THE WEEKLY
REFLEKTION
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The Weekly Reflektion 51/2024
Thank you to the people that attended our Breakfast seminar on 27thNovember and for the feedback we received. We plan to hold a Teams version on Wednesday 18th December 0800 hrs. Let us know if you would like to participate and let your colleagues know. In an industrial context, culture refers to the shared values, beliefs, behaviours, and […]
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The Weekly Reflektion 50/2024
The justice system is not specifically set up to identify learning and to prevent recurrence. Its focus is to identify where laws have been broken and who is responsible, apportioning blame and to ensuring justice is done. Unfortunately, the justice system often fails here as well. Do you ensure that potential learnings are identified, and […]
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The Weekly Reflektion 49/2024
Accidents and incidents are often attributed to human error and in many cases, this may be the case. Why people did what they did, and why they considered it rational in the situation and circumstances they were in, needs to be understood before we play the human error card. Sometimes a more detailed investigation discovers that it was not human error at all. […]
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The Weekly Reflektion 48/2024
Reflekt will organise a breakfast seminar Wednesday 27th November. In the seminar we will consider what the offshore petroleum industry can learn from the Grenfell Tower fire in 2017. The seminar will be held at the Quality Hotel Pond in Forus from 0800 to 1000. A light breakfast will be served beforehand. There is plenty of free […]
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The Weekly Reflektion 47/2024
Reflekt will organise a breakfast seminar Wednesday 27th November. In the seminar we will consider what the offshore petroleum industry can learn from the Grenfell Tower fire in 2017. The seminar will be held at the Quality Hotel Pond in Forus from 0800 to 1000. A light breakfast will be served beforehand. There is plenty of free […]
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The Weekly Reflektion 46/2024
Reflekt will organise a breakfast seminar Wednesday 27th November. In the seminar we will consider what the offshore petroleum industry can learn from the Grenfell Tower fire in 2017. The seminar will be held at the Quality Hotel Pond in Forus from 0800 to 1000. A light breakfast will be served beforehand. There is plenty of free […]
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The Weekly Reflektion 45/2024
Reflekt will organise a breakfast seminar Wednesday 27th November. In the seminar we will consider what the offshore petroleum industry can learn from the Grenfell Tower fire in 2017. The seminar will be held at the Quality Hotel Pond in Forus from 0800 to 1000. A light breakfast will be served beforehand. There is plenty of free […]
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The Weekly Reflektion 44/2024
Reflekt will organise a breakfast seminar Wednesday 27th November. In the seminar we will consider what the offshore petroleum industry can learn from the Grenfell Tower fire in 2017. The seminar will be held at the Quality Hotel Pond in Forus from 0800 to 1000. A light breakfast will be served beforehand. There is plenty of free […]
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The Weekly Reflektion 43/2024
Reflekt will organise a breakfast seminar Wednesday 27th November. In the seminar we will consider what the offshore petroleum industry can learn from the Grenfell Tower fire in 2017. The seminar will be held at the Quality Hotel Pond in Forus from 0800 to 1000. A light breakfast will be served beforehand. There is plenty of free […]
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The Weekly Reflektion 42/2024
Reflekt will organise a breakfast seminar Wednesday 27th November. In the seminar we will consider what the offshore petroleum industry can learn from the Grenfell Tower fire in 2017. The seminar will be held at the Quality Hotel Pond in Forus from 0800 to 1000. A light breakfast will be served beforehand. There is plenty of free […]
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The Weekly Reflektion 41/2024
Reflekt will organise a breakfast seminar Wednesday 27th November. In the seminar we will consider what the offshore petroleum industry can learn from the Grenfell Tower fire in 2017. The seminar will be held at the Quality Hotel Pond in Forus from 0800 to 1000. A light breakfast will be served beforehand. There is plenty of free […]
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The Weekly Reflektion 40/2024
Welcome to Reflekt’s breakfast seminar Wednesday 27th November. In the seminar we will consider what the offshore petroleum industry can learn from the Grenfell Tower fire in 2017. The seminar will be held at the Quality Hotel Pond in Forus from 0800 to 1000. A light breakfast will be served beforehand. There is plenty of free […]
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The Weekly Reflektion 39/2024
The culture at your facility may be the result of many years hard work to ensure people display the right behaviours and that safety standards are maintained. The culture may be the result of a passive approach where people themselves have had to find out how they can work safely. In some cases the culture reflects a […]
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The Weekly Reflektion 38/2024
Most companies encourage people in their organisation to speak up when they observe actions and conditions that are not safe. There is no guarantee that anything will be done, however by not reporting, then nothing will be done. Sometimes the consequences are easy to see, and sometimes the consequences are far greater than could be imagined. One thing […]
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The Weekly Reflektion 37/2024
There are several methods advocated for investigations into incidents and accidents and there are no doubt advantages and disadvantages with each of these. They are all based on the scientific method that requires systematic observation, measurement, experiment and analysis, and the formulation, testing, and modification of hypotheses. The scientific method is arguably under pressure from postmodernism that questions the basic assumptions of […]
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The Weekly Reflektion 36/2024
Reduction in risk to an acceptable level presupposes that the potential threats and hazards associated with the operation or situation, are identified and then assessed. Often the risk assessment team uses previous experience to identify these threats and hazards, and limits themselves to these, after all what else could go wrong? Every so often a new hazard […]
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The Weekly Reflektion 34/2024
Sometimes we are carrying out our work as normal, thensomething happens that makes us realise that we could be so much better. A colleague points out a potential improvement, a chance mistake reveals a previously unknown function, or we may even read the instructions and procedures. Once we are aware of the improvement we kick ourselves […]
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The Weekly Reflektion 33/2024
