People wonder if industry does not know
how to prevent a Major Accident,
we do know we just don’t always use the knowledge.
Trevor Kletz

Seminars and lunch and learns

Reflekt have developed several seminars that we use to highlight key factors in the prevention of Major Accidents. The seminars use the learning from major accidents or similar events, and we have found these a good starting point for discussion and reflection. The seminars can be organized at our offices, your offices or through Teams or Zoom. 

Line in the sand 

Sometimes someone says enough is enough and starts to do something to prevent undesirable events. A ‘line in the sand’ is drawn and from that moment, things get better.  

In this seminar Reflekt use the Kings Cross Underground fire in November 1987, the US Navy Subsafe project from 1963 and the Formula One focus on reduction of driver fatalities from 1994.

The focus for the seminar is how poor management engagement can be a cause or contributory factor in an incident, accident including a Major Accident and how good management focus can contribute to prevention of incidents, accidents and of course Major Accidents. A key aspect of the management focus is how to engage the organisation in what is to be achieved. In particular how the demands and counter demands are created. That is, if you (the management) want to achieve this then we (the organisation) need this.

When deviation becomes normal

What happens when deviation from established safe practices becomes institutionalized within an organization? What happens when deviation becomes normal?

In this seminar we use the Challenger Space Shuttle disaster in January 1986 and the Herald of Free Enterprise capsize in March 1987.

In the seminar we present some of the factors that allowed normalization of deviance to occur and we suggest some ideas on how to recognize the symptoms. We will also discuss ways to address normalisation of deviance. If you do not recognize that something can happen, there is little chance you will try to do something about it, until the incident comes…and then you have to act.

What does good look like?

The expectations to ‘what good looks like’ in an operation, well or project often drives the focus for the organisation and the indicators that are set up to monitor performance. The intention being that focus on the right things will give good results. Achieving good results will satisfy the expectation on ‘What good looks like’. Monitoring the right things will ensure that the way to achieving good results is clear and any deviation from the desired performance will be resolved underway.

Our experience however indicates that not everyone in the team/organisation has the same picture of ‘what good looks like’ as each other and of the management. Not everyone has the same interpretation of what the management want to achieve. This is an important consideration in how to achieve the balances between safety and performance and risk and opportunities and may lead to different people focusing on different things.

The two examples we use in the seminar are the design and building of the Scottish Parliament Building in Edinburgh from July 1997 to February 2007 and The Texas City Refinery explosion in March 2005. One of our reflections from the seminar is whether what good is like is the opposite of what bad is like. We believe it is not that simple. Measures to ensure ‘good’ and barriers to avoid ‘bad’ are complementary, interconnected, and interdependent, but are not necessarily the same.

Creeping Change

Creeping change is the accumulation of small changes, which often go unnoticed, and since they progress gradually are difficult to keep track of. The changes are often not subject to any formal management of change process that would lead to a hazard identification or risk assessment. Creeping change can occur in many different forms and problems often occur when changes accumulate and some of these interact in unexpected ways. A combination of seemingly insignificant technical, operational and/or organisational changes can have potentially catastrophic consequences and lead to a Major Accident.

Three Major Accidents are used to highlight the dangers of creeping change. The Exxon Valdez tanker grounding in Alaska in March 1989, the Nimrod aircraft that exploded over Afghanistan in September 2006 and the fireworks explosion in Enschede, Netherlands in May 2000.

At the seminar Reflekt present some ideas on how to identify creeping change and to mitigate the potential consequences of creeping change.

Reflekt AS