Learning from disaster

Jul 07 2010 by Brian Amble Print This Article

While the world's attention remains focused on the massive environmental damage along the Gulf coast caused by the April explosion on the Deepwater Horizon oil rig, operated by BP in the Gulf of Mexico, which killed 11 workers, it is a reminder that drilling for oil and gas in the ocean is both a costly and risky process.

There have been other major mishaps in ocean oil drilling operations and the probability is there will be more, particularly in deep water venues.

However, as terrible and devastating as some of these incidents are, and they are relatively few, there are lessons to be learned as companies assess their own risk levels. There is no doubt there will be a fresh examination of the offshore oil industry's approach to major risk and safety following the Deep Water catastrophe.

Rhona Flin, a professor of applied psychology at the University of Aberdeen's Industrial Psychology Research Center, has been researching North Sea offshore oil safety since 1987, just a year before Great Britain experienced perhaps its worst industrial disaster when the Piper Alpha oil platform was destroyed by fire and explosion, killing 167 people.

In particular, Flin has been investigating the competence and abilities of decision makers during catastrophic occurrences, not only on oil platforms, but in several high risk professions where those in charge must take immediate action during extremely stressful situations. Her work has taken her to more than a dozen platforms and rigs in the North Sea to conduct offshore safety research.

Following the Piper Alpha incident, a Public Inquiry Report was issued by the British government and concluded that Occidental Petroleum, the platform's operator, was unprepared for the kind of disaster that struck and the platform's Offshore Installation Manager (OIM) was overwhelmed and not properly trained to handle the fast-breaking developments. His inaction and the resulting breakdown of the platform's command system contributed to an unnecessarily higher number of fatalities, the report stated.

Piper Alpha also led to Flin being awarded a grant from the United Kingdom's Health and Safety Executive (HSE), whose mission is the prevention of death, injuries and ill health in Britain's workplaces, to look at the selection, training and competence of offshore managers to handle crisis management situations, not only in the oil industry but also within other organizations who may deal with major incidents including the military, emergency services and aviation sectors.

"Although the Piper Alpha platform was well-equipped to deal with the evacuation and the crew was trained in fire fighting and emergency response procedures, it appears the crisis on board Piper could have been managed more effectively," Flin wrote in her report. "This led the HSE to look more carefully at the human factors aspects of safety management systems," she added.

In a number of major disasters she reviewed, Flin investigated the common threads that led to problems because of incident commanders' inability to immediately assess and be aware of the developing situation. In other words, she examined the human factor.

The fundamental skill sought in incident commanders across high risk professions is the ability to make decisions under pressure and to provide leadership to ensure the crew members know how to perform their roles, Flin said. The goal is to avoid confusion and chaos among the crew.

She pointed out that those in charge of high risk operations "to some degree already possess desired characteristics, including self-confidence, ability to cope with stress, like being a leader, and are comfortable making decisions quickly and with minimal, if any, consultation."

Offshore installation managers are hired, though, for their abilities to operate an oil platform or rig and to meet production schedules. The reality, though, is that managers "accept the role of crisis manager as a minor element of their overall job requirements," Flin said.

However, just because a manager is effective in routine situations does not mean he or she can handle a crisis situation, Flin said.

So how can organizations ensure they employ people with the "right stuff" to successfully manage emergencies?

The answer lies in assessments and training. Organizations can determine if their managers possess these qualities through a variety of psychological assessments. They then can be trained in specific skills for incident command positions and be given practice making difficult decisions in ambiguous, high risk, time-pressured situations, usually using some kind of simulation, said Flin.

"The training is normally conducted in simulators and simulated scenarios in offshore sites. They are schooled in the most likely problems, such as fires, explosions helicopter and boat crashes," she said. "However, major incidents usually have unforeseen combinations of problems or failures and that is why it is important to have command managers who can quickly assess situations and make timely and accurate decisions," she added.

And what about incidents deemed a "low-likely event," as one BP executive classified the blowout that occurred on the Deep Horizon rig? Flin said "one way to produce scenarios with unexpected failures is to take them from the companies' 'near miss' data set."

By studying and examining "near miss" events, organizations can review the risks and institute procedures that can help prevent, or at least minimize, disasters like the Gulf oil spill.

One highly reliable training method is Crew Resource Management (CRM), which has been widely and successfully used in the aviation industry. CRM focuses on human factors responses to error management during both routine and emergency operations.

When Captain Chelsey Sullenberger landed a plane loaded with passengers in the Hudson River in 2009, both he and the crew were highly trained and professional and reacted to the emergency in such a way that led to all passengers escaping without injury.

Diane Damos, president of Damos Aviation Services in Gurnee, IL, a consulting company that offers services on all aspects of pilot hiring, said the safe landing can be attributed partly to CRM. "The Hudson River incident was an excellent example of Crew Resource Management teamwork," she said.

"CRM training is now used by all major international airlines and is mandatory training for commercial pilots in the United Kingdom," said Flin.

In a study that appeared in the journal Human Factors, Eduardo Salas of the University of Central Florida and an acknowledged authority on CRM and team training and his colleagues found CRM training improved the performances of military pilots.

"The results of these evaluations are applicable to a variety of team contexts….in which teams perform tasks under environmental and organizational conditions that resemble those faced by aviation teams," Salas and his fellow researchers noted.

Indeed, Flin added that one significant innovation following the Piper Alpha disaster was the introduction of formal assessment of offshore mangers' competence in crisis management.

She added regular evaluations in commanders' skills to deal with emergencies are important to the success of any crisis management program and that regulatory authorities for high reliability industries should demand evidence of competent assessments for key decision makers in emergency response situations.

Sometimes, though, there is a conflict between production and the safety commitment of an organization, Flin noted.

"I think there existed on the Piper Alpha a very strong production culture. Oil platforms cannot be turned off and on like a tap. If they are shut-down, it can take days and a lot of work to get them back to full production, thus costing thousands of dollars in lost revenue.

"There was a reluctance to shut down the Piper Alpha as well as two connected platforms because the offshore managers did not fully assess the developing crisis and it was too late by the time they did act," Flin said.

"I think one of the very key cultural variables is where the balance is set between production and safety trade-offs and how site and senior managers are 'calibrated' in this respect. Companies need to assess the level of safety commitment and risk awareness in all their managers," she said.

With colleagues, she has been instrumental in developing an upward appraisal tool to rate managers' safety commitment, as well as climate surveys at offshore installations which seek the opinions of workers on their perceptions of safety practices on the platforms. These tools have been used by oil companies in different countries as part of their safety management practices.

"It is important to listen to workers because they are closer to the platform's operations than others and are aware of potential safety problems and issues," Flin said.


Older Comments

I would refer you to Man Made Disasters: the Failure of Foresight. B.A.Turner 1978 The problem of understanding the origin of disaster is the problem of understanding and accounting for harmful discharges of energy which occur in ways unanticipated by those pursuing orderly goals.

Events preceding and surrounding disasters may then be seen as problems in accounting for biases and inadequacies in habitual ways of handling information relating to impending energy discharges. Disasters equal energy plus misinformation and the only way to come to a better realisation of what will and will not profit the future is to link understanding to action.

The task for financiers, money markets and governments is to locate and resolve the problems created by the misinformation that provoked so disastrous an outcome.

We must continue efforts to improve our knowledge and never allow our ideas to become fixated on glimpses of one holy grail, for in a world dominated by large scale organisations and dependent on large scale technology the line of holy grails stretches to infinity.

Janet howd