sandman, an advocate of effective risk communication, uses the example of how Exxon communicated their environmental policy following […]
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The Weekly Reflektion Week 26 / 2020
The Staines air disaster in 1972 remains the deadliest air accident (as opposed to terrorist incident) in the United Kingdom. The investigation found that it was the indirect result of an ongoing industrial dispute with BEA. The summer is often the time for the risk for industrial disputes to increase. We should consider the possible […]
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The Weekly Reflektion Week 25 / 2020
Reflekt was started in October 2017 and our focus was to use the insight from investigations into Major Accidents to learn and hence prevent future Major Accidents. We also believed that these insights would provide learning to improve performance in other areas. Reflekt has organized seminars and lunch and learns, facilitated workshops, and carried out […]
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The Weekly Reflektion Week 24 / 2020
Appreciation of peoples’ efforts and good behaviours is important to encourage more of the same. There are many ways to recognize people who do a good job, for example, verbal and written feedback, rewards, bonus etc. It is important that there is a clear connection between the efforts and behaviours and the recognition, and that […]
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The Weekly Reflektion Week 23 / 2020
This week’s Reflektion concerns a train crash in 1988 in Paris where a chain of events caused an incoming train to collide with a stationary outgoing train. Driver error was identified as the cause. Given today’s prevailing view that human error is a symptom and not a cause, we will revisit the accident. People make […]
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The Weekly Reflektion Week 22 / 2020
On the 11th November 1976, the Norwegian Petroleum Directorate (NPD) sent a letter to Mobil Exploration Norway Inc (Mobil) that was later claimed to be the most expensive letter ever sent in Norway. The NPD could not accept the design of the Statfjord B platform as an integrated Production, Drilling and Quarters platform. The letter and […]
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The Weekly Reflektion Week 21 / 2020
This week’s Reflektion concerns an aircraft incident in 1972 which, if lessons had been properly identified and mitigating actions implemented, would have prevented the deaths of 346 people less than two years later in an air crash outside Paris. Learning lessons from our own incidents, and from other incidents is an important part of our […]
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The Weekly Reflektion Week 20 / 2020
In the previous weeks’ Reflektions we have discussed the importance of ‘resilience’ and an organisation’s ability to adapt to be able to manage a hazardous situation that was not anticipated. We have also suggested some techniques to develop resilience in your organisation. This week we will look at the resilience of the offshore team on […]
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The Weekly Reflektion Week 19 / 2020
In last week’s Reflektion we described two near misses in the aviation industry where the resilience of the air crew was a factor in the prevention of a disaster. This week we will present some of our ideas on how resilience can be developed in an organisation. In order to do this, we would like […]
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The Weekly Reflektion Week 18 / 2020
Resilience is defined as an ability to recover from or adjust easily to misfortune or change. Resilience is also associated with adaptability to unforeseen circumstances. How dependent are we on our people and organisation being resilient? If this quality of ‘resilience’ is important, how do we train, educate and encourage people to be resilient? Predicting […]
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The Weekly Reflektion Week 17 / 2020
John Paterson in his book ‘Behind the Mask, Regulating the Health and Safety in Britain’s Offshore Oil and Gas Industry makes the following statement regarding learning. ‘There is some recognition within the industry of this ability to learn from major events but an inability to learn from near misses.’ The learning from major events are often forced […]
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The Weekly Reflektion Week 16 / 2020
In the week 13 Reflection we quoted from W.G. Carson in 1981, 7 years before the Piper Alpha disaster. These were prophetic words on the limitations of the UK regulations for the offshore industry. In the week 14 Reflektion we looked at some of the evidence presented to the Burgoyne Committee set up in the […]
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The Weekly Reflektion Week 15 / 2020
In last week’s reflection we quoted prophetic words from W.G. Carson in 1981, 7 years before the Piper Alpha disaster.‘The British authorities’ complacent belief in the superiority of their own regulatory approach will retain even the semblance of credibility only as long as a similar tragedy does not overtake an installation operating in the British […]
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The Weekly Reflektion Week 14 / 2020
The PSA main issue for 2020 is ‘Never another Major Accident’. Have you done anything to improve your systems for Major Accident prevention as a consequence of the PSA main issue? Have you taken any initiative in your company that builds on the main issue for PSA? Major Accidents in the North Sea have had […]
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The Weekly Reflektion Week 13 / 2020
In last week’s Reflektion we talked about the importance of listening to what people say and trying to understand the message that they are trying to convey. This week we will also talk about communication and the importance of giving people the information they need to make their decisions. When you are asked for information […]
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The Weekly Reflektion Week 12 / 2020
Edward Jenner worked as a doctor in England in the 1790’s and he experienced at close hand the tragedies associated with smallpox. At that time about 10% of the population died of smallpox every year and this figure was higher in the cities (20%) where people were in close contact with each other. Following up […]
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The Weekly Reflektion Week 11 / 2020
This week’s Reflektion considers the failure of Israel to correctly interpret the intelligence signals leading up to the Yom Kippur War of 1973 because of their basic assumptions concerning their enemy.