Getting the basics right in any activity or task is an all encompassing intention that is easy to state, important to implement, however often difficult to put into practice. Then a major accident occurs, the follies are exposed and the outrage drives change, despite some entrenched resistance. It is unfortunate that so many people need to […]
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The Weekly Reflektion 32/2024
Collecting data, and analysing it to find the causes behind an incident is one of the keys to a good investigation. Jumping to immediate conclusions may be easy and cheap in the short term, but is not likely to provide the learning required in the long term. Do you have the stamina to challenge established truths? John Snow (1813 […]
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The Weekly Reflektion 31/2024
Carrying out a risk assessment requires identification of likely hazards and threats and how these can be mitigated to ensure the future is safe. Some hazards and threats may be considered to be unlikely that the risks are not assessed. Some hazards and threats are not thought about at all. This is where our creativity becomes important. Do you consider the […]
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The Weekly Reflektion 30/2024
Carrying out a risk assessment before getting on with the job requires identification of likely hazards and threats and how these can be mitigated to ensure the task can be carried out safely. Some hazards and threats may be considered toounlikely that the risks are not assessed. Some hazards and threats are not thought about at […]
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The Weekly Reflektion 29/2024
In organisations where the employees are worried that being honest may expose them to consequences that may affect their careers, the causes behind an incident may be difficult to identify. How do you handle lack of openess and honesty during investigations? During my career in the oil and gas industry, I have led many investigations […]
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The Weekly Reflektion 28/2024
Regulations governing HSE in the Norwegian petroleum industry contain risk- and performance-based requirements.The regulations are described as functional where the intention with each regulation is described and the responsible party, that is the operator and others participating in activities covered by the regulations, need to put in place specific solutions, processes and procedures that meet the […]
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The Weekly Reflektion 27/2024
Organisational change is challenging and often many individual changes are implemented. Sometimes the interaction between these changes result in chaos and risks can become high and unmanageable. There is then an effort to get the organisation back on the road again. Hopefully before a serious incident occurs. Does chaos emerge when you make an organisational change? The emergent pattern of Langton’s ant Langton’s Ant is […]
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The Weekly Reflektion 26/2024
Prevention of Major Accidents is one of the primary goals for the management in any company. Continually finding and making improvements that will reduce major accident risk is challenging. Improvements need to be prioritised within the contraints of budgets and available time and resources. Consideration needs to be given to the effort and likely impact. Sometimes […]
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The Weekly Reflektion 25/2024
The principles of inherent safety are key to understanding how to manage risks effectively. The hierarchy for actions and measures, in order of importance, is; eliminate the hazard, substitutute the hazardous material for something less hazardous, apply technical measures to isolate the people from the hazard, provide procedures that reduces the potential for exposure to the hazard, and finally protect the […]
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The Weekly Reflektion 24/2024
A legacy is the long-lasting impact of particular events, actions, etc. that took place in the past, or of a person’s life.The chemical and process industry has a legacy. This legacy is shaped by disasters and hopefully the long-lasting impact is the collective learning that we can use to prevent further disasters. The next disaster is […]
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The Weekly Reflektion 23/2024
IOGP has issued Life-Saving Rules (LSRs) and everyone that works in the oil industry should know these and why they are important. IOGP estimate that 376 lives could have been spared in the period 2008-2017 if the people involved had followed the LSRs. Report 459 contaoning LSRs can be downloaded from the IOGP website and of course once downloaded […]
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The Weekly Reflektion 22/2024
The need for change is almost inevitable. The change may be a response to external factors. It may internally driven and be intiated to achieve existing or new objectives, for example, improved safety, better financial performance, or even survival. The intention of the change is always positive. Failure to manage the change properly can however result in very […]
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The Weekly Reflektion 21/2024
A focus on one aspect of any industry can lead to a lack of focus on other things, just as important. We often strive for breaking records, but we must not lose sight of the bigger picture. Memorial to the Gresford Disaster erected in 1982 Do you strive for records without considering the possible consequences? An explosion and fire at the Gresford colliery […]
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The Weekly Reflektion 20/2024
Leading questions are often used to communicate incorrect information and misrepresent a situation. They are also used to suggest an answer that is desired, allowing the questioner to prevent any contradiction of an already established view, or avoid taking actions that may be required. Is your bad news, bad news? Thanks to Morten Andreassen in Presight Solutions AS for relating a conversation he […]
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The Weekly Reflektion 19/2024
The identification of hazards and the assessment of how these can affect our facility are key factors in preparing people to handle them when they arise. We construct scenarios, we put plans and procedures in place and we train our people so that when that fateful day comes, they will be ready. Yet, still the unexpected happens, and […]
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The Weekly Reflektion 18/2024
In many industries we are relient on computers, PC’s andautomated systems for a safe and efficient operation. We are then dependent on the way people interact with these and how the human machine interfaces (HMI) are set up. Are your human-machine interfaces designed to help or hinder? Air Inter Flight 148 was a scheduled flight from Lyon […]
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The Weekly Reflektion 17/2024
In today’s society we value our freedom of speech. The right to say what we think and to express our views freely and withour prejudice. We also have a right to follow our beliefs and put our trust, faith, or confidence in (someone or something). Freedom of speech is however not absolute. Mostlegal systems generally set limits on the […]
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The Weekly Reflektion 16/2024
