On a wing and a prayer

Shell Brent Bravo disaster: “The installation manager and supervisors were working under a regime where production had to be maintained at all costs. Safety was a secondary issue almost totally ignored by the Managers in Aberdeen.”

John

You may wish to publish this as a follow up and contribution to recent inputs on your blog site.  It is also certainly in the NASA and Shell examples a spectacular illustration of how ineffective at such times the so called governance process was included the much heralded concept amongst a management team of shared collective responsibility.

Article By Retired Shell International HSE Group Auditor Bill Campbell: “Forget about the consequence, it won’t happen, will it?”

Piper Alpha on fire shortly after the second explosion

Dutchdude on September 2nd spoke about the acceptance of risk being a trend amongst staff who have not witnessed serious events themselves, and therefore assume it won’t happen. I am sure he has a point, as they say, you don’t know what you don’t know. So inexperience is a factor.

When I was involved in the assessment of OIM’s re their ability to manage major emergencies I also found overconfident candidates, who seemed to lack imagination (never thought thro’ in their heads what could happen and how they would manage under the circumstances through internalising – a sort of mind game of scenarios) to psychologically prepare themselves. Such candidates had a higher failure rate. So perhaps misplaced confidence and optimism is a quality that should be avoided for those that make risk decisions.

However, my overriding experience, and the root causes of some major events confirms that when people decide to continue with an operation that is acknowledged as risky to the degree of being dangerous they do so because of the pressures they are working under and on a wing and a prayer they just hope that the worst case won’t happen
They appear to ignore the potential consequences (it won’t happen) and are focussed on they hope the unlikely probability of the event and ignore, and in some cases won’t even discuss, the potential unthinkable consequences. Some examples:

NASA and Challenger Disaster

With NASA’s total programme in jeopardy due to costs and schedule and political pressure to stop the whole campaign further delays were unacceptable, at least in the mind of the Launch Controller and his team. For several days the cold overnight temperatures had lowered the resilience of the o-ring seal designed to prevent rocket fuel leakage.  The team were fully aware that the o-ring was unreliable under the cold ambient conditions, the manufacturer confirmed this in writing and had recommended not to launch but on the fateful day the launch took place. The o-ring failed some 75 seconds into the flight with catastrophic consequence.

Texas City Refinery Explosion

At the time of the explosion there should have been no loss of life.  The two operators present to witness the leak of liquids from the tower had run away to safety leaving their truck running (thought to be the ignition source).
Unfortunately, an encampment of trucks and trailers had been located within 300 feet of the tower and in a hazardous Zone 1/2 area.  These trailers were occupied by workers carrying out new construction and remedial work on the plant. The aftermath of the explosion was 16 deaths and many injuries. The risk assessment that supported the placement of the construction camp argued that the risks were acceptable on the basis that the presence of hydrocarbons in this vicinity was highly unlikely totally ignoring the potential consequences of that decision.

Brent Bravo 1999

The installation manager and supervisors were working under a regime where production had to be maintained at all costs. Safety was a secondary issue almost totally ignored by the Managers in Aberdeen.  No work was allowed to maintain or inspect safety critical systems just in case the process was tripped accidentally.  The only available Fire pump was operating continually to augment the service water pumps. The service water discharge to sea valve had jammed in fully open position.  Such violations in the operation of process equipment including violations of the permit to work system were common.  Changes were being carried out on the installation, for example temporary pipe repairs, without the prior approval of the design authority. There were many overrides and inhibits on the process control and fire and gas systems, many were not recorded in the control room log.  The performance of ESD valves and other safety critical equipment was being falsely reported to allow the installation to continue in operation. In early October 1999 the complete Shell Expro manage to team (circa 33 senior Managers including Directors) were informed about this state of affairs. There was no denial that the circumstances as described were other than factual, no one attempted to justify any of this. The recommendation to cease operations on Brent Bravo, to further carry out an inquiry into this state of affairs and in the interim suspend the Asset Managers onshore, was ignored.  It was made very clear to the Team that apart from the criminal illegality of operating an offshore installation in this manner, continued operation with no remedial action would inevitably lead to a serious incident including possible multiple fatalities. The consequences of all this was ignored. I can only assume that the complete team (collective responsibility) either thought or hoped that a serious event would not occur and were prepared to take that risk despite the potential consequences, or quite frankly, didn’t give a damn for the health and safety of the 156 persons on board.

PS:
A technical report completed by Shell after the fatalities in 2003 found that the installation was if anything in worse condition than that observed in 1999. In 2004 Shell pled guilty on all counts at Stonehaven Sheriff Court of operating this installation for a prolonged period of time when it was knowingly in a dangerous condition thus contributing through their criminal neglect to the deaths that occurred in September 2003.

Bill Campbell

BBC News: Shell fined £900,000 over deaths

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