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The Weekly Reflektion Week 10 / 2020
Do you know how your utility and process systems might be connected? How easy would it be to get hydrocarbons into a utility system and perhaps into a non-classified area? Do your HAZOPs specifically consider this eventuality? An incident on a facility in the Norwegian sector highlights the importance of separation of process and utility […]
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The Weekly Reflektion Week 08 / 2020
This week’s Reflektion considers the Yorkshire dam disasters of 1852 and 1864. Do you know where the requirements in the standards you use originated? Are you vigilant for signals that the standards could be improved? In the 19th century in Yorkshire, dams were being built to guarantee a supply of water for power for the […]
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The Weekly Reflektion Week 08 / 2020
This week’s Reflektion considers the attitude of management to acceptance and encouragement of ‘Stop the job’ mantra, which many consider to be a barrier to major accidents. Thanks to Pam Currie for input to this Reflektion. How do you encourage your organisation to ‘stop the job’ if they consider something to be unsafe? Is anybody […]
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The Weekly Reflektion Week 07 / 2020
In our Weekly Reflektion last week, week 6/2020 we discussed the explosion on the Rough platform in 2006. This week’s Reflektion considers the evacuation and the challenges in launching the lifeboat. Are you carrying out your training on equipment and systems that are the same as the equipment and systems you use in practice? Sometimes […]
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The Weekly Reflektion Week 04 / 2020
In our Weekly Reflektion for week 35/2018 we presented a near miss at the Sullom Voe terminal in Shetland and used the phrase ‘There but for the Grace of God go I’. The phrase was allegedly a statement by the English Reformer John Bradford in the sixteenth century made while watching a group of prisoners […]
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The Weekly Reflektion Week 05 / 2020
During multi-national NATO exercises, communication between nations is one of the main issues being tested. Sometimes these communication weaknesses become fatal. Are the assumptions made in roles and responsibilities in your operation clear? When you change the organisation, do you use management of change procedures to manage risk? When you remove a position do you […]
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The Weekly Reflektion Week 04 / 2020
Reflekt was started in October 2017 and since then we have produced 115 Reflektions that we hope have been interesting reading and perhaps provided useful learning. Reflekt has also organised five seminars on learning from Major Accidents. Our belief that the unique insights from the investigations into Major Accidents can be used both to prevent […]
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The Weekly Reflektion Week 03 / 2020
The subject of this week’s Reflektion is the Ladbroke Grove rail crash in London, England. Reflekt will be organising a breakfast seminar in April 2020 where we will consider the three ‘R’s’, Reliability, Robustness, Resilience. Watch out for more information on our web site. Do you have an effective action tracking process? Have performance […]
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The Weekly Reflektion Week 02 / 2020
In last week’s Reflektion we talked about the criticism Florence Nightingale received from Dr. James Barry and how this criticism led to hygiene changes in the military hospital at Scutari in Istanbul and the many lives this saved. This week will use an example where the criticism was warranted but the way it was communicated […]
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The Weekly Reflektion Week 01 / 2020
Happy New Year to all our readers. We hope that a quiet reflection over all you have done in 2019 will give an inspiration to how you can be better in 2020. We are sure that most of you have not experienced a Major Accident in 2019. We also hope that you will not assume […]
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The Weekly Reflektion Week 52 / 2019
This week’s Reflektion concerns an aircraft disaster that had an impact on all our flights today. Do you know why they brief those near to escape exits how to open the doors? Or why there is such excellent legroom at these exit seats? It has not always been like that! 22nd of August 1985, was […]
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The Weekly Reflektion Week 51 / 2019