Do we at Reflekt talk too much about learning from Major Accidents and how improvements can be made to your operation without the devasting consequences of a disaster? Is it actually possible to talk too much about learning? We don’t think so and true to our word, here is our latest effort to prompt you to do something. […]
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The Weekly Reflektion 15/2024
Learning from previous disasters is a recurring theme in our Reflektions. Why did they not know about this disaster? Why did they not learn from that disaster? Where was the learning process? What is the learning process? Even when the learnings from a disaster are taken into legislation, standards, and guidelines, the follies of the […]
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The Weekly Reflektion 14/2024
Athletes at the highest-level search for perfection in their training and preparation for major events. Many will have a focus on the 2024 Olympics in Paris and perhaps one opportunity to achieve the highest accolade, an Olympic Gold Medal. Whether their efforts are ‘good enough’ will only be revealed when they cross the finishing line. Some of the athletes […]
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The Weekly Reflektion 13/2024
The Norwegian Ocean Industry Authority (Havtil) is asking the companies working in the Norwegian Petroleum industry to pay more attention to people and the role of the working environment. Its main issue for 2024 – don’t forget the working environment! – lays a basis for reflection, discussion,and action. Are you ensuring the working environment at your facility […]
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The Weekly Reflektion 12/2024
Learning from Major Accidents is not a recent innovation. Ever since hazardous materials have been manufactured and stored, accidents have occurred, and efforts have been made to learn and prevent the recurrence of similar accidents. Many countries have reacted to Major Accidents by passing laws and developing standards. When these are continually updated, they should represent […]
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The Weekly Reflektion 11/2024
A good risk assessment is an important factor before taking an action, starting an activity and before a decision is made. There are different techniques and methodologies used and these fulfill a specific purpose, e.g. design risk assessment, Total Risk Assessment (TRA), HAZOP, HAZID, pre job assessment, etc. An important prerequisite for any risk assessment is that […]
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The Weekly Reflektion 10/2024
In all operations there are some tasks that are more important than others since they can have serious consequences if mistakes are made. We need to differentiate between critical and non-critical tasks and have processes in place to ensure critical tasks are carried out properly. MV Golden Ray after capsize In your operation are you conscious of what is critical and non-critical? The MV Golden […]
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The Weekly Reflektion 09/2024
Risk communication often involves scaring people when the hazards are significant, but the risk is perceived to be low and calming them down when the hazards are not significant but are perceived to be high. There is often a poor correlation between the hazards that upset people and the hazards that cause serious harm. Smoking is an interesting example, as is driving a car. When we work with risk […]
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The Weekly Reflektion 08/2024
Organisational cultures can change over time, with continued success, or apparent success, people may become complacent. In our Reflektion week 12/2018 we used a quote from Andy Grove founder and former CEO of Intel. ”Success breeds complacency. Complacency breeds failure. Only the paranoid survive” The Apollo 1 Command Module after the fire Do you demand nothing short of perfection for how […]
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The Weekly Reflektion 07/2024
When changes are made, people with the necessary competence should be involved in evaluating the risks arising from the change. Competence is also an essential element indetermining measures that should be taken to mitigate these risks. Do we ensure that people with the right competence are involved when making changes, and do we take their advice? Coldharbour Hospital in Sherborne, Dorset, England was […]
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The Weekly Reflektion 06/2024
Reflekt’s main theme is learning from major accidents and the Weekly Reflektions are our way of communicating stories that we hope will help to prevent future events that could develop into a major accident. A major accident is characterised by a single incident with multiple fatalities, significant environmental impact and/or substantial financial losses. The event often generates […]
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The Weekly Reflektion 05/2024
Reflekt has been and still is very critical to the decision to both the prosecution for negligence and the guilty verdict of the Officer of the Watch on Helge Ingstad for the collision with Sola TS in 2018. In investigations we have carried out our main concern has been to extract learnings from the incident to prevent a recurrence. Learning and experience transfer […]
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The Weekly Reflektion 04/2024
This year is the 40th anniversary of the Bhopal disaster, arguably the worst industrial accident that has occurred. 20 000 people lost their lives directly or indirectly and over 500 000 people were treated for injuries. The Bhopal disaster is part of our industrial legacy, and it should be a reminder of the hazards associated with what […]
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The Weekly Reflektion 03/2024
Human Performance was a focus area for the Institution of Chemical Engineers Hazards 33 conference in Birmingham in November 2023. Understanding why people do what they do and why it makes sense for them to do it is a key element in a successful investigation. This development from ‘Human Error’ and pointing out what went wrong to […]
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The Weekly Reflektion 02/2024
Many industries are using remote monitoring and operation in the search for safer, more reliable, and lower cost operations. This inevitably requires secure communication systems and often a central control room where incoming information is assessed, and actions taken. When conditions become extreme there is also a requirement for anticipation of the consequences and prompt […]
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The Weekly Reflektion 01/2024
Prevention of Major Accidents is a journey that will never actually end so we will never know if we are ultimately successful. Our objective therefore is to stay on the road and keep on trying. The question on how many times we need to try is difficult to answer. However, we at Reflekt are certain […]
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The Weekly Reflektion 52/2023
Many companies are making the transition from ‘Human Error’ to ‘Human Performance’ in the way they investigate incidents and accidents and how they improve their performance. The ‘Human Error’ approach was based on the identification of what went wrong, who made the mistakes and led to actions to correct mistakes to prevent recurrence. The investigations most often did not get to the root of […]
