THE WEEKLY
REFLEKTION
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The Weekly Reflektion 01/2025
A Safe and Happy New Year to all our readers. Many people may be familiar with the traditional children’s song ‘There’s a hole in my bucket’. The song comes from the German state of Hesse, and is an exchange between two characters, Liza and Henry and their attempts to solve the problem with the hole in Henry’s bucket. It starts with […]
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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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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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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 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 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 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 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 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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