This week’s Reflektion is a follow up on the Reflektions in week 49 and week 50 and concerns the process of changing of our mental models. Learning is not the just the accumulation of knowledge. Learning is the application of new knowledge and new experience to a desired end. Learning requires a change in the […]
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The Weekly Reflektion Week 50 / 2019
This week’s Reflektion is a follow up on week 49 Reflektion on human error and considers the concept of mental models. Do you have ‘human error’ down as one of the main causes for accidents and incidents? What mental model did the person(s) involved in the accident or incident have and how did this influence […]
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The Weekly Reflektion Week 49 / 2019
This week’s Reflektion is inspired by a presentation on Causal Learning that we recently attended and some reflections around the concept of ‘human error’. Do you have ‘human error’ down as one of the main causes for accidents and incidents? Maybe you should think about the cause of human error rather than human error as […]
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The Weekly Reflektion Week 48 / 2019
The subject of this week’s Reflektion is the Southall rail crash in London, England in 1997 and the consequences of disabling safety systems. Do you disable safety systems without applying mitigating actions? How do you ensure that disabled safety systems do not lead to a disaster? On the 19th September 1997, a high-speed passenger train […]
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The Weekly Reflektion Week 47 / 2019
This week we are reflecting over the collapse of the Ponte Morandi bridge in Italy, and the relevance of the causes to other industries. Degradation of materials in areas we cannot get to can lead to challenges. Do we make incorrect assumptions based on lack of data? How do you evaluate how ‘robust’ something needs […]
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The Weekly Reflektion Week 46 / 2019
This week we are reflecting over the design of a facility, the potential actions that could be taken by the people involved in the operation of that facility and how that affects the ‘mind set’ for the safety of the operation. Do we know how the operators will react in a difficult situation? What is […]
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The Weekly Reflektion Week 45 / 2019
This week we are reflecting over the petroleum industry’s attitude towards learning and considers two recent major projects in Norway. Do we learn because we have to, because we think we should or because we really want to? Following any incident or accident, and in particular incidents and accidents that have significant consequences, there is […]
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The Weekly Reflektion Week 44 / 2019
This week’s Reflektion is based on the story of Thomas Midgley Jr. and his role in developing leaded petrol. Do you let commercial interests get in the way of the promoting a safe product? Do you understand why people are sceptical when industry maintains that it will be OK? Thomas Midgley was a mechanical engineer […]
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The Weekly Reflektion Week 43 / 2019
This week’s Reflektion is based on the fire-fighting response to the Buncefield oil storage terminal fire in 2005. What scenarios do you train for in your emergency response exercises? How far will the scenario escalate, and do you have a strategy for the response? On the 11th December 2005, a fire broke out at the […]
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The Weekly Reflektion Week 42 / 2019
This week’s Reflektion is inspired by the 1969 ‘24 hours of Le Mans’ motor race. Thanks again to Ole Martin Dahle for bringing this to our attention. It’s 1969, and 400,000 people are watching the start of the 37th ’24 hour of Le Mans’ race. Part of the attraction of the race was the legendary […]
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The Weekly Reflektion Week 41 / 2019
This week’s Reflektion is inspired by the Titanic disaster in 1912, and the company management mantra. Thanks to Ole Martin Dahle for bringing this to our attention. Does your company have an HSE vision? What do you do to operationalise it? Most companies have, in their governing documentation, a statement summing up the attitude with […]
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The Weekly Reflektion Week 40 / 2019
This week’s Reflektion is based on the Piper Alpha disaster and asks the question. What do you do with important information presented at your meetings? Do you just take note and move onto the next item on the agenda? Or do you take the information seriously? The Piper Alpha disaster occurred on the 6th July […]