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The Weekly Reflektion 51/2023
Reflekt are now entering the world of artificial intelligence and we are looking at using AI in preparation of our weekly Reflektions and in making lessons learned more available. We hope that AI will improve learning to help in the prevention of major accidents and performance in general. The following Reflektion was generated entirely by Chat GPT, a step change in the way Reflekt approach the future. It should […]
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The Weekly Reflektion 50/2023
The principle of identifying dangers and threats to your operation and establishing barriers to prevent these causing an incident and/or reducing the consequences of any incident is well established in the world of process safety. Even then we still experience serious accidents and people get hurt. This principle is also relevant to cyber safety. Our increased use […]
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The Weekly Reflektion 49/2023
The principle of using ‘barriers’ to prevent incidents and accidents and to reduce the consequences of incidents and accidents has been around for a long time. It is the essence of the prevention of major accidents. Unfortunately, as long as we have been using ‘barriers’ we have being finding ways to compromise these ‘barriers’ and […]
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The Weekly Reflektion 48/2023
During our working day, we often tend to focus on prioritisingthe less important things, rather than the important issues.Sometimes we are distracted, sometimes the more important tasks are more complex and difficult, and sometimes the more important things are just routine and relatively boring. Wreckage from the Eastern Air Lines Flight 401. Do you focus on the important issues? Eastern […]
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The Weekly Reflektion 47/2023
Cyber safety is in vogue and rightly so. There are many examples of cyber attacks where IT systems have been hacked and the victims have been defrauded of millions and/or threatened with destruction of important information unless a ransom is paid. Cyber attacks on Operational Technology (OT) systems, for example, PLCs (programmable logic controllers) that are the basis for […]
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The Weekly Reflektion 46/2023
Safety culture is often a point on the agenda at management meetings. Many international companies have a standardised approach to the way they try to build a good safety culture, however they often experience challenges when an approach that functions, for example, in a western European country doesn’t function in a country in South-east Asia. This may be due to […]
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The Weekly Reflektion 45/2023
Most of us are focussed on costs to improve the ‘bottom line’. Cost-saving initiatives are part of our everyday lives. How do you make sure cost-saving initiatives do not have unforeseen consequences? On 31 October 1858, the normally harmless Halloween sweetstreat killed several children, causing panic across Bradford, England, and a rapidly rising death toll. This is how a […]
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The Weekly Reflektion 44/2023
Many companies and organisations talk about the 1, 2, 3 of taking control of disasters and organising a response to an emergency. The three steps are: assess your needs, create a plan, and engage your support network. In industry these emergency situations are often described in an emergency response analysis and the plans are pre-determined in the emergency response […]
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The Weekly Reflektion 43/2023
Normalisation of deviance in some form has been around for a long time, however the terminology became well known through Diane Vaughans studies on the space shuttle Challenger disaster in 1986. Normalisation of deviance is particularly dangerous when practices that have a potential to be deadly, become established at a facility or in an organisation. Normalisation leads […]
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The Weekly Reflektion 42/2023
Normalisation of deviance in some form has been around for a long time, however the terminology became well known through Diane Vaughan’s studies on the space shuttle Challenger disaster in 1986. Normalisation of deviance is particularly dangerous when practices that have a potential to be deadly, become established at a facility or in an organisation. Normalisation means these practices are accepted […]
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The Weekly Reflektion 41/2023
Sometimes conflicts arise and an attempt must be made to resolve these. While not all conflicts have a Major Accident potential, they can undermine the working environment and restrict discussions, hence lead to poor learning and experience transfer. Often conflicts remain unresolved because the parties in the conflict can’t find any common ground to start the process. How […]
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The Weekly Reflektion 40/2023
The main purpose of a Major Accident investigation is to identify measures that will prevent Major Accidents. It is the responsibility of all managers to ensure that their organisation learns and failure to learn is negligence. While there may be many reasons why learning does not take place, there are no excuses when the Major Accident happens to you […]
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The Weekly Reflektion 39/2023
Starting up a facility after a maintenance shutdown is a critical phase and needs the full attention of the operations team. Equipment has been opened, flanges disturbed, modifications carried out, safety systems maintained and hopefully re-instated correctly etc. There is a high level of uncertainty on the integrity of the facility and the risk is high. Mitigation measures need […]
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The Weekly Reflektion 38/2023
Inherently safer design has several basic principles that if adhered to will save lives. Keep the hazardous material contained and if it does have to be released then do it in a safe way. Keep the people away from hazardous materials and hazardous situations. If no one is there, then no one gets hurt. If […]
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The Weekly Reflektion 37/2023
Built-in obsolescence is one of the characteristics of our present day. Little is repaired and buying new is normally considered cheaper. Building schools with built-in obsolescence may lead to a disaster unless we understand the consequences. If your house was built to last 30 years, would you live there worry-free after the 30 years were up? The Weekly Reflektion from week 47/2019 discussed the Ponte Morandi bridge in Genoa which collapsed n 14th August […]
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The Weekly Reflektion 36/2023
There are many indicators that could be used to determine whether you have safe and efficient operations. If you know what you are looking for, you can build up a pretty good picture of how you are doing. However, if you cannot distinguish the relevant indicators, you may not have the right impression. When the indicators you are using confirm what […]
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The Weekly Reflektion 35/2023
