Let’s put aside the inflammatory accusations of BP’s blunder in the Gulf, summarized in Mother Jones, magazine’s September/ October issue cover story: the company “has to lie, cheat and stall its way out of a problem;” scientists have been bribed to keep their research secret; fishermen have been paid off to avoid rioting; BP’s Gulf oil-spill plan included a wildlife assessment for walruses and an on-call expert who has been dead for years.
OK, we get the picture.
And let’s back off from conclusions reached in an Associated Press article published this summer: 1) disasters of all sorts result from the acts of stupid, thoughtless, arrogant, people; 2) a cycle of hubris is more or less a hopeless condition of human nature.
Damning critiques could fill a library since the Deepwater Horizon rig went down on April 20. We’ll let investigators tackle the big picture. What is important for safety and health pros with day-to-day responsibilities is the question posed by The Wall Street Journal:
“Why didn’t the crew recognize the warning signs in the final hours?”
For safety and health pros, the event might be a collapsing trench, a hole in a roof, a forklift in reverse, an explosion from accumulated dust, a shirt caught on a conveyor, a crane that tips over, trash that catches fire, a car wreck, a slip on ice.
If the signs were present, why didn’t someone catch them?
Actions in the final hours before virtually any high-consequence incident (in aviation, the nuclear industry, oil and chemical processing industries, etc.) are connected to so-called upstream organization issues: management decisions gone wrong, corporate hubris, maintenance cuts. Those are often easier to document with a paper trail of emails, etc. than what went down in the final hours. That can be shrouded in an invisible fog of botched communications and misunderstandings, much to the frustration of professionals looking for answers.
The fog descends in the form of disruptions, distractions and disagreements, for example. Workers become disoriented, perhaps worsened by fatigue.
In the case of the Deepwater Horizon rig, the fog built up gradually throughout the day of April 20. How? For one thing, key changes took place, changes to a critical safety test of the well’s stability that were “unorthodox,” not well-explained nor understood on the rig, according to The Wall Street Journal report. There was disagreement about the need for and timing of making the change. Control room operators struggled to interpret test readings.
A critical shift change occurred at 6 p.m. on April 20. The dayshift tool pusher supervisor who said “something wasn’t right” with the drilling operation was replaced by the nightshift supervisor who said “nothing unusual” was going on.
“Management of change,” a critical component of process or system safety, was poorly executed. It contributed to the developing fog.
There were other contributors:
So out of this clash of cultures, poor communication, pressure, impatience, confusion and fatigue a fog enveloped the Deepwater Horizon on April 20.
In the 1990s, Dr. Edward Zebrowski studied the Chernobyl nuke meltdown the Piper Alpha oil rig fire, the Bhopal gas release, and the Challenger space shuttle explosion. He categorized common contributors to the fog of doom, many on display in the Gulf on April 20:
Diffuse responsibilities. Dissent not allowed. Safety subordinate to other performance goals. Undefined responsibility and authority for safety.
The 126 Deepwater Horizon workers were not stupid and arrogant people in the final hours. They were caught in a quickly mushrooming fog.
Check your incident reports and investigative findings. How often are perceptions and recollections of what happened clouded or contradictory? What contributed to the fog? And if a culture of safety has somehow diffused accountability to the point no one is in charge, you need a culture change - immediately.