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The Weekly Reflektion Week 39 / 2019
This week’s Reflektion is inspired by the Tay Bridge disaster in December 1879, which was the subject of a previous Reflektion in week 52/2017 Are you aware of the criticality of the assumptions you make? Which performance indicators are you monitoring? The Tay Bridge disaster occurred during a violent storm on Sunday 28th December 1879. […]
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The Weekly Reflektion Week 38 / 2019
This week’s Reflektion is inspired by my son and his response to my question on what was the most important factor for preventing accidents. ‘Do nothing’ he suggested. When things are going well should we just leave things alone and assume they will continue to go well? In the Reflektion in week 37 we were […]
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The Weekly Reflektion Week 37 / 2019
This week’s Reflektion is inspired by the HSE philosophy in the kindergarten my son attended. ‘No child should hurt themselves more than what is good for them’. How can you learn by doing when you are not allowed to fail while doing it? The HSE philosophy in the kindergarten my son attended is based on […]
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The weekly Reflektion Week 36/2019
This week’s Reflektion is inspired by the philosopher Sir Francis Bacon and his theory on ‘observation and experimentation’. What is the practicable purpose of the knowledge you have? How do you assess the uncertainty of the knowledge you have? Sir Francis Bacon is often regarded as the first to promote the scientific method and advocate […]
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The weekly Reflektion Week 35/2019
This week’s Reflektion is on the question ‘Is good enough, good enough?’ Is good enough, good enough? Is this just a matter of semantics or is there a deeper question to be considered? The Petroleum Safety Authority (PSA) in Norway issues a regular newsletter with their reflections on the petroleum industry in Norway. One of […]
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The weekly Reflektion Week 34 / 2019
This week’s Reflektion is inspired by the BBC Radio series ‘The Infinite Monkey Cage’ and their program discussing risk. How do you communicate the risks associated with your business? Do you intend to assure or scare? Statistics are often used in risk communication and can be useful to assure people that the risks associated with […]
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The Weekly Reflektion Week 33 / 2019
This week’s Reflektion concerns the Ocean Ranger tragedy offshore Newfoundland in 1982. Do you make the most of your learning opportunities? Are you looking for signals that may indicate you have a challenge? The Ocean Ranger semi-submersible drilling rig was drilling the third well on the Hibernia oilfield 166 miles east of St Johns, offshore Newfoundland […]
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The Weekly Reflektion Week 32 / 2019
This week’s Reflektion revisits the Lac-Mégantic train crash and discusses the actions taken and their effect. Thanks to Pam for spotting an article in the New York Times. This emphasizes the importance of an international network! When things go wrong, those with authority often promise to make it right. But, do they? Do you revisit […]
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The Weekly Reflektion Week 31 / 2019
This week’s Reflektion is on whether you see the consequences of the innovation and new technology. The inspiration for the Reflektion is from Tom Phillip’s excellent book ‘Humans: A Brief History of How We #¤!?& It All Up’ Where will development of this technology lead? When you say ‘A’ do you need to prepare for […]
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The Weekly Reflektion Week 30 / 2019
This week’s Reflektion is based on Nigeria Airways Flight 2120 that crashed shortly after taking off from Jeddah, Saudi Arabia on 11 July 1991. Would you let commercial pressures compromise the safety of your operation? Where is your limit for taking chances? Nigeria Airways Flight 2120 was a chartered passenger flight from Jeddah, Saudi Arabia, […]
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The weekly Reflektion Week 29/2019
This week’s Reflektion is based on the loss of the German submarine U-1206 in April 1945. The cause of the loss was a new type of toilet.
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The weekly Reflektion Week 28 / 2019
This week’s Reflektion concerns the incident at Lake Peigneur in Louisiana where communication between a well and a salt mine shaft led to serious consequences.
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