People often end up living near facilities where hazardous materials are used and/or produced. The risks involved in your operation therefore can affect people or organisations outside your operation and it is essential that this is considered in your risk assessment. Cheapside Street after the explosion Do you communicate the risks identified in your operation to all those that could be affected? The Cheapside […]
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The Weekly Reflektion 34/2023
Society may accept that a few people die every day as result of accidents and incidents that could actually have been avoided. Even though the sum of these fatalities may be high on a yearly basis there is no outrage factor that drives the change that is required. When all these people die in a single day or single event then […]
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The Weekly Reflektion 33/2023
When things are not as they should be, signals, both strong and weak, are sent from different parts of the organisation warning of an impending situation. These signals may not be seen, may be misunderstood may be ignored. Failure to react to these signals can be fateful. Beirut Harbour area after the blast Are you looking for signals, and do you make […]
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The Weekly Reflektion 32/2023
There is no doubt that technology will continually be developed, and that new technology will have a significant impact on our lives. Development in technology is also likely to have a significant impact on Major Accident prevention. Technology that removes people from the hazard follows an important principle in inherently safer design and is positive. Technology that improves the functionality […]
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The Weekly Reflektion 31/2023
Once we get an idea or concept firmly anchored in our minds it is difficult to shift. We become totally convinced that our view of the world is correct and even arguably obvious information that indicates we are wrong is not enough to change our minds. When we, in addition, receive confirmation that our views […]
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The Weekly Reflektion 30/2023
Innovation and continuous improvement inevitably lead to changes in the way things are done. The way these changes are handled is critical to avoid Major Accidents. OceanGate’s Titan submersible vehicle Do you have an effective process for management of change and qualification of new technology? Innovation and continuous improvement are necessary if we are to […]
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The Weekly Reflektion 29/2023
The fire at the waste sorting plant in Stavanger showed an organization poorly prepared to meet the challenges that its activity could reasonably expect it to be. With a focus on sorting efficiency and no systematic safety work going on, the operative organization was not prepared for an emergency. CCTV of Waste Reception Area showing location of original fire and conveyor […]
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The Weekly Reflektion 28/2023
‘What gets measured gets done’ is an expression that is often used in Management books as a key to achieve objectives. Key Performance indicators (KPIs) are often set up and at the monthly meetings the indicators are reviewed often with the traffic light approach just to make sure everyone knows the ongoing status. ‘Green’ we can relax, ‘Amber’ we need to watch […]
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The Weekly Reflektion 27/2023
Investigations into incidents and accidents are essential to find direct and underlying causes and to initiate measures to prevent recurrence and improve performance. The failure of processes and systems is demonstrated by the fact that an incident has occurred, and the incident and its circumstances give pointers on where to look for improvements. Just as […]
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The Weekly Reflektion 26/2023
Multiple barriers are often essential to ensure safety and security. This is particularly important where the systems are complex and the value of the people, environment and assets that are being protected are high. Sometimes the number of barriers in place creates an illusion that the probability of all barriers being breached is very low. That is the holes in […]
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The Weekly Reflektion 25/2023
Automation has been a major factor in the development of industry and will continue to be so with increased scope for digitalization and the advent of Artificial Intelligence (AI). Allowing AI to take decisions is already an important element in driverless cars. The increased use of beweaponed drones has raised the question of whether AI should be […]
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The Weekly Reflektion 24/2023
The Swiss Cheese model was developed by James Reason at the University of Manchester and is often used in the prevention of major accidents. The model depicts a complex system where hazards are prevented from causing harm by a series of barriers. Each barrier has weaknesses, or holes – hence the similarity with Swiss cheese. […]
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The Weekly Reflektion 23/2023
Management visits to site are an opportunity to test the water with regards safety. The busy manager, out and about, walking around and talking to people. Casing the joint as it were. The value of these visits can be significant if the manager has a genuine intention to understand safety and has questions that will encourage […]
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The Weekly Reflektion 22/2023
The legal system throws up some interesting examples of assigning blame and finding people negligent. Sometimes the concept of ‘beyond reasonable doubt’ doesn’t seem to be as important as finding a person(s) and administering justice. What is the legal system trying to achieve in its pursuit of determining negligence? In last week reflektion (week 21/2023) we asked the question ‘Is the […]
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The Weekly Reflektion 21/2023
Whan a Major Accident occurs there is often a public outcry and there follows a demand to find the person/people responsible. The public want punishment for these people for not doing their duty, perhaps a tendency towards an ‘eye for an eye’, ‘tooth for a tooth’ mentality that serves for justice in the minds of many. The major accident itself is normally investigated by a team of […]
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The Weekly Reflektion 20/2023
In our daily routines we expect to interface with others with a similar understanding of what is an ‘acceptable’ risk, for example when we are driving on the roads. Different groups may however have different levels of ‘acceptable’ risk. These worlds sometimes meet with unfortunate consequences. The Helge Ingstad after the collision with the TS Sola Are we aware of the dangers when our view of ‘acceptable’ […]
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The Weekly Reflektion 19/2023
Getting the team together and organizing a social function with a few games is often a good way to create the team spirit that provides the basis for good performance. Often a few glasses of beer provide a catalyst for discussion. Sometimes even the beer-games can provide interesting insights into risk and uncertainty. Do you […]
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The Weekly Reflektion 18/2023
