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EDITORIAL COMMENTS: Close encounter of the complacent kind

September 1, 2010
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I spent a lot of this summer, like many of you,reading BP stories. From all the reports, speculations,editorials, attacks and defenses, one word kept coming up - complacency. BP, its partners and contractors, possessed the knowledge, the equipment, the safety experts, the top engineers, the protocols, plans and management systems that should have prevented the catastrophe.

But as a past VP of safety for BP said in an email passed along to me, fatal decisions were made on the rig “because they had done so before” and gotten away with it. According to a federal investigation, a Transocean rig supervisor told a maintenance technician who protested that a crucial safety device had been bypassed, or disabled:“Damn thing been in bypass for five years.Matter of fact, the entire (Transocean) fleet runs them in bypass.”
 

Duly warned

Bad decisions. Missed warnings. Pushing the limits. I can relate. One Sunday this past July was another 90+ degree day in the Philadelphia region.We’d had at that point more than 30 days over 90 degrees in June and July. And it’s no dry heat in the Delaware Valley. There’s always a blanket of smothering humidity. “Horrid heat grips region”was a headline in the Philadelphia Inquirer that particular Sunday. The National Weather Service extended its excessive heat warning. Fourteen deaths in Philadelphia had been confirmed as heat-related,according to the paper.

So there it was: knowledge. I read expert advice on how best to yield to the heat. I had the requisite experience, too: it had been a record-breaking sweltering summer. So what did I do on this Sunday in July? Decided to take a run, a jog is more like it, through Valley Forge National Park, a short drive from home.

Again, let’s compare notes. More than 50,000wells had been drilled on federal leases beneath the Gulf before disaster struck. I’ve run through Valley Forge hundreds of times. I had my plan, my protocols,just like the drillers. Run early, before eight a.m. Bring along a water bottle. Wear a flimsy tee short, light clothing. Run on the trail that affords the most shade. On the stinking hot days, lay off the hills.
 

"Pushing production"

So what did I do? Circumvented my best-laid plans. The night before I’d been out late and slept in. I got a late start; I knew it. It was past eleven when I started my jog. And early on I decided to “push production,” you might say. I’ve read that enough about drillers’ mindset. I parked by the Visitor Center and jogged along the North Outer Line Drive. This trail is more open and exposed to the sun beating down than my usual route. I can’t explain why, but I pushed up the distance to swing around the National Memorial Arch, head up and past Wayne’s Woods, a picnic area, hang a U-turn where the trail meets the South Outer Line Drive, and then back-track to my car. Roughly a four-mile jaunt.

There’s a theory by James Reason that catastrophes such as the BP debacle occur when a series of breakdowns, bad decisions, etc., line up in precisely the order of a long chain of falling dominos that proceed to a catastrophic conclusion. He calls it the Swiss Cheese model of disasters. All the holes of multiple slices line up so a disaster of errors runs through the system unchecked. I worked my own Swiss Cheese model that Sunday morning. A series of lousy decisions. I ran later than was prudent. Further than was necessary. On a trail more hilly and sunny than I’d usually take. But “because I had done so before” and never paid a price, nothing seemed out of order.

Nothing was out of the ordinary until about 100, 200 yards from my car on the trail back to the Visitor’s Center. I was gulping for air. Slowed to a half-walk, half-jog, and said, “This is it. I gotta stop.” Damn, I wasn’t going to make my goal. I stopped on the asphalt trail and started to wobble. Heat exhaustion. Me?
 

The Good Samaritan

Valley Forge attracts more than 1.2 million visitors a year. On a day like this when the high reached 96 degrees, with the heat index above 100, the parking lots are empty. Reenactment soldiers in their blue wool uniforms go home. Very fortunately for me a fellow I’ll call John spotted me in my distress and came over. I can’t exactly remember our conversation but it went something like: “Man, you don’t look too good. You OK? You sit down here, OK?” He called to his wife, “Go call the Park Ranger Service.” John poured a bottle of water on my head. Another fellow materialized next to me. “You’ve lost a lot of liquid. Did you pass out? Are you dizzy? Don’t move.”

I don’t think I blacked out, but I had trouble putting thoughts together and answering these guys. Someone handed me a cell phone but I couldn’t remember my wife’s number. I’m lousy with names and numbers. I should have called the house line; that number is embedded in my head, but I wasn’t thinking straight. I was on the ground and could not get up. John handed me a large plastic bottle of SmartWater®. A green and white park ranger patrol car pulled up, dome light flashing. Great. I’m the center of a scene created out of my own stupidity. “I’ve got an ambulance coming,” said the ranger. I started to come around after inhaling the water bottle and getting my wind back. I stood up, a little shaky at first, but I was able to talk the ranger out of the ambulance. We decided he’d drive me back to my car, then tail me on the short ride home.

“Have you had many people fainting in this heat this summer?” I asked Gordon, the ranger, on the way back to my car. “Just last Wednesday we had a man, 57, die of a heart attack bicycling through Wayne’s Woods. He just went down. There was nothing we could do.”

After we pulled into my driveway, I asked Gordon for the name and address of John. I mailed him a six-pack of water bottles.

And now I read those BP stories a little differently. Hubris, recklessness, complacency, denial, tell me about it. 

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