Management visits to worksites are important for both conveying messages and receiving information and are typically included in the company Key Performance Indicators (KPIs). The intention is encouraging management to move away from their back-to-back meetings and ‘little time to reflect’ working day and go out and see how the workers are surviving at the sharp end. What signals […]
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The Weekly Reflektion 17/2023
Quality and quality assurance is vital to the safe and successful delivery of any project. One of the key elements in quality assurance is the application of appropriate standards. The assessment of what standards apply, and their correct application is in turn dependent on people with the necessary knowledge and experience. How do you ensure that standards are applied […]
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The Weekly Reflektion 16/2023
The project “Development in risk level – Norwegian shelf” (RNNP) was initiated in 1999 and is an annual review of indicators that show trends related to risk and in particular major accident risk. Risk reduction is a stated objective for the industry and all the participants are committed to contributing to this objective. There is however a recognition […]
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The Weekly Reflektion 15/2023
The project “Development in risk level – Norwegian shelf” (RNNP) was initiated in 1999. The background for the project was the parties’ need to shed light on uncertainty related to the safety consequences caused by the major structural changes in the petroleum industry at the end of the 1990s. The ‘parties’ involved are the industry, the unions and […]
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The Weekly Reflektion 14/2023
Situation awareness is about understanding what is going around you and being able to make good decisions based on the information available. Situation awareness also requires a recognition of the context for the information, and this is often determined by the person(s) experience. The connection between experience and situation awareness is important. How will your people react […]
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The Weekly Reflektion 13/2023
Before any critical activity a risk assessment is normally carried out to ensure the hazards associated with the activity are identified and the risks from carrying out the activity are acceptable. Similar activities may have been carried out before and it seems appropriate to review previous risk assessments to gain the benefit of any experience transfer. However, it may […]
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The Weekly Reflektion 12/2023
The James Reason Swiss cheese model is often used to show barriers in place to prevent a major accident. The Swiss Cheese metaphor illustrates the holes that depict potential failure of or limitations to the barriers. Sometimes the cheese model is depicted as a bow tie showing a hazardous event and barriers to prevent this event on the left and barriers to […]
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The Weekly Reflektion 11/2023
The blowout on the Macondo well on 20th April 2010 led to the deaths of 11 persons and the loss of the drilling rig Transocean Deepwater Horizon. The clean-up of the oil spill and the various settlements and fines ultimate cost BP 61.6 billion dollars. BP, at that time one of the biggest companies in the […]
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The Weekly Reflektion 10/2023
Peer reviews are used in the academic world to verify the quality of research and the validity of any conclusions arising from that research. The academic work and ideas are subject to scrutiny of others that are experts in the same field (peers). Peer reviews are also a useful tool for stimulating experience transfer and […]
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The Weekly Reflektion 09/2023
Individual risk and overall risk are different concepts that need to be managed with different processes and be handled separately. Do you assume that if the individual risks identified in the risk register are managed then the overall risk requirement is satisfied? Risk management and risk reduction is the foundation for the Norwegian PSA regulations. In the Activities regulations §29 the following is stated: […]
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The Weekly Reflektion 08/2023
Good communication is vital during an incident, and special competence is needed to communicate the right things at the right time, to the right people. Are you clear about what you communicate and why? When a Major Accident or serious incident occurs, communication becomes very important in limiting the negative consequences for the companies involved, but also […]
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The Weekly Reflektion 07/2023
The senior management often turns to external consultants to help them make changes that will achieve the company objectives. Sometimes these changes are forced upon the company due to external factors, for example a fall in the oil price. Sometimes the changes required are essential for the continuation of operation. However, without a guiding hand […]
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The Weekly Reflektion 06/2023
Most companies experience periods where workload is high, multiple challenges need to be faced, and the people feel like they have their backs against the wall. The management in the company has of course a responsibility to ensure safety and profitability. They also need to help the organisation cope with their problems and emerge stronger […]
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The Weekly Reflektion 05/2023
In an effort to improve productivity, or achieve an optimisation in a delivery, or perhaps just to keep the organisation on its toes, positions are removed or added, reporting lines changed, workloads increased, and positions or people moved to different geographical locations. Are our risk assessments for organisational changes effective, or just tick-the-box exercises? One of our subscribers, and someone we have worked […]
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The Weekly Reflektion 04/2023
There is an ongoing discussion in the safety community on Safety 1 and Safety 2 and whether these approaches to safetyare different paradigms or just two sides of the same issue. While this may be an interesting academic discussion, we should not lose sight of the practical implications. Our view is that there are merits in both approaches, and it is […]
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The Weekly Reflektion 03/2023
When organisations are busy, undermanned, and have other important tasks to perform, investigations are often not prioritised. Sometimes the objective is carry out an investigation rather than getting to the root of the problem. After a potentially fatal accident, do you hope that statistics are on your side, and do nothing? In February 2022, an […]
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The Weekly Reflektion 02/2023
The drive to cut costs can lead to poor decision making with catastrophic consequences. This same drive can also lead to attempts to cover up poor decisions and result in failure to take corrective action in case the decisions are exposed. When things start to go bad how far do you let them go before you react? On 28th November […]
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The Weekly Reflektion 01/2023
Systemic failures in the Norwegian Navy, on the Sola TS and Fedje Vessel Traffic Service were causes of this collision. Should we put the blame on human error or address the systemic failures? This is the third Reflektion regarding the collision between the Sola TS oil tanker and the Norwegian Navy frigate Helge Ingstad. The […]
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The Weekly Reflektion 52/2022
Labour shortages led to the bridge crew of the Helge Ingstad being less experienced than was the norm, but the job had not got any easier. Were the bridge crew on Helge Ingstad negligent, or did the Norwegian Navy set them up to fail? This is the second Reflektion focussed on the incident on 8th November […]
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The Weekly Reflektion 51/2022
The Helge Ingstad sinking involved three parties, the Helge Ingstad itself, the tanker Sola TS, and the local marine vessel traffic service. The incident illustrates some of the challenges associated with people, the way people communicate and the assumptions they have when they are trying to make sense of the world around them. People in […]
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The Weekly Reflektion 50/2022
The investigations into major accidents often note the signals before the accident that indicated some things were not right. The disregard for safety precautions, the breaches of the control of work procedure, recurring incidents, concerns from the staff. Sometimes the signals are strong, for example a dropped object from 20 meters. Sometimes the information may […]
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The Weekly Reflektion 49/2022
When we are thinking about our Reflektions and especially what to write about next week, we are seldom short on material on accidents and incidents. There are unfortunately many ‘good’ examples of Major Accidents that we can use. The challenge is to find the right context and ensure there are relevant points that our readers […]
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The Weekly Reflektion 48/2022
The investigation into major accidents usually leads to recommendations on improvements in safety. While we may not be aware of all of these, we have an expectation that they will be implemented. How do you align your objectives in your ‘One Team’ concept? The Los Rodeos Airport in Tenerife airport suffered with poor visibility when low clouds. On 27th March […]
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The Weekly Reflektion 47/2022
Drilling wells and carrying out projects are examples of activities that involve personnel from different companies working together to complete the required tasks safely and effectively. However, these companies may not have the same individual commercial goals and sometimes these differencescan lead to poor performance and a disappointing result, at least for some of the participants. In the petroleum industry an example […]
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The Weekly Reflektion 46/2022
Our days are full of alternatives and choices, and we need to decide which of these to follow. In our workplace we also make decisions and sometimes these can have significant consequences. We need to have a process that considers all the relevant information, the potential hazards, the uncertainties, and the consequences, before a decision […]
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The Weekly Reflektion 45/2022
Language and communication have been major factors in the evolution of humans. The ability to learn and adapt to changing environments gave homo sapiens a great advantage despite obvious deficiencies in strength and speed compared with other predators and prey. Before the advent of writing systems communication was verbal, and it is likely that the […]
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The Weekly Reflektion 44/2022
Automatic safety systems fulfil an important function in the prevention of unsafe conditions and the escalation of any incident. Failure to register and react to alarms and overriding key safety functions can compromise this function and make any facility vulnerable to a Major Accident. It seems obvious that alarm handling and control of overrides should […]
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The Weekly Reflektion 43/2022
The current energy crisis in Europe demonstrates how important power is to industrial and domestic users and to maintain the services society requires. Like many aspects of life, we only really appreciate them when we are close to losing them. We cannot afford to be complacent on essential services. The Viking Sky cruise ship nearly […]
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The Weekly Reflektion 42/2022
During wartime and busy periods rules and regulations are often relaxed to ‘get the job done’. How do we ensure we focus on the right things when the context of our operations change? On 6th December 1917, during the First World War, two ships collided, causing an explosion which killed at least 1782 people and demolished […]
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The Weekly Reflektion 41/2022
Risk assessments are used extensively in decision making and it is important one understands the dynamics taking place in the assessment process. Obviously, we would expect the participants in the risk assessment process to be objective, the data accurate and the analysis of the data thorough and unambiguous. In the real work this may not […]
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The Weekly Reflektion 40/2022
Risk assessments are a key part of ensuring that any activity or project can be carried out safely. Risk assessments can be major activities with multiple participants perhaps over several days. Risk assessments can also be short and sweet and consist of a quick review before the job gets done. What are the factors that influence whether […]
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The Weekly Reflektion 39/2022
Using solutions that others have used before you does not necessarily mean that it will work for you. Sometimes the circumstances are not quite the same, or maybe the others were just lucky and got away with it. Resultant derailment and diagram showing situation immediately before collision (Source: BNSF) Do you have contingencies prepared if the activity doesn’t go to plan? On November 13, 2021, about 2343 hrs, a freight train consisting of […]
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The Weekly Reflektion 38/2022
One of the main concerns raised at risk assessments associated with lifetime extension of facilities is assurance of competence and capacity in the organisation until the facilities are decommissioned. People in the organisation often recognize the technical challenges and feel they have the necessary control to ensure prudent operations at the current time. They are […]
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The Weekly Reflektion 37/2022
Acronyms are abbreviations formed from the initial letters of the words in the expression being abbreviated. Some acronyms become so well established that they replace the original name or expression, e.g., NASA, IOU, SNAFU. Often the acronym becomes memorable and conveys a distinct understanding. The acronyms we are using today are WYLFIWYF and WYFIWYF. Are you aware that the mandate for an investigation and […]
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The Weekly Reflektion 36/2022
Having people that are competent to carry out their work and exercise their responsibilities is of course essential. Just as essential is ensuring that there are enough people with the full range of competencies needed for the work to be undertaken. The Tretten bridge after it collapsed Do you have the competence to ensure your […]
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The Weekly Reflektion 35/2022
People doing safety critical work should have sufficient restbefore work. Regulatory requirements and company policiesshould be put in place to ensure this. Seaway Falcon pumping sea water on to Ekofisk Bravo platform during the blowout. ©NTB How do you ensure cost saving measures do not reduce the safety level? In April 1977, an oil well blowout occurred at the Ekofisk Bravo platform. The direct cause of […]
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The Weekly Reflektion 34/2022
When a design weakness has been identified, compensating measures have to be agreed and implemented. The tail elevators showing the right one locked down in the wrong position for take off Are your compensating measures adequate? Thanks to Neil Sultan, one of our subscribers for bringing this incident to our attention. On 8th March 2017, an MD83 aircraft, a variant of the DC-9 from Boeing McDonnell […]
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The Weekly Reflektion 33/2022
An organisation continually receives information that is relevant to its operation and that can be used to make improvements. This of course requires a proper interpretation of that information and avoidance of unsubstantiated assumptions. Pic.1 A steel helmet used by British soldiers in WW I. Pic.2 Distribution of bullet holes on allied aircraft How do you use available information […]
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The Weekly Reflektion 32/2022
A management system describes the processes and procedures that should be followed to carry out all activities in a safe and effective manner. The management system should include a learning process that ensures that these processes and procedures are continually reviewed and updated from experience in their application and changes in regulations and standards. Gas in the sea surrounding the Snorre A […]
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The Weekly Reflektion 31/2022
The culture of a company is set by the management and what the management decides to focus on and not to focus on. When the company is involved in the manufacturer of aircraft or any other activity that can lead to Major Accidents, safetyshould of course be a management focus, some may say the primary […]
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The Weekly Reflektion 30/2022
In last week’s Reflektion, week 29 -2022, we talked about how economic pressure and competition with Airbus led to the modification of the Boeing 737 MAX and the tragic consequences of two air crashes and 346 people dead. This week we will look at how the modification caused the crashes. Next week we will try […]
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The Weekly Reflektion 29/2022
The aircraft industry is highly competitive and a key factor for commercial airlines is fuel efficiency. Reducing operating costs will lead to lower fares and more customers. The customers also expect that safety standards will not be compromised in the drive to cut costs. Are you able to maintain and improve your safety standards through periods of turbulence and […]
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The Weekly Reflektion 28/2022
Convicting a criminal of a crime is the goal of police investigations. During the investigation the evidence has to be looked at objectively. This is not always the case as the police, being human, are influenced by many factors and biases. Justice is not always done. How do you avoid confirmation bias in your investigations? Marius Kolstad, a former Norwegian bodybuilding champion, was […]
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The Weekly Reflektion 27/2022
The investigation of any incident is influenced by our biases. When we know the outcome, this can affect the way we approach the investigation. In some cases, we are not even aware that we have had an incident, until the events are seen through another perspective. Do you let your biases influence your judgement? Sidney […]
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The Weekly Reflektion 26/2022
The Petroleum Safety Authority (PSA) main issue for 2022 is ‘Capacity and Competence – the key to safety’. PSA emphasizes the importance of an organization possessing the right capacity and competence. However, possessing is not enough. Your competence must be utilized properly to ensure you fulfill your responsibilities. Are you fulfilling your ‘see to it’ duty? The Norwegian petroleum industry has undergone significant […]
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The Weekly Reflektion 25/2022
Making the effort to tell others about the incidents that you have had may prevent similar incidents in other companies. While there is no guarantee that anyone else will learn from your incident you can certainly guarantee that they will notlearn if they know nothing about it. Do you make the effort to tell others about your incidents? The […]
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The Weekly Reflektion 24/2022
We often hear people claiming that the only thing that doesn’t change in their organization is continuous change. The drive for better performance, whether improving safety, reducing the effect on the environment, increasing production, reducing costs, etc, inevitably leads to a change. However, we are not always so good at understanding why something is in place before we […]
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The Weekly Reflektion 23/2022
Walking the talk is an expression that is often used to emphasize the importance of management living up to what they say. ‘Actions speak louder than words’, is used in the same context. Putting out the last of the fires at the Texas City Refinery in 2005 What does walking the talk mean in your company? We would […]
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The Weekly Reflektion 22/2022
Continuous improvement is an important factor in ensuring safe and efficient operations and pre-supposes learning and a learning process. However, not all cultures are so receptive to innovation and new thinking to benefit from learning. Do you have a culture that encourages learning or discourages learning? We would like to invite you to a ‘Listen and Reflekt’ lunchtime […]
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The Weekly Reflektion 21/2022
A simple ‘human error’ can lead to fatal consequences. Sometimes a simple solution could have prevented the human making that error and the pain and misery of lost loved ones could have been avoided. Do you design your systems to prevent the inevitable mistakes that people will eventually make? We would like to invite you to […]
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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